03
2010-01-19 JCM
Received by:
Chris Masterson 0
Christine Fulton 0
Sue Rose ~
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Town of Wappinger
Agreement for the Use of the Town
Hall Facilities for Meetings
FOR INTERNAL USE ONLY
Date Received:
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Agreement for the Use of the Town Hall Facilities for Meetings
WflfPIN~-E~ foP WItf.-Nf{L foo'1BflL1- IttVD c.J-l€E((
Name of Organization or Group
LEWI5 SDtJ~'I WILLi~s /f(e,ic(e."f:
Name of person representing the Organization or Group
9/'1:- 3g-l.f - '116 7
Phone No.
Address
This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as
noted below:
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( )
Senior Citizens Room
Large Meeting Room
Other: Specify:
The group is not expected to exceed 50 persons
Date(s): ItfItIL. Wj 'l0/0 Time:
.
q IJM - 3f/YJ
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.
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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 temrination 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: It:: 0 J A fJ ·
For: WltfftvJ&e-u fDP Wftf-(lJ~(L t-oD,13f1i,l f11VD CHeER-
(Name of Group or Organization)
Date:
3- )10. 10
fj; c~
T Clerk
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Approved:
Date:
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CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIYYYY)
03-24-2010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Two Logan Square HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
Philadelphia, PA 19103 INSURERS AFFORDI NG COVERAGE
Balail. Gwen.Steele@marsh.com
INSUIml INSURER'" Lexlnaton Insurance Companv
Mid Hudson Conference INSURER B; National Union Fire Insurance Companv
Wapplngers Pop Warner Little Scholars INSURERC;
10 Brothers Road INSURER 0;
Wapplngers Falls, NY 12590 INSURER E; American International Specialty Lines Insurance Companv
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED TO THE INSURED NAMED ABOVE OR THE POLICY PERIOD INDICATED. NOTWlTHSTANDNG
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 SUBJECTTO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR TYPI! 0' INSURANce POUCY NUMBER DATE',MM:~E Pg~Y:';'~N LIMITS
LTR
A GENERAL LIABILITY 9471391 08-01-2009 08-01-2010 EACH OCCURANCE $ 1,000,000
X POMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 50,000
== bCLAIMS MAOEIIPCCUR MED EXP (Anyone person) $
PERSONAL $ AOV INJURY $
GENERAL AGGREGATE $ 5,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS -COMP/OP AGG
~POLICY n~:& n LOC Delaware # 9471393 08-01.2009 08-01.2010 Sexual Abuse 1 Mil/1 Mil
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $
ANY AUTO (Ea acddeI1t)
- ALL OWNED AUTOS
- BODILY INJURY $
SCHEDUll:D AUTOS (Per p<non)
~
HIRED AUTOS BODILY INJURY
- $
NON-OWNED AUTOS (Per accident)
-
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY -EAACCIDENT $
~ ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
EXCess LIABILITY EACH OCCURANCE $
=:J OCCUR DCLAIMSMADE AGGREGATE $
$
~ DEDUCTiBlE
RETENTION $
WORKER'S COMPENSATION AND I~R'STATU- ; I 10TH. $
EMPLOYeR'S LIABILITY TORY LIMITS ER
E.L. EACH ACCIDENT $
E.L DISEASE -EA EMPLOYEE $
E.L DISEASE -POLICY LIMIT $
OTHER
A Inland Marine/Sports Equip 4194887 08-01-2009 08-01-2010 $ 0
B Excess Accident Medical SRG91 08336 08-01-2009 08-01.2010 $ 100,000
$
DESCRIPTION OF OPERATlONSlLOCATlONSIVI!HICLEllmXCLUSlONS ADOED BY ENDORSEMI!NT/SPECIAL PROVISIONS
Pop Warner Tackle and Flag Football Activities including Cheer1eadlng and Dance Programs.
Additional Insured Status Is provided as per Fonn 72984 (4/99) and CG2026 (11/85) attached to the policy.
This Is primary per the terms of policy form CG0001 (12/07)
CERTIFICATE HOLDER I X I ADDmONAL INSURED: INSURER LI!TTER :A CANCELLATION
Town ofWapplngers Falls Town Hall SHOULD ANY ~ THe ABove DESCRIBED POLICIES BE CANCALLEP BEFORE THE EXPIRATION
DATI! THEReoF, THI! ISSUING INSUReR WILL ENDEVOR TO MAL ~ DAYS WRmEN
20 Middle Bush Rd. NOTICE TO THE CERTlI'lCATe HOLDI!R NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBUGATlON OR UABfLITY OF ANY KIND UPON THE INSURER,IT'S AGENTS OR
Wappingers Falls, NY 12590 REPRESENTATIVES
AUTHORIZI!D IU!PResENTATlVE ~ .J. t)~
CBRT It 203-2009-4114