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2021-05-13 JPP
Town of Wappinger
Application for Hawkers
0-
.....,,Veddler's License
4d., . y
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Serial #: l I ay
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ONN 0 C\e
The undersigned does hereby apply to the Town ofCVappiW*wn Clerk for a
NEWX RENEWAL TEMPORARY
(1 weekend onlay)
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 conn
application, does state the following:
1) Applicant:
NAME: Andres Magana AGE:
CURRENT ADDRESS:
7 W Cross St. Ste 7E Hawthorne NY 10532
(St #) (Street) (City) (State) (ZIP)
PHONE#
3608383126
PERMANENT ADDRESS (if different):
1413 N 22nd Street Washougal WA 98671
(St #) (Street) (city) (State) (ZIP)
If Applicant is an Agent or Employer:
Applicant's Employer APTIVE ENVIRONMENTAL LLC
Address of Employer 51'32 N 300 W Ste 150 Provo i ji-----a4604-,
(St. #) (Street) (City) (State) (ZIP')
Proof of Employment
(attach to application)
2) Nature of Business:
Door to door solicitation of Aptiye's pest contro � services through residential
2naas of Wapp'nqpr. nn foot . . . .. ......
I Motor Vehicle (circle one): car truck van
L On Foot &/or with vehicle drawn by hand or animal
Vehicle Info: Vehicle Make -M-da3 Vehicle Model
License Plate # CMB1821 State of Registration wA
Operator's License Number WDL3N785843B
L Weights & Measures Certificate Certificate 9 N/A
� Dutchess County Health Dept Permit Permit # N/A
202-05-1.3 JPP
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, Mount 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. &-/-I 20,
Wappingers Falls, N.Y.
Sworn to before me this
d y of V) 1', 20L4
No6y Public
Signature of Applicant
. Lee A. Freno
No" Public, State of NewYo6c
No. DIFR6327313
Qualified in Dutc aria County
Commission Ares ilei
* 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.
A�Q p 7 a
CERTIFICATE OF LIABILITY INSURANCE
DATE {MMIDDIYYYY}
6/412025
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(les) 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 endorsemenl(s).
PRODUCER
Graham Company,
a Marsh & McLennan Agency, LLC company
30 S 15th Street, 20th Floor
CONTACT
NAME:
PHONEFAX
c Ext): 215-567.6300 Nn ; 215-569.3025
Ar No,
ADoaess: MMAEastGrahamHolden Unit marsh mma.com
Philadelphia PA 19102
INSURERS AFFORDING COVERAGE NAIC#
INSURERA: Safety National Casualty Corporation 15105
INSURED APTIENV-01
APTIVE ENVIRONMENTAL, LLC
5132 N 300 W. Ste 150
INSURERS : !Evanston Insurance Company 35378
INSURERC: Lexington Insurance Company 19437
INSURER D: Steadfast Insurance Company 26387
Provo, UT 84604
INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER,10874380D9 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
TYPE OF INSURANCE
ADDL
I D
SUBR
WVD
POLICY NUMBER
POLICY EFF
MWDDlYYYY
POLICY EXP
MWDDIYYYY
LIMITS
C
X
COMMERCIAL GENERAL LIABILITY
Y
27734516
11/112024
11/1/2025
EACH OCCURRENCE $ 1,000,000
CLAIMS -MADE I OCCUR
PREA SET ERENT
occErrD nce $ 300,000
MED EXP (Any one person) $
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GFNEHALAGGREGATE $ 2,000,000
POLICY 0 PRO JFGT I LOC
PRODUCTS - COMPIOP AGG $ 2,000,000
$
OTHER:
A
AUTOMOBILE
LIABILITY
CA 6676643
11/112024
11/1/2025
COMBINED SINGLE LIMIT $ 3,000,000
Ea accident
BODILY INJURY (Per person) $
X
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Pernaoident) $
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE $
Per aceidanl
$
D
UMBRELLALIAB
X
OCCUR
SXS8430074-00
11/1/2024
11/1/2025
EACH OCCURRENCE $2,000,000
AGGREGATE $
X
EXCESS LIAS
CLAIMS -MADE
DED HFTFNTION
$
A
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y 1 N
ANYPROPRIEfOR(PARTNERIEXECUTIVE ❑
OFFICE RIMEMBEREXCLUDED?
NIA
LDS 4088513
P5 4068512
11/1/2024
11/1/2024
11/1/2025
11/1/2025
X STATUTE EEAH
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E -L. DISEASE -POLICY LIMIT $ 1,000,000
B
ConlracloYsPollution
MKLV1ENVi04535
11/1/2024
11/1/2025
FachPollution
C
Excess LIabIhY
52114892
11/1/2024
11/1/2025
Candllion Urnit/Agg: $5,000,000
Limit: $3,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 101, Additional Remarks Schedule, may be attdched if more space is required)
The Excess Liability policy referenced above with Steadfast 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.
The Town of Wappinger, NY is an additional insured on the above General Liability policy if required by written contract.
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
Wappingers Falls NY 92590
A1ORIZED PRESENTATIVE
01988-2015 ACORD CORPORATION, All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD