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Town of Wappinger EmployeesFOR INTERNAL USE ONLY Received by: Christine Fulton Jessica Fulton ^ Date Received: 3 / ~ /at~.~'~ Serial #: 't,W ~ Application C $1 Cert. of LI Notified Recrea ion (date:~~1~1 2010-O1-19 JCM Town of Wappinger Agreement fo ~he Use of the Town Hall Facilitie fo>~~~~~~ MAR 0 5 ~~i2 N OF WAppINGER ~~~ ~, -TOWN CLERK Agreement for the Use of the Town Hall Facilities for Meetings _~ ',~ Name of O~aani tion or Gr u ., ~ /l n Name of person represent~fig th rgan' dtfon or Group a~ _ ~%S~D 2~ 7 _ a 7 Y~ Address Phone No. This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as noted below: ()~ (()~ The group is t expected to exceed / ~- persons Date(s): ¢.~~ `~ yp ~ Time: 'S!~ ~f -~ ~ ~~ k~~ 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. Senior Citizens Room Large Meeting Room Other: Specify: 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. 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. Sign For: Date: ~~~ ~ v~- Approved: Town Cler Date: ~ ~j J ~~ ACORDT,A CERTIFICATE OF LIABILITY INSURANCE w-TE tYYI o7rosnoll THIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER. THIS CERTIFlCATE DOES NOT AFFlRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFlCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED REPRESENTATIVE OR PRODUCE AND THE CERTIFlGATE HOLDER IMPORTANT: ff the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorser!. ff SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain poGcaas may require an endorserrlerrt. A statement on this certificate does not confer rigtrts to the certificate holder in lieu of such s . PRODUCER ACT NAME: MASS MefCh t~rldefwr)tl K$JC Insurance Group, Inc. • U--c, No. ExO: 888-580-8041 AX: (A/C, No): 26059-5995 1712 Magnavox Way ADDRESS: KK MassMerchandisin ndkinsurance_com Fort Wayne 1N 46804 cusTOMER ro IFLSURED tN8U AFWRWNG COVERAGE NAiC 0 LINDA THOMAS A: Nationwide Mutual Insurance Com n 3787 DBA: LINDA THOMAS- Licensed Zumba Instructor B: PO Box 623 uRER c: Fishkill, NY 12524 A Member of the Sports, Leisure & Entertainment RPG COVERAGES CERTIFlCATE NUMBER: W00099174 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE L)STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVIRTHSTANDING 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ~ ~p POLICY NUMBER POLY EfF POLICY EXP LIIYRTS LTR If A GENERAL uaelLnY 6BRPG0000004951i600 07/1611011 07/16/2013 EACH OCCURRENCE $1,000, X COMMERCUIL GENERAL LIABILITY 12;01 AM ED 12:01 AM DAMAGE TO RENTED $300, PREMISES Ea oaurren~ CLAIMS-MADE XaOCCUR MED EXP (Arty one person) ~ 000 PERSONAL & ADV INJURY $1,000, GENERAL AGGREGATE ~ rea $3,000, GEN'L AGGREGATE LIMB APPLIES PER: PROIXH;TS-COMPI~ AGG per yea $1 000 POLICYPROJECT ~LOC PROFESSIONAL LIABILITY $1,000, LEGAL LIAB TO PARTIGPANTS $1,000, AUTOMOBILE LJABILnY COMBINED SINGLE LIMB Ea Aaident ANY AUTO BODILY INJURY (Per person) ALL OWNED AUTOS BODILY INJURY (Per aoddent) SCHEDULED AUTOS PROPERTY DAMAGE Per accident HIRED AUTOS NON-0WNED AUTOS Not provided wtrle in Hawaii UIY®RELLAWIB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DEDIx;TIBLE RETENTION WORI(ERS COMPENSATbN N / A WC STATU- OTHER AND EMPLOYERS' LIA8LITY Y / N TORY LIMITS ANY PROPRIETORSHIP/PARTNER/ ECUTIVE OFFICER/MEMBER E E.L EACH ACCIDENT X EXG_UDED? E.l DI~ASE - EA EMPLOYEE (Mandatory in NN) V Yom. describe uWer E.L DISEASE -POLICY LIMB oESCIaPTION of oPERAnoNS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL IXCESS MEDICAL 1 more >it»u ) Certified Instructor of. ZUMBA (R) a.uc t trwr~ t c nv~vcrc a.nna.~• • -- r rvn Evidence of Coverage ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN CCORDANCE YYfTH THE PRICY PROVISIONS. UTHORD~D REPRESENTATIVE ~-rT' ~=-.~.~ Coverage is only extended to U.S. events and activities. " NOTICE TO TEXAS INSUREDS: The )usurer for the purchasing group may not be subject to alt the insurance laws and regulations of the State of Texas ACORD 25 (2009/08) The ACORD name and logo are registered marks of ACORD ©1888-2009 ACORO CORPORATION. All rights reserved.