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HomeMy WebLinkAboutLoveshack Fancy 3 c7 -- p euc� ��� RECEIVE® AUG 2 3 2011 Southold Town Clerk CoAncew I 10A APPLICATION FOR FILMING/STILL PHOTOGRAPHY PERMIT NO: Please Print or Type APPLICATION DATE: August 22"d 2017 NAME OF APPLICANT: Dela Kirisome MAILING ADDRESS: 210 l lth Ave STE 1104 New York,NY. 10001 PHONE. BUSINESS. 646-455-0714 HOME: 646-455-0714 NAME OF ORGANIZATION/ COMPANY: LOVESHACKFANCY MAILING ADDRESS: 210 11`h Ave STE 1104 New York, NY. 10001 PHONE: 646-455-0714 FAX: DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): Photoshoot for digital usage DATE(S) AND TIME(S) OF PROPOSED FILMING/PHOTOGRAPHY: September 6th 8am-6pm PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) Horton Point Park Beach, Southold NY (Beach) NAME OF PERSON IN CHARGE AT SITE: Dela Kirisome NUMBER OF PERSONS AT LOCATION (cast& crew included): 10 NUMBER AND TYPE OF VECHILES AT LOCATION: 3 vehicles TYPE OF SPECIAL EQUIPMENT: none ANY SPECIAL REQUIREMENTS: none Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1179 Southold,NY 11971 INDEMNIFICATION AGREEMENT TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT The Applicant shall indemnify and hold harmless the Town from and against all suits, claims, demands or actions for any damage and/or injury sustained or alleged to be sustained by any party or parties in connection with the performance of filming or still photography by the Applicant, his employees or agents or any subcontractor and in case of any such action brought against the Town, the applicant shall immediately take charge of and defend the same at his own cost and expense. In addition, the Applicant will name the Town as an additional insured on any applicable policies. August 22nd 2017 Signature Date Dela Kirisome Printed name Marketing &PR Manager Title DATE(MMIDDIYYYY) �AC"R"® CERTIFICATE OF LIABILITY INSURANCE 8/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) PRODUCER CONTACT Juda.th H1 ins NAME gg FAX Fabra.cant & Fabricant, Inc. A/CN o Ext (516) 621-9000 A/C No•(516)621-0092 1251 Old Northern Boulevard E-MAIL ADDRESS P.O. BOX 9004 INSURERS AFFORDING COVERAGE NAIC# Roslyn NY 11576 INSURERA.Sentinel Ins. Co. 11000 INSURED INSURER B Loveshackfancy, LLC INSURERC. 210 11th Ave Rm 1104 INSURERD, Unite 435 3R INSURER E New York NY 10001 1 INSURER COVERAGES CERTIFICATE NUMBER:16-17 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DA AGE A CLAIMS-MADE OCCUR PREM SESOEa occu ence $ 1,000,000 12SBAUL1576 11/6/2017 11/6/2018 MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 M'OTHER L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRO F—]JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident A ANY AUTO BODILY INJURY(Per person) $ AOSCHEDULED 12SEAUL1576 11/6/2016 11/6/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X PROPERTY DAMAGE $ NON-OWNED t AUTOS Per acciden $ X UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10,000 12SBAUL1576 11/6/2016 11/6/2017 $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Town of Southold and Silver Sands Motel are included as Add3.t3.onal Insured with respect to work performed by Named Insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. Southhold, NY 11971 AUTHORIZED REPRESENTATIVE gym__ Kenneth Fabricant/MEE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r201401) Doroski, Bonnie From: Doroski, Bonnie Sent: Thursday, August 31, 2017 8:17 AM To: Blasko, Regina; Doherty,Peter, Fisher, Robert; Flatley, Martin; Kruszeski, Frank; Norklun, Stacey; Orlando,Vincent; Standish, Jeff,Verity, Mike Subject: Emailing:filming permit-loveshack_20170831071421 Attachments: filming permit-loveshack_20170831071421.pdf Please review the attached application for filming, September 6, and let this office know if there are any questions/concerns or cost necessary. Thank you. Bonnie J. Doroski Deputy Town Clerk Your message is ready to be sent with the following file or link attachments: filming permit-loveshack_20170831071421 Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 RECEIVED AUG 2 3 2017 Southold Town Clerk APPLICATION FOR FILMING/STILL PHOTOGRAPHY PERMIT NO: Please Print or Type APPLICATION DATE: August 22° 2017 NAME OF APPLICANT: Dela Kirisome MAILING ADDRESS: 210 11`x' Ave STE 1104 New York, NY. 10001 PHONE: BUSINESS: 646-455-0714 HOME: 646-455-0714 NAME OF ORGANIZATION / COMPANY: LOVESHACKFANCY MAILING ADDRESS: 210 11"' Ave STE 1104 New York, NY. 10001 PHONE: 646-455-0714 FAX: r * k •r. � � � x x � = * x T � x � fi �= T x x � k � c * � �: * x x * � >;: >;c x � � � r � � * � � x DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): Photoshoot for digital usage DATE(S) AND TIME(S) OF PROPOSED FILMING/PHO'T'OGRAPHY: September 6`" Sam-bpm PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) Horton Point Park Beach, Southold NY (Beach) NAME OF PERSON IN CHARGE AT SITE: Dela Kirisome NUMBER OF PERSONS AT LOCATION (cast& crew included): 1.0 NUMBER AND TYPE OF VECHILES AT LOCATION: 3 vehicles "TYPE OF SPECIAL EQUIPMENT: none ANY SPECIAL REQUIREMENTS: none Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 INDE.MNIFICATION AGREEMENT TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT The Applicant shall indemnify and hold harmless the Town from and against all suits, claims, demands or actions for any damage and/or injury sustained or alleged to be sustained by any party or parties in connection with the performance of filming or still photography by the Applicant, his employees or agents or any subcontractor and in case of any such action brought against the Town, the applicant shall immediately take charge of and defend the same at his own cost and expense. In addition, the Applicant will name the Town as an additional insured on any applicable policies. . August 22"" 2017 Signature Date Dela Kirisomc Printed name Mu ctin & PR Manager Title DATE(MM/DO/YYYY) � CERTIFICATE OF LIABILITY INSURANCE 8/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Judith Higgins NAME: gg Fabricant & Fabricant, Inc. �A/ONN Ext): (516) 621-9000 a/c No: (516)621-0092 1251 Old Northern Boulevard E-MAIL ADDRESS: P.O. Box 9004 _ INSURER(S)AFFORDING COVERAGE __MAIC# Roslyn NY 11576 INSURERA:Sentinel Ins. Co. _ 11000 INSURED INSURER B: Loveshackfancy, LLC INSURERC: 210 11th Ave Rm 1104 INSURERD: Unite 435 3R INSURERE: New York NY 10001 INSURERF: COVERAGES CERTIFICATE NUMBER:16-17 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE IN;D SUER POLICY NUMBER MMI PICY EFF POLICY EXP LTR DD YYYY MM DD YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �l DAMAGE TO RENTED 1,000,000 A CLAIMS-MADE I X I OCCUR PREMISES1Ea occurrence $ 12SaFAUL1576 11/6/2017 11/6/2018 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ $ 2,000,000 _ POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGO $ 2,000,000 X PRO- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident __ ANY AUTO BODILY INJURY(Per person) $ AALL OWNED SCHEDULED __ AUTOS _ AUTOS 12SBAUL1576 11/6/2016 11/6/2017 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY c TY IAMAGE $ X HIRED AUTOS X AUTOS -- --- $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5 000 000 A EXCESS LIAB _ CLAIMS-MADE AGGREGATE $ __ 5,000,000 III-X-1 RETENTIONS 10,000 12SBAUL1.576 11/6/2016 11/6/2017 $ WORKERS COMPENSATION PER - AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROP RIETOR/PARTNER/EXECU I IVEN/A E.L.EACH ACCIDENT _ $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Town of Southold and Silver Sands Motel are included as Additional Insured with respect to work performed by Named Insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25 ACCORDANCE WITH THE POLICY PROVISIONS. Southhold, NY 11971 AUTHORIZED REPRESENTATIVE Kenneth Fabricant/MF"I' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I N S02.5 00140 T1