24
:--No V,, 10, 21) 1 0-1 0: 03AM-DC P LANN] NG DCWWA
No, 2444 p, 2
2010-01-19 JCM
Date Received:
Chris Masterson 0
Christine Fulton 0
.
Sue Rose 'f(
U-I JQ/-L2-
Town of Wappinger
Agreement for the Use of the Town
Hall Facilities for Meetings
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FOR INTERNAL USE ONLY
Received by:
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Serial #: /;~~~
Applica.tion 0 $100.00 ert.ofLI
o Notified Recreation (date: )
Agreement for the Use of the Town Uan Facilities for Meetings
'b"'+V,",,/VJ ~ ~ l. nt^i^j lL.I p""/~ D vTZ. - rn ~ WV\.CTS J2...,I ~ ~ ~ "-"1-
Name of Organization or.oroup , , ft7t...T!.~ C--wv\V\;\.f~
~A~ Do1:"\~'
Name of person representing the Organization OJ Group
..:2~ ~~'^s+, ').~..f1, ~~lL-U_fr"L IJ.vo.3.
Address
1~S~ ~~(p -3 ~t S-
Phone No-
This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as
Doted below:
( ) Senior Citizens Room
~ Large Meeting Room
( ) Other: Specify:
The group is not expected to exceed 1"'-
Date(s): Tw.... I ~ (.. I "1
persons
Time: , -::, r ~ (1A.'r{\Vc. t Se. i vtp .... Il? ~PM l
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 roles 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 ofthe
_ 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 acc~ss to specific area to be used should be nwie with the Town Clerk at the time this form is
submitted.
No application shall be considered a.pproved until it has been submitted to the Town Clerk for review and
Clearance.
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Nov.. 10. 1010-10:03AM-DC PLANNING DCWWA
No. 2444 P. 3
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 tennination 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: ~ .1 p~'
For: D~~~~~ ~~j ltll)ur- ~ M~R. ~P-,(, ~.CMkt-
(N e Of Group or gaxiiz on)
Date: t I
Approved:
Date:
~
;
Nov..18. 2&10 9: 16AM
DC PLANNING DCWWA
No. 2505
P. 2
~
OP ID: LLEM
ACORD' CERTIFICATE OF LIABILITY INSURANCE I OA TEO IMMlPDIYYYYJ
~ 11/12/10
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERl1FICATE 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 CONSnTUTE A CONTRACT BElWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOL.DER.
IMPORTANT: If the certificate holder i5 an ADDITIONAl INSURED, the pOlicy(ies) mu5t be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and condition5 of the policy, certain policies may require an endorsement. A statement on this certificate does not confer righls to the
certificate holdar In lieu of such andorsamant(s).
PROOUCE:R 845-567-1000 ~~~CT
Marshall & Sterling, Inc. 845-567-1030 r~g,N~a. Enl, I r~ NOI:
103 Executive Drive, Suite 300 ~'R~S5:
New Windsor, NY 12553 COSTOMER III II: DUTCH-R
INSURER/S) AFFORDING COVERAGE NAIC.
INSURED County of Dutchess INSURER A :Argonaut Insurance Co.
Office of Risk Management INSURER B :
22 Market Street
Poughkeepsie, NY 12601 INSURER C :
INSURER D :
INSURER E :
INSURER F:
COVE.RAGES
CERTIFICATE NUMBER:
REVISION NUMBER'
THIS IS TO CERTIFY THAT THE POLICIES 01= INSURANCE LlSTE:D BELOW HAVE BEEN ISSUED TO TI1E INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO w-lICH 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 'M'E OF INSURANCE ~:f~, II~~~~I LIMITS
LTR ioN"" WVrl I'OLlCY HUMIlER
GENERAL LIABILITY EACH OCCURRENCE S 1.000.00C
-
A ..!. ~MERCIAL GENERAL LIABlUTY 14611579 10/01/10 10/01/11 PREMISES lEa oe<:uJTena=\ S 100,OOC
- CLAIMS-MADE [!] OCCUR MED EXP (Any olle OeOlOn) S C
. PERSONAL & ADV INJURY S 1,OOO,OciiJ
GENERAL AGGREGATE S 2,OOO,OOC
~L AGGREnE ~MI~ APnS PER: PRODUCTS - CQMPIOP AGG S 2,OOO,OOC
POLICY P':;'PT LOC s
AuTOMOBiLe LIABILITY COMBINED SINGLE LIMIT 1,OOO,Ooe
- (Ea ecCident) S
A ~ ANY AUTO 4611579 10/01/10 10/01/11
BODILY INJURY (Perp,.,..on) S
'-- ALL O'MllEO AUTOS BODILY INJURY (Par~cdclenl) S
'-- SCHEDULED AUTOS PROPERTY DAMAGE
~ HIRED ~.UTOS (Per acQdenQ S
~ NON-o'MIIEO AUTOS S
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11MBREUA LIAS ~ OCCUR EACH OCCURRENCE S 10,OOO,00e
I--
EXCESS LIAS CLAIMS-MADE AGGREGATE S 10,OOO,OO[
A 4611579 10/01/10 10/01/11
I-- DEDUCTIBLE S
X RETENTION S S
WOMERS COMPENSATION I V;CSTATU- I IOJ~-
AND EMPLOYERS' LIABlUTY Y/N
ANY PI',OPRIIOfOR/PARTNERISXECUTIVE D NIA E.L. EACH AeCl DENT s
OFFICER/MEMBER ~C"uoeb7
(~n..lary In NIlI EL. DISEASE. EA EMPLOYEE S
If yea, OeaCl1b8 unoer
DESCRIPTION OF OPERATIONS belOW E.L DISEASE. POUCY UMIT S
OE5C1\lPTIOIII OF OPERA:!KIIIS I LOCAnoNS J VEHICLES JAbCh ACORD 101, AdCllllanal Remark. Sclled....., If mare $pue.. require.,
For Dutchess COl.," Department of Plannlllg & Developmellt's Transportatio"
Council's use offa~' ity'.
CERTIFICATE HOlOER
CANCEllAnON
WAPPI.3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Wappinger ACCORDANCE WITH THE POLICY PROVISIONS.
20 Mlddlebush Rd
Wappingers Falls, NY 12590-4004 AI/lllORIZEP R.EPRI'5=IIITfl,1'lIIE
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ACORD 25 (2009/09)
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