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HomeMy WebLinkAboutThe New School ELIZABETH A.NEVILLE,MMC � �� Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 CM Southold,New York 11971 REGISTRAR OF VITAL STATISTICS "'`" � Fax(631)765-6145 MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER Telephone(G31)7G5 1800 FREEDOM OF INFORMATION OFFICER www•south rga OFFICE OF THE TOWN CLERK NOV 6 2017 TOWN OF SOUTHOLD APPLICATION FOR FILMING/STILL PHOTOGRA14nthold Torn Clerk PERMIT NO: Please Print or Type ' APPLICATION DATE: / i NAME OF APPLICANT: E r- 4�- j MAILING ADDRESS: !3 �_ ` ' (,._ r PHONE: BUSINESS: r HOME: NAME OF ORGANIZATION /COMPANY: ,.A �f R � - t� P MAILING ADDRESS: 'ye- PHONE: oc FAX: DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television, Catalog, Magazine, etc.): DATE(S) AND TIMES) OF PROPOSED FILMING/PHOTOGRAPHY: PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) NAME OF PERSON IN CHARGE AT SITE: NUMBER OF PERSONS AT LOCATION (cast & crew includ-gid): I NUMBER AND TYPE OF VECHILES AT LOCATION: TYPE OF SPECIAL EQUIPMENT: ANY SPECIAL REQUIREMENTS: NJ Signature - Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 i 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. f ' 1 Signature Date w Printed name Title * * * RECEIPT * * * Date: 11/14/17 Receipt#: 229655 Quantity Transactions Reference Subtotal 1 Application Fee - Non-Refund 11.18.17 $100.00 1 Clean-Up Deposit 11.18.17cleanup $250.00 1 Daily Filming Permit 11.18.17filming fe $100.00 Total Paid: $450.00 Notes: Payment Type Amount Paid By CK#122.123.125 $450.00 Breese, Tracey Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Breese, Tracey 1343 Central Avenue Greenport, NY 11944 Clerk ID: BONNIED Internal ID: 11.18.17filming fee ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/9/2017 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). ACT Carmel Kretchmer PRODUCER NAME Arthur J. Gallagher Risk Management Services, Inc. PHONE 973-939-3631 FAX e. 973-299-1864 200 Jefferson Park E-MAIL Carmel_kretchmer a com Whippany NJ 07981 @ Jg INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:United Educators In 10020 INSURED NEWSCHO-01 INSURER B The New School INSURER C Attm Mr. Howard Bressler INSURER D: 80 Fifth Ave., Suite 800 New York NY 10011 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER:2122916991 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. TIN SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY CGL201700337800 4/1/2017 4/1/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $1,000,000 _ CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence MED EXP(Any one person) $5,000 X Al CGL 06-2008 PERSONAL&ADV INJURY $INCLUDED GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 X POLICY PRO LOC PRODUCTS-COMP/OPAGG $1,000,000 JECT $ OTHER: EI $ AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ Per accident HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ pER OTH- WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ _ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Student: Tracey Breese shooting, "Two women meet on the beach in search of a lost ring". Location: McCabe's Beach, Southold, NY. Shooting date: November 18, 2017 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Elizabeth A. Neville THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold Town Cler/Southold ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Route 25,P.O. Box 1179 Southold NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD