Dutchess County Transportation
Dec,20, 2010 1:13PM
DC PLANNING DCWWA
No,2810 p, 2
.
2010-01-19 JCM
FOR INTERNAL USE ONLY
Town of Wappinger
Agreement for the Use of the Town
Hall Facilities for Meetings
Received by: Chris Masterson 0
Christine Fulton ~
Sue Rose 0
Date Received: /3- laD ~ D
Serial #: "dr=>'_
~pplication 100.00 ~fLI
'A Notified Recreation (date: I d.-J a D )
J.
Agreement for the Use of the Town Hall Facilities for Meetings
~~l~~-bLd1~CU\/4\~h~ &fMICA'(~M~~~i4t ~~
N!!le Org zation or Group r t\~ ~~- A"\;I~ I
~~ ~.b vtc.. :t'faJe.t+- ']
Name ofp son representing the Organization or Group
. ~~ ~ h ~'t-I -z.v( 0'J P~~k/Lu1'J'~ pi ':;L(pO 3-
Address
.~ 1ljJ-'..n It -6!;l 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
{YJ Large Meeting Room
( ) Other: Specify:
Time;
I.P - 0 p'
~ -=J-'; 00- D".Jo r"'" (.s-e:J-vtp "I. ~ ~ t)'Q i'VV1 )
The grouIJ ,is not expected to exceed 100
Date(s):.1h~ I ~~~~
.fvI~ AJ2-k...!.. f\.1 CN\ ,-::r- a.., 'S \
It should be wderstood that groups using the Buildings' Facilities for evening meetings must select dates when
Town Meetings are normally scheduled (ie., 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.
persons
You and your Organization hereby agree to adhere to the rules set forth on the attached page by signature of an
authorized member ofyoUT 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 furm is
submitted.
No application shall be considered approved until it has been submitted to the Town Clerk for review and
Clearance.
" .'
Dec.20. 2010- 1: 13PM~DC PLANNING DCWWA
No.2810 P. 3
i
2010.01.19 JCM
Terms of the agreement mu.st be strictly adhered to by the contracting group as any disregard or abuse of the roles
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 roles and regulations fOf the use of the Facilities in the Town of Wappinger Town
Hall, and will comply with these requirements.
Signed: ~ .Jj)r-
For: fJ)Grl- / ~ W'MJ~ -aA (C{L16) ~~~(J~
(Name of Group or Orgam:l:mon)
Date: 12110
Approved: ,. (,~
Town CIeri<:
Date:
Nov. 18. 2010 9:16AM
DC PLANNING DCWWA
No. 2505
P. 2
i
OP 10: LLEM
ACORD' CERTIFICATE OF LIABILITY INSURANCE I DA TEi (MMlllDIYYYYI
~ 11/12/10
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERllFICAtE ~OLDER. tHIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. lltlS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BElWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certifICate holder is an ADDITIOI\lAL INSURED. the policy(ies) must be endornd. If SUBROGATION IS WAIVED, subject to
the terms lInd conditions of the policy, certain policies may require an endorsement A statement on tills certificat~ does not confer rights to the
certificate holder In Ilou of such endorsoment(s).
PROOUCER 845-567-1000 ~~~CT
Marshall & Sterling, Inc. 845-567-1030 l:tlg~o!;nl; I r~ NOI:
103 Executive Drive, Suite 300 ~L
NewW;ndsor, NY 12653 REllS:
CUSTOMER lD': DUTCH-R
IHSUAEI\lSJ AFFORDING COVERAGE NAIC.
INSURED County of Dutchess INSURfR A :Argonaut Insurance Co.
Office of Risk Management INSURER B :
22 Market Street
poughkeepsie, NY 12601 INSURER C :
INSURER. D :
INSURER E :
INSURER F :
~
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER'
THIS IS TO CERTIFY THAT THE POLICIES of INSURANCE LISTED BELOW f1AVE BEEN ISSUED TO TI1I: INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO VvHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. TNI: 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 TYl'E OF INSURANCE ~:~I ~~~I UMITS
LTR ".",.. WVD POLICY NUMBER
GENERAL LIABIUTY EACH OCCURRENCE S 1,000,000
-
A .!- jMERCIAL GENERAL UABlUTY 4611679 10/01110 10/01/11 PREIAISES lOa occumonce' S '00,000
- CLAIMS-MADE 00 OCCUR MED EXP (Anyone oersonl S 0
- PERSONAL & ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
~~AGGREn ;'MI~ Af'r!~t: PER: PRODUCTS - COMPIOP AGG 5 2,000,000
POLICY ~CPT LOC s
AuTOMOBile llABlUTY COMBINED SINGLE LIMIT 1 ,OOO,OO~
- (Ee eccidenl) $
A ~ ANY AUTO 4611679 10101/10 10/01/11
BODilY INJURY (PC( p"'$on) $
- ALL OWNED AUTOS BODilY INJURY (Per ecdoenll $
r--- SCHEDULED AUTOS PROPERTY DAMAGE
L HIREO AurDS (Per sc6denQ $
~ NON<lWNED AUTOS $
i
UM8REL1.A UAe ~ OCCUR EACH OCCURRENCE $ 10,000.000
>--
EXcESS LIAS ClAIMS-MADE 4611579 AGGREGATE s 10,000,000
A 10/01/10 10101/11
- DEDUCTIBLE S
X RETENTION · S
WORKERS COMPENSATION 1.,.~.JTf:I#c, T PJ~-
AND EMPLOYEIUl' UABIUTY V/N
P-NY PROPRIETOR/PARTNER/EXeCUTIVe 0 N/A ~ E.L. EACH ACCIDENT S
OFFICER/M~eeR EXCLUDEO?
