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Block, CasperFOR INTERNAL USE ONLY Received by: Joseph P_ Paoloni Grace Robinson I: Lori McConologue 1!-1 Date Received: Serial #: 2021-05-1 3 ) JPP Town of Wappinger Application for Hawkers & Peddler's License 101,11 C\e The undersigned does hereby apply to the Towof W" inger Town Clerk for a NEWX RENEWAL TEMPORARY (I weekend only) 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: 1) Applicant: NAME- Casper Block AGE: CURRENT ADDRESS: 7 W Cross St. Ste 7E Hawthorne NY 10532 (St #) (Street) (city) (State) (ZIP) PHONE# 2087310944 PERMANENT ADDRESS (if different): 2976 E State Street Ste. Twin falls ID 83616 (St 4) (Street) (City) (State) (ZIP) If Applicant is an Agent or Employer: Applicant's Employer APTIVE ENVIRONMENTAL L,LC Address of Employer 5132 N 300 W Ste 150 Provo UT 84604 (St. #) (Street) (city) (State) (ZIP) Proof of Employment -(attach to application) 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 El Motor Vehicle (circle one): car truck van E On Foot &/or with vehicle drawn by hand or animal Vehicle Info: Vehicle Make 06(x Vehicle Model n er- LicensePlate# j3&,T[7o-G- State of Registration 1_0 Operator's License Number HC223376F :: 'Weights & Measures Certificate Certificate # I Dutchess County Health Dept Permit Permit 2021-05-13JPP 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 rules, regulations and Laws governing ones activities in the Town of Wappinger as a Peddler or Hawker. Dated: _OU f CID , 20 Wappingers Fails, N.Y. Sworn to before me this 7� ay of 20 Nota Public Francis J. Gius€o Notary Public, Mate of New York Reg. No. 01616387461 Qualified in Dutchess County 6ornmission Expires FeibruaTy 11, 2027 �J Sign tore of .Applicant 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. �e CERTIFICATE OF LIABILITY INSURANCE DATE(MI1fIDo7YYYY, 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. It 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). PRODUCER Graham Company, a Marsh &McLennan Agency, LLC company One Penn Square West CONTACT NAME. PHONE FAX o • 215-567-6300 Arc Nal: 215-569-3025 ADDRESS: holden unit rahameo.com ARE INSURER S. AFFORDING COVERAGE NAIC# Philadelphia PA 19102 INSURER A: Safety National Casualty Corporation 15105 MKLM6MMP1000778 INSURED AFITIENV-01 Aptive Environmental, LLC 251 W River Park Drive, Floors 1-3 INSURER IB: Markel American Insurance Company 28932 INSURER C. Navigators insurance Company 42307 INSURER D _ Evanston Insurance CompaDy 35378 Provo, LIT 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 BEEN REDUCED BY PAID CLAIMS. INSR LTR L7 TYPE OF INSURANCE ADSL SUER POLICY NUMBER POLICY M1DDfYYYY MMIDDIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY MKLM6MMP1000778 '(11112023 111112024 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR TED PREMISES %a occurrence PREMIS TORE carr $1,000,000 MFD EXP (Any one parson $10,000 PERSONAL A ADV INJURY 51,000,000 GEN'L AGGREGATE LIMIT APPLIES PER7 I GENERAL AGGREGATE $ 2,000,000 POLICY L-1 ECT LCC PW7DUCTS-COMPIOPRGG $2,000,000 $ OTHER; A AUTOMOBILE LIABILITY CA 6676643 1111/2023 11/1/2024 CDMI3I 1IQLE LI VIT Ea accident $ 3,000,000 BODILY INJURY (Per psreon) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY {Per accident} $ HIRED NON -OWNED AUTOS ONLY _ AUTOS ONLY PROPER' Per accident $ 5 C UMBRELLA LIAB X OCCUR GA23EXCZ0FD491G 111112023 11/1/2024 EACH OCCURRENCE $ 2,000,000 AGGREGATE�� $ — X EXCESS L1A6 CLAIMS -MADE DED RETENTIONS $ A * WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN LDS 4068$13 PS 4068512 11/1/2023 111112023 111112024 11/1/2024 X I PER ETH- STATUTE ER L. EACH ACCIDENT $ 1,000,000 ANYPROPRIETORIPARTNERIExECUTivE OFFICER1MElIBEREXCLUDED? NIA EE. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NH) Jt yyes, describe under DESCRIPTIONOFOPERATIONS below E.L. DISEASE -POLICY LIWT $1,000,000 D Contractor's Pollution MKLV7ENV105074 11/1/2023 1111/2024 Each Pollution F Excess Liability 52114852 111112023 111112024 Condition UrnitlAgg: Limit: $9,000,000 $3,000,000 DESCRIPTION OF OPERATIONS] LOCATIONS I VEHICLES (ACORD 161, Addltionaf Remarks Schedule, may be attached if 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. SHOULD ANY OF THE ABOVE DESCRIBER 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 AUT ORIZED PRESENTATIVE Wappingers Falls NY 12590 (D1888-2015 ACORD CORPORATION. All rights reserved.