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Mat Bus Corp C4 2010-01-19 JCM FOR INTERNAL USE ONLY Town of Wappinger Received by: Joseph P. Paoloni Agreement for the Use of the Town Grace Robinson rr�LE �q#Jacilities for Meetings Date Received: E C 2 2 2017 Serial 4: Application P60 m Cert, ofT9WN OF WAPPINGE TnWN Notrfied Recreation (date: agreement for the Use of the Town Hall Facilities for Meetings Narne of Organization or Group 1114�- cl Name�f PersiTrepresentin the Organization or Group J . Address Phone No. This will coriffirn the arrangements being requested for your groups' use of the WappingerTown Hall Facilities, as noted below: Senior Citizens Room Large Meeting Room Other: Specify: The group �_�_pot expected to exceed persons Date(s):--- Time: It should be understood that groups using the Buildings' Facilities for evening meetings must select dates when Town Meetings are normally scheduled (i.e., Justice Court, Planning Board, etc.) Special requests will be considered upon their own nacrit, and arrangements can be made for access to, and closing, the building at the close of your meeting. You and your Organization hereby agree to adhere to the rules set forth on the attached page by signature of an Z� authorized member of your Organization or group. The Town of'Wappinger reserves the right to suspend temporarily this agreement should the Town have need of the L-1 facility for its own purposes. AdN,ance notice will be given as soon as possible on such occasions. The '"Fown Clerk Should be informed prornptly of any schedule change or cancellation of your group actii,ities. Arrangements for access to specific area to be used should be triadc with the Town Clerk at the tirne this forni is submitted. No application shall be considered approved until it has been submitted to the Town Clei-1 for review and Clearance. *ftWA4 1 f 2010-01-19 JCC Terms of the agreement must be strictly adhered to by the contracting group as any disregard or abuse of the rules for use of the facilities will result in termination of use by the offending group, and they will not be granted reinstaternent. I have read and understand the rules and regulations for the use of the Facilities in the Town of Wappinger Town Hall, and will comply with these requiremelItS. Signed: For: (Name of Group or Organization) Date: Approved: Town CYerk" Date: I * * * RECEIPT Date: 12/22/17 Receipt#: 86504 Quantity Transactions Reference Subtotal 1 Building Use Fee 86504 $100.00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CASH $100.00 Mat Bus Corp. Name: Mat Bus Corp. Clerk ID: GR Internal ID:86504 ACORO® DATE(MMIDD"YY) CERTIFICATE OF LIABILITY INSURANCE 12/19/2017 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(iss) 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 Stephen Persaud Capacity Coverage Company of New Jersey, Inc. PHONE (201)661-2456 No: (201)661-7804 One International Blvd. ADMDRE :spersaud@capcoverage.com 3rd Floor INSURERS AFFORDING COVERAGE NAIC N Mahwah NJ 07495 INSURERA:United States Fire Insurance 21113 INSURED INSURER Lexington Insurance Co 19437 MAT BUS CORP INSURER C:NJM Insurance Company 3000 Orthodox Street INSURER D: INSURER E Philadelphia PA 19137 INSURER F COVERAGES CERTIFICATE NUMBER CL1552664428 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 Y EXP LTR TYPE OF INSURANCE ADPL SUER POLICY NUMBER MMIDDPOL)CYIYYYY MEFF MlDD1YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 EENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE I—XI OCCUR 06-8870704 11/30/2016 2/31/2017 MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PROr Ll LOCI $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 153000479 6/22/2017 6/22/2018 BODILY INJURY(Per accident) $ AUTOSAUTOS A NO OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ X Garage Keepers $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 9,000,000 B EXCESS LIAB CLAIMS-MADE 038183184 /22/2017 6/22/2018 AGGREGATE $ 9,000,000 DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y 1 N - FR ANY PROPRIFTOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 11000,000 OFFiCERIMEMBER EXCLUDED? NIA 7/02/201-1 7/02/2018 D (Mandatory in NH) 32490228 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required) The certificate holder is included as an Additional Insured, but only as respects to claims arising out of the negligence of the Named Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Wappinger Hall ACCORDANCE WITH THE POLICY PROVISIONS. 20 Middlebush Road Wappingers Falls, NY 12590 AUTHORIZED REPRESENTATIVE ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025l7nlnn it M Tha AC( on nnma enrl Inn^mra raniefararl mmrire of arnon