(""'n"lory In NIlI . .. EL DISEASE. EA EMPLOYEE S
If Yiia, OeaCllDe unO.r
DESCRIPTION OF OPERATIONS belOW E.L DISEASE _ POUCY UIAIT $
Dt:SCRIPTION Of OPERA~~NS / LOCATIONS I VEHICLES jAlUc~ ACORD 1 D1, A.llIIlon.1 R."....r~. SCIledule, If more spoce I. required)
For Dutchess Coun Department of Plarulln9 & Development'$ Transportation
Council's use offa"l ity.
WAPPI-3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELlVl:RED IN
Town of Wappinger ACCORDANCE WITH THE POLICY PROVISIONS.
20 Mlddlebush Rd
Wappingers Falls, NY 12590-4004 /lUTlfORIZEP IU:f'Rt:St:/IlT/lTlVE
-;L~ ~d2 dJ--
I
CERTIFICATE HOLDER
CANCELLATION
ACORD 25 (2009/09)
@ 1988.2009 ACORD CORPORATION. All rights I'9s9rved.
The ACORD name and logo are registered marks of ACORD
No v, 18, 201 0 9 : 1 6 AM
DC PLANNING DCWWA
No, 2505
p, 2
.
OP 10: LLEM
..---.,
ACORD' CERTIFICATE OF liABiliTY INSURANCE I DA T~ (MMJDIIIYYYYI
~ 11/12/10
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERltFICATE 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 BElWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOL.DER
IMPORTANT: If the certificate holder i$ an ADDITIONAl-INSURED, the policy(ie$) mu5t be endorsed, If SUBROGATION IS WAIVED, subject to
the terms and condition5 of the policy, certain policie$ may require an endorsement. A statement on this certificate does not confer rights to the
certificate holdsr In lieu of such endorssment(s).
PRODUCER 845-567 -1000 ~~~l~cT
Marshall & Sterling, Inc:. 845-567-1030 f~gN~" C",: I FAX
iAIC NOI:
103 Executive Drive, Suite 300 ~:tR'Fs5:
New Windsor, NY 12553 ClJSTouER III': DUTCH-R
INSUAER(S) AFFDRDING COVERAGE NAIC.
INSURED County of Dutchess INSURER A :Argonaut Insurance Co.
Office of Risk Managemont INSURER B :
22 Market Street
poughkeepsie, NY 12601 INSURER C :
INSURER D :
INSURER E :
INSURERF:
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE L1STE:D BELOW f1AVE BEEN ISSUED TO TI1E INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION O~ ANY CONTRACT OR OTHER DOCUMENT 'MTH RESPECT TO w-tICH 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 TYl'E OF INSURANCE I,;~"a- wvn J>OLICY NUMIlER ~~tlD~1 ~~~~~I LIMITS
LTR
GENERAL LIABILITY EACH OCCURRENCE S 1.000.000
-
A ~ ~~ERCIAL GENERAL LIA81UTY ~611579 10/01/10 10/01/11 PREMISES rEll OCCAlmln""\ S 100.000
- CLAIMS-MADE [I] OCCUR MEO EXP (Any ane oifSonl S C
. PERSONAL & ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2.000,OOc
~LAGGREnE ~MI~ AP~~t PER: PRODUCTS. COMPIOP AGG S 2,000,000
POLICYI~~T LOC S
AuTOMOelU! LIABlU'lY COMBINED SINGLE LIMIT S 1,000,00e
- (Ea eccid""l)
A ~ ANY AUTO 4611579 10/01/10 10/01/11
BODILY INJURY (P.rpor.on) S
""- ALL OWNED AUTOS BODILY INJURY (Per ecooenl) J
- SCHEDULED AUTOS PROPERlY DAMAGE
~ HIRED AUTOS (Per accidenQ S
~ NON-oWNED AUTOS J
S
UMlIREliA LIAB ~ OCCUR EACH OCCURRENCE S 10,000,000
-
EXcESS LIAB CLAIMS-MADE AGGREGATE S 10,000,000
A 4611579 10/01/10 10/01/11
- DEDUCTIBLE S
X RETENTION S S
WORKERS COMPENSATION I VIC Sl A TU- I jOJ~-
AND EMPLOYERS' LIABIUlY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE 0 N/A E.L. EACH Aeel DENT s
OFFICER/MEMBeR exCwosb1
tlol:ln..'ol}' In Nil} E.L DISEASE. EA EMPLOYEE S
II ~ea, CeaCl1tle uncar
DESCRIPTION OF OPERATIONS billow E.L DISEASE. POUCY UMIT S
DsScP,lrTION OF OPERAT~NS /l.OCAnONSI VEHICLES JAll:lcn ACORD 'D', Addltlan.lllcmarks Sclledule,lfmore $JIOce I. require.,
For Dutchess Coun Department of Planning & Development's Transportation
Council's use offael ity,
CERTIFICA TE HOLDER
CAN CELLA TlON
WAPPI-3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOnCE WILL BE DELIVERED IN
Town of Wappinger ACCORDANCE WITH THE POLICY PROVISIONS.
20 Mlddlebush Rd
Wappingers Falls, NY 125904004 AUTllORIZED II.EPRE5ENTA"TlVE
-;h~~d2 ~
I
ACORD 25 (2009/09)
~ 1988.2009 ACORD CORPORATION. All rights reservlld.
The ACORD name and logo are registered marks of ACORD