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Chandler, SamReceived by: Joseph P. Paoloni Grace Robinson Lori McConologue lice 2021 -OS -1 3 ,TPP" 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 application, does state the following-, 1) Applicant-, NAME: Sam Chandler CURRENT ADDRESS: 7 W Cross St. Ste 7E Hawthorne (St 9) (Street) (City) PHONE # 9188109002 PERMANENT ADDRESS (if different): 9013 N 156TH EAST PL OWASSO AGE: NY 10532 (State) (ZIP) OK 74055 (St #) (Street): (City) (State) If Applicant is an Agent or Employer-, Applicant's Employer APTIVE ENVIRONMENTAL LLC Address of Employer 5132 N 300 W Ste 150 Provo UT 84604 (St. 4) (Street) (City) (State) (ZIP) Proof of Employment (attach to application) (ZIP) Tape a 2"X 2" color photo (less than 60 days Old) 2) Nature of Business: Door to door solicitation of Aptive's pest control services, through residential areas of Wappinger, on foot F1 Motor Vehicle (circle one): car truck van [I On Foot &/or with vehicle, drawn by hand or animal Vehicle Info: Vehicle Make 1-ot-40, Vehicle Model cIr License Plate 4 State of Registration Operator's License Number D083504856 :1 'Weights & Measures Certificate Certificate 4 El Dutchess County Health Dept Permit Permit # 2021-05-13 JPP 3) Veteran Status ❑ 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 roles, regulations and Laws governing ones activities in the Town of Wappinger as a Peddler or Hawker. Dated: jeO z ZQ z 20-zy Wappingers Falls, N.Y. Sworn to before me this Zo ay of 20 _4 Nota Publi Francis J. Giusto Notary Public, &tate of New fork Reg. No, 01616387461 Qualified in Dutchess County Commission Expires February 11, 2027 Application roust 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. IeO A� Rl' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 611412024 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 endorsement(s). PRODUGER Graham Company, a Marsh & McLennan Agency, LLC company One Penn Square West CONTACT 1IAME: PRONE215 567-6300 FAX Nc :215-569-3025 E-MAIL ADDRESS: holden unit rahamcC.com INSURER(S)AFFORDING COVERAGE NAIC## Philadelphia PA 19102 INSURER A: Safety National Casualty Corporation 15105 MKLM6MMP1000778 INSURED APTtENV-01 Aptive Environmental, LLC 251 W River Park Drive, Floors 1-3 INSURER B: Markel American Insurance Company 28932 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 BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.. LIMITS SHOWN MAY HAVE 13EEN REDUCED BY PAID CLAIMS. fNSR LTR TYPE DDLSUBR POLICYNUMBER POLICYEFF _ MMIDDIYYYY POLICY EXP MWI)DIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY MKLM6MMP1000778 11/112023 111112024 EACH OCCURRENCE $1,000,000 CLAWS -MADE ®OCCUR DAMAGETO RENTED PR£Mf5E5 Ea occurrence $ 1,400,000 EXP (Anyone person $ 10,000 -MED PERSONAL& ADV INJURY $ 1,000,000 GEN'L AeGREGATE LIMIT APPLIES PER" GENERALAGGREGAT£ $ 2,000,000 POLICY ECT LOC PRODUCTS -COMPIOPAGG $2,000,000 $ OTHER: A AUTOM08ILE LIABILITY CA 6676543 111112023 31/112024 COMBINED sl GLE LIMIT $ 3,000,000 f=a accident R3D1Y INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS 20DILYINJURY (Peraccident) $ PROPERTY DAMAGE $ Pe accident HIREDNtlN-OUVlIED AUTOS ONLY AUTOS ONLY C UMBRELLA LIABX OCCUR GA23EXCZ0FD49IG 111112023 111112024 EACH OCCURRENCE $ 2,00D,000 AGGREGATE i X EXCESSLfAS CLAIMS -MADE DED RETENTION$ i A A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN LDS 4068513 PS 4068512 111112023 11/112023 11/1/2024 11/112024 X I PER OTH- STATUTE ER ANYFROPRIETORIPARTNERIEXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? NIA EL. EACHACCIDENT $1,000,000 '— E.L. DISEASE- EA EMPLOYEE $ 1,000,000 (Mandatory in NH) Jf yss, r€sscride under DESCRIPTIONOFOPERATIONS below EL. DISEASE -POLICY LIMIT 17000,000 D Cuniractur's Pollution MKLV7ENV105074 1111/2023 1111!2024 Each Pollution E Excess LiabilityH: 52114892 11!112023 11I1f2024 Condition LimiVAgg: $5,000,000 Limit $3,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, may be attached ifmore 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 I m 0 1988-2015 ACORD CORPORATION. All rights reserved.