17
,.
2010-01-19 JCM
FOR INTERNAL USE ONLY
Town of Wappinger
Agreement for the Use of the Town
Hall Facilities for eetings
W IV.
Received by: Chris Masterson 0
Christine Fulton 0
Sue Rose ~
Date Received: S- / XQ. / 12-
Serial #: lJ
o Application 0 $100.00 ~ert. ofLI
o Notified Recreation (date:~
Agreement for the Use of the Town Hall Facilities for Meetings
N~~ ~\)( k ~I~ud C~Y\1-t 0
Name of Organization or Group \,..,
L\,::>c.- S.\C\( ?'~ l'-
Name of~erson representing the Or, ganization or Grf)UP,\ (\ /. \ "S 2 7
')15 [i-<-Lv..:.1\ ve.. 6 I If J ' l \ W'.') wa u ) H ~ '-l 2:>
Address
gys - 11 2 - I Y S \
Phone No.
This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as
noted below:
( ) Senior Citizens Room
~ Large Meeting Room
( ) Other: Specify:
The group is not expected tq exc~ed S 0 persons
Date(s): -,\;...to '6 I; \ I 2-Q, \ 0
-tNLL o...((IVO 10:\:;\)(;.171) 1--ei\vc>V'(:)()\y<hJ
Time:CV))le \')~\.l(~ )).3o-Ll'.ao
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. J. A. , C'1 0' J'
'. .' _ i .('JCt~ - .#i/\).D /}A/lr;~ r-
IlI,}cl/,.. C. y(I~ ~ 8Qpf.. ~ J" ~. Ck,.. .,. ~,...
cAJ1~~ tfl 00 b-uo ,-
2010-01-19 JCM
Tenns 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:
~~~~
For:
N -tv.) L\~"~ ~ \'0D6 Ce V' -\LI\,
(Name of Group or Organization)
Approved:
<6 ) 1-:3 ) 20 \ ru
fror. ~ .~
Town ClerK: -
f-'-l :An 0
Date:
Date:
ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDlYYYYl
8/17/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The Treiber Group 516-745-0800 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
AJ Gallagher Risk Mgmt Svcs ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
377 Oak Street
Garden City, NY 11530-0601 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Great Divide Insurance Company 25224
New York Blood Center, Inc. INSURER B: Liberty Mutual Insurance 23035
310 East 67th Street INSURER C: American Guarantee and Liability Ins 26247
New York, NY 10065 INSURER 0:
INSURER E:
Client#. 22569
NYBLOOD
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER PJll"~i~:~~.r8,w\E P~~fl,If:~/~~N LIMITS
A ~NERAL LIABILITY GFP1000077P1 09/15/09 09/15/10 EACH OCCURRENCE $1.000000
X COMMERCIAL GENERAL LIABILITY ~~~t~'E,JO RENTED $50.000
- ~ CLAIMS MADE [!] OCCUR MED EXP (Anyone person) $5 000
PERSONAL & ADV INJURY $1 000000
- GENERAL AGGREGATE $3 000 000
~'L AGGREnE ~~~ APFt PER: PRODUCTS - COM PlOP AGG $1.000 000
POLICY JECT LOC
C ~OMOBILE LIABILITY CP0380042402 09/15/09 09/15/10 COMBINED SINGLE LIMIT
~ ANY AUTO (Ea accident) $1,000,000
>-- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
>--
~ HIRED AUTOS BODILY INJURY
$
~ NON-OWNED AUTOS (Per accident)
----J PROPERTY DAMAGE $
(Per accident)
~RAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
A ::i]ESS/UMBRELLA LIABILITY CFX1000049P1 09/15/09 09/15/10 EACH OCCURRENCE $5.000 000
X OCCUR 0 CLAIMS MADE AGGREGATE $5 000 000
$
~ DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND WC2Z21092563010 04/09/10 04/09/11 X I //,gJi~~~ I IOJ~-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1,000,000
If yes, describe under $1,000,000
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT
A OTHER Professional PFP1000096P1 09/15/09 09/15/10 $1,000,000 Each Claim
$3,000,000 Aggregate
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
additional insured coverage is afforded by form SSM-0061 (7/07)
RE: Blood Drive 8/31/10
As respects to General Liability the certificate hodler is included as
Additional Insured where required by written contract.
(See Attached Descriptions)
COVERAGES
CERTIFICATE HOLDER
CANCELLATION
Town of Wappingers
20 Middlebush Road
Wappingers Falls, NY 12590
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ....30.... DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001/08) 1 of 3
#S256525/M250016
@) ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-5 (2001108) 2 of 3
#S256525/M250016