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2019-4 Hindi Samaj Temple 2010-01-19 JCM FOR INTERNAL USE ONLY. Town Of Wappinger er _ pp g Received by: Joseph P. PaolOn1 D �W[EnAgreement for the Use of the Town Grace Robinson ❑ Hall Facilities for Meetings OCT I Date Received: _1_/ 2019 -" Serial #: a019 J4TOWN OF W PPINGER !r I ❑ Application 7 $100.00 ❑ Cert. of LI ❑ Notified Recreation(date: } Agreement for the Use of the Town Hall Facilities for Meetings Name of Organization or Group Name of person representing the Organization or Group Address Phone No. This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as noted below: (�C} Senior Citizens Room (pe) Large Meeting Room ( ) Other: Specify: The grow is not expected to exceed 55 persons Date(s): 10-H--iq 7Vm- l Time: Ll-::,-190-rq 9A(A —,-*f'rn/'-tfM,1 'E0 — �j Li t-i r9 GPM -- (IP cr)-j 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 merit, 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 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 facility for its own purposes. Advance notice will be given as soon as possible on such occasions. The Town Clerk should be informed promptly of any schedule change or cancellation of your group activities. Arrangements for access to specific area to be used should be made with the Town Clerk at the time this form is submitted. No application shall be considered approved until it has been submitted to the Town Clerk for review and Clearance. i J 2010-01-19 JCM 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 reinstatement. 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 requirements. Signed: r For: ,— (Name of Group or Organization) I Date: p--/0'LIQ. Approved: Town Clerk Date: 201.0-01-19 .ICM FOR INTERNAL USE ONLY Town of Wappinger Rement for the Use of the Town. Received by: Joseph P. Paoloni Grace Robinson 4VAFacifities for Meetings Date Received:, / / SE P 18 2019 Serial #: TQ WN f WAPPINGER = y TOWN1 'In .' Application $100.00 Cert. of LI Notified Recreation (date: } "' Agreement for the Use of the Town Hall Facilities for Meetings Hil'ibu Name of Organization or Group Narne of person representing the Organization or Group 03 C'.s�� Hcac Address Phone No. This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as noted below: ( } Senior Citizens Room Large Meeting Room ( } Other: Specify: The group is not expected to exceed (3 persons Datc(s): C� y Lg si Time: 6-- 1 o pxo 10-4 - lt 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 merit, 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 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 facility for its own purposes. Advance notice will be given as soon as possible on such occasions. The Town Clerk should be informed promptly of any schedule change or cancellation of your group activities. Arrangements for access to specific area to be used should be made with the Town Clerk at the time this form.is submitted. No application shall be considered approved until it has been submitted to the Town Clerk for review and Clearance. 2010-01-19 JCM 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 reinstatement. J 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 requirements. I Signed: ! For: A-J LQAA&Al10Y /o ff i (Name of Group or Organization) Date: Approved: Town Clerk Date: AC�� DATE(MMMD1YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/0212019 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 have ADDITIONAL INSURED provisions or 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 NAME: Jennifer M L6WItZI(e Church Mutual Insurance Company PHONE 1-800-554-2642 Option 1 FAX 855-264-2329 F.t - AIC.No): 3000 Schuster Lane E-MAILE-MAILpustomerservice@churchmutual.com P.O.BOX 357 INSURERS)AFFOROING COVERAGE r---,-.--^.� NAIC# T Merrill WI. 54452 INSURER A: Church Mutual Insurance Company 18767 INsuRED HINDU SAMAJ INC INSURERS: T �� INSURER C: 3 BROWN RD INSURER D INSURER E: WAPPINGERS FALLS NY 12590-4531 INSURERF: COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MWDDNY" fMMMD= LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,004 r OCCUR DAMAGETO S(RENTED CLAIMS-MADE PREMISES Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 10,000 A _ Y 0203353-02-204588 0411612019 04/16/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERALAGGREGATE _ $ 3,000,000 X POLICY PET El LOC PRODUCTS-COMPIOPAGG $ 1,000,000 T OTHER: $ _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident,Z_.-____,__, ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ � AUTOS ONLY AUTOS _ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per a 'dent . $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LL&BILITY Y/N STATUTE ER ANYPROPRIETORIPARTNERIEXECUTIVE ❑ NIA E,L.EACH ACCIDENT $ OFFICE RIMEMBEREXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H more space is required) Practice for dance recital 10/4119, 10/19/19,10120/19,10126119 and 11!1!19 SAAP 519-A220 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WAPPINGERS FALLS TOWN HALL ACCORDANCE WITH THE POLICY PROVISIONS. 20 MIDDLE BUSH R❑ AUTHORIZED REPRESENTATIVE WAPPINGERS FALLS NY 12590-4004 ©1988-2015 XCORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD