Hammond, JacksonFOR INTERNAL USE ONLY
Received by: Joseph P, Paoloni E
Grace Robinson 71
Lori McConoloL-ue
2021-05-1 3 ) ,IPP
Town of Wappinger
Application for Hawkers
& Peddler's License
License for Hawking and Peddling pursuant to Town of Wappinger Local Law No. 10 of 1992,
regulating Hawkers and Peddlers in the Town of Wappinger, and in c(
application, does state the following: "A
1) Applicant:
NAME-. Jackson Hammond AGE:
CURRENT ADDRESS:
7 W Cross St. Ste 7E Hawthorne NY 10532
(St #) (Street) (City) (State) (ZIP)
PI -IONS 4 8014935525
PERMANENT ADDRESS (if different):
2403 East 6660 South Cottonwood Hei, UT 84121
(St #) (Street) (city) (State) (ZIP)
If Applicant is an Agent or Employer,- Tape a 2"X 2"
Applicant's Employer APTIVE ENVIRONMENTAL LLC — color photo (less
Address of Employer 5132 N 300 W Ste 150 Provo UT 84604 than 60 days Old)
(St. 4) (Street) (City) (State) (ZIP)
Proof of Employment (attach to application)
2) Nature of Business:
Door to door solicitation of Aptive's pest control services through residential
areas of Wappinger, on foot
U Motor Vehicle (circle one): car truck van
0 On Foot &/or with vehicle drawn by hand or animal
Vehicle Info: Vehicle Make To LA 0 Lc,\ Vehicle Model L4
License Plate # —ST
tate of Registration Q
Operator's License Number 231617499
1:1 Weights & Measures Certificate Certificate
0 Dutchess County Health Dept Permit Permit #
2021-05-13 JPP
3) Veteran Statics
❑ Veteran Applicant - Exempt from license fee (attach certificate from Dutchess County)
Names of all other municipalities in which the applicant has been a vendor in the preceding G
months:
4) Compliance
That the applicant, if the License requested hereby is granted, consents and agrees to conduct the
aforesaid business or activity pursuant to all of the terms and regulations of the Local Law above
specified, and all other rules, regulations and Laws governing ones activities in the Town of,
Wappinger as a Peddler or Hawker. ,,,�
Dated. 61-20-02*20
Wappingers Falls, N.Y.
Sworn to before me this
�b d 20
Notary kublic
Francis J. Giusto
Notary Public, State of New York
Reg. No. 01 G 16387461
Qualified in Dutchess County
mraimian Exp4as Febioary 11,. 2027
Of
Application must be accompanied by a fee of Two Hundred Dollars ($200.00) plus $50 for
each addition to the original license per year, payable to the Town of Wappinger. This is a
non-refundable fee.
Applicants possessing a valid Dutchess County Veterans Vendors License are exempt from
the $200.00 fee, provided that a copy of said license is attached to the application.
Ab JVjb'P CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIODNYYY)
6/14/2024
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed,
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 endorsements).
PRODUCER
Graham Company,
a Marsh & McLennan Agency, LLC company
One Penn Square West
CONTACT
PHONE PAx
o o • 215-567-6300 Arc No: 215-569-3025
ASS: holden unit rehamco-com
DDRE
INSURERN AFFORDING COVERAGE NAIC.#
Philadelphia PA 19142
INSURER A: Safety Natianal Casualkt Corporation 15105
MKLM6MMiP1000778
INSURED APTIENV-01
INSURER B: Markel American Insurance Company 28932
Aptive Environmental, LLC
251 W River Park Drive, Floors 1-3
INSURER c. Navigators Insurance Company 42307
INSURER D. Evanston Insurance Company 35378
Provo, UT 84604
INSURER E: Lexington insurance Company 19437
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1821872424 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 13Y 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
LTR
TYPE OF INSURANCE
ADDL
5UBR
POLICY NUMBER
POLICYEFF
POLICY EXP
Y
LIMITS
B
X COMMERCIALGENERALLIABILITY
MKLM6MMiP1000778
111112023
11/1/2024
EACH OCCURRENCE $1,000,000
CLAIMS -MADE � OCCUR
DAMAGETORENTED
PREMISES Eaeccurenee $1,000,000
MFD FXP(Ony oneperson) $10,000
PERSONAL &ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE $ 2,000,000
POLICY❑ JECT PRO � LOC
PRODUCTS-COMPfOPAGG 52,000,000
$
OTHER:
A
AUTOMOBILE LIABILITY
CA 667$643
111112023
111112024
COMBINED SIN7111 LIMIT $ 3,000,000
.Ea accident
BODILY INJURY (Per person) $
X ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accident)_
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
C
UMBRELLA LIAB
X
OCCUR
GA23EXCZCFD491C
1111/2023
1111/2024
EACH OCCURRENCE $ 2,000,000 _
X
AGGREGATE $
EXCESS LIAB
CLAIMS -MADE
DED RETENTION $
A
A
.ANYPROPRIETORlPARTNER/i7AEGUTfVE
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y l N
LDS 4058513
P$ 40$$512
11111,2023
111112023
11/1/2024
1111/2024
PER OTH-
X I STATUTE ER
E.L. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory in NH)
NIA
F1_.DISEASE -FA EMPLOYEE $1,000,000
If yes, dascifbe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY OMIT $1,000,000
D
Ccntractur's Pollution
MKLV7ENV105074
1111/2023
1111/2024
Each Pollution
E
Excess Liability
52414892
11/112023
11(112024
ConditionLimidAgg: $5,(100,000
LimIt $3,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required)
The Excess Liability policy referenced above with Navigators Specialty Insurance Company provides limits in excess of the Auto Liability only.
The Excess Liability coverage referenced above with Lexington insurance Company provides limits in excess of the primary General Liability and Excess Auto
Liability policies.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION .DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Wappinger, NY
20 Middlebush Road A T ORIZED PRESENTATIVE
Wappingers Falls NY 12590 dAl
®1988-2015 ACORD CORPORATION. All rights reserved.