Broxton, JustinFOR INTERNAL USE ONLY
Received by: Joseph P. Paoloni.
Grace Robinson.
Lori McConologue
Date Received:
Serial:
9,1' ', ,
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The undersigned does hereby apply to the Town of Wappingn Clerk JUST04
NEWX RENEWAL TEV iil1KP0lry4AY
-5
(k w.:",1 WQT'E
License for Hawking and Peddling pairsuant to Town of Wappinger Local LaA
regulating Hawkers and Peddlers in the Town of Wappinger, and in connects
application, does state the following:
1) Applicant:
NAME: Justin Broxton AGE:
CURRENT ADDRESS:
7 W Cross St. Ste 7E Hawthorne NY 10532
(St #) (Street) (city) (state) (ZIP)
PHGNE 3607471261
PERMANENT ADDRESS (if different):
17208 SE Fisher Drive wa Vancouver WA 08683
(St ) (Street) (city) (State) (ZIP)
If Applicant is an Agent or Employer:
Applicant's Employer APTIVE ENVIRONMENTAL LLC
Address of Employer 5137 N 300 W Ste 1 0 proyn UT 8460
(St. #) (Street) (City) (State) (ZIP
Proof of Employment (attach to application)
2) Nature ,tioK�
of Business:
Door door solicitatonof AoDiest control -n - ® s r.1 resideratinI
r60ra- •II Mr
L Motor Vehicle (circle ane): car truck van
L On Foot &/or with vehicle drawn by hand or animal
Vehicle Info: Vehicle Make Vehicle Model
License Plate # State of Registration
Operator's License Number wd141p28g53b
L Weights & Measures Certificate Certificate # N/A
L Dutchess County Health Dept Permit Permit 9 N/A
NUMN
ICFN$r,
FEDERAL, t.1WT
APPLY
4a r"
O ca.As
a Doe 04/10120
00 SSS 0510,,
4b EXP 04;
etio
�I
3) Veteran Status
L 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 6
months: White Plains, Maunt Pleasant, Clarkstown
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: ) Z' , 20
Wappingers Falls, N.Y.
Sworn to before me this
171,'d o ff, 20
ta
Nory Public
Lve A. Frano
Notary Public, Stam of Nein Yolk
No. 01 FR6327313
Qualified in Outchm County,
Commission Expires xpires 7161 '10 Z�7
Sign ure 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 $200.00 fee, provided that a copy of said license is attached to the application.
AC[aM®DATE
CERTIFICATE OF LABILITY INSURANCE
(MMIDDIYVYY)
5/4/2025
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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).
PRODUCER
Graham Company,
a Marsh & McLennan Agency, LLC company
30 S 15th Street, 20th Floor
CONTACT
NAME:
PHONEFAX
o Extl: 215-567-6300 Aro No): 215-569-3025
(AJC,No.
ADDRESS: MMAEastGrahamHolden Unit marshmme.Bum
Philadelphia PA 19102
INSURERS AFFORDING COVERAGE
NAIL#
INsuRERA: Safety National Casualty Corporation
15105
11!112024
INSURED ARTIENV-01
APTIVE ENVIRONMENTAL, LLC
5132 N 300 W. Ste 150
INSURER 8: Evanston Insurance Company
35378
INSURER 0: Lexington insurance Company
15437
INSURER D: Steadfast Insurance Company
26387
Provo, UT 84604
INSURER E
TO RENTED 300,000
PREMISES (Ea occurrence)
INSURER F
COVFRAGFS CFRTIPIr ATR NII IHIII 1f1A7AgAMo RFVIgIf1AI IMI IIIAPRR•
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.
ILTR
TY PE OF INSURANCE
JNSD
S VOR
POLICYNUMBER
MMI�IDIYYYY
MMI�DIYYYY
LIMITS
C
X
COMMERCIAL GENERAL LIABILITY
Y
27734516
11!112024
1111/2025
EACH OCCURRENCE $1,000,000
CLAIMS -MADE � OCCUR
-
TO RENTED 300,000
PREMISES (Ea occurrence)
MED EXP (Any oneperson) $
PERSONAL& ARV INJURY $ 1,000,000
AGGREGATE LIM17 APPLIES PFR:
GENERAL AGGREGATE $2,000,000
GEN'L
POLICY F71 JECT PRO' Fx] LOC
PRODUCTS - COMCOMP/017AGO $ 2,000,000
$
OTHER:
A
AUTOMOBILE
LIABILITY
CA 6976643
11/1/2024
11/112025
COMBINED SINGLE LIMIT $ 3 000,000
Ea accident
BODILY INJURY (Per person) $
X
ANY AUTO
OWNED 5CHEDULFD
AUTOS ONLY AUTOS
BODILY INJURY (Per accident) $
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE $
Per accldeni
D
UMBRELLA LIAB
IX OCCUR
SXS 6439974-00
11/112024
11/1/2025
EACH OCCURRENCE $ 2,004,000
X
EXCESS LEAS
GLAIMS-MADE
AGGREGATE $
DED RETENTION $
$
A
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANYPROPRIETOP/PARTNFP/EXECIJTIVE
OFFICE RIMEMBEREXCLUDED?
NfA
LDS 4068513
PS 4068512
11/112024
11/112024
11/1/2025
11/1/2025
X STATUTE OTT
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
(Mandatary In NH)
Ii yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 1,000,000
6
C
coniracIVSPollution
Excess Liability
MKI-VlENVID4535
52114892
11/1/2024
11/1/2024
11/1/2025
11/1/2025
EachPolluticn
CondI ion Limit/Apg: $5,000,000
Limit: $3,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101, Additional Remarks Schedule, may 6e attached It more apace is required}
The Excess Liability policy referenced above with Steadfast Insurance Company provides 1111 n 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.
The Town of Wappinger, NY is an additional insured on the above General Liability policy if required by written contract.
CERTIFICATE HOLDER CANCELLATION
Town of Wappinger, NY
20 Middlebush Road
Wappingers Falls NY 12590
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTIORITEb PRESENTATIVE
01988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD