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Jakubowski-Lewis, DanielFOR INTERNAL USE ONLY Received by: Joseph P. Paoloni. D Grace Robinson Li Lori McConologue Date Received: Serial Toi� Apph The undersigned does hereby apply to the Town of Wappinger Town NEWX RENEWAL License for Hawking and Peddling pursuant to Town of Wappinger L regulating Hawkers and Peddlers in the Town of Wappinger, and in c application, does state the following: 1) Applicant: NAME: Daniel J aku bowski -Lewis AGE: CURRENT ADDRESS: 7 W Cross St, Ste 7E Hawthorne NY 10532 (St #) (Street) (City) (State) (ZIP) PHONE# 9084047645 PERMANENT ADDRESS (if different): 126 West 2nd Ave Roselle NJ 07203 (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 I JT 84604 (St. #) (Street) (City) (State) (ZIP) Proof of Employment (attach to application) (ZIP) R Nature of Business: Jill El: I iii!R*PEI 1141110-01,0110, F! Nj I M111 �•iN11 IM, WNW-M-ne ayff 4-m. Y -c. tx.10228, 115365 12036 W� Yom:, 4L., AMI., 0%.X,1015 0 WIA'na WWE 04,01' FOR "PtAl 0" pvlftr,osjrS L Motor Vehicle (circle one)- 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 Nw-fiber J02281536512036 L Weights & Measures Certificate Certificate # N/A Dutchess County Health Dept Permit Permit # N/A u• a.: 2021-05-13 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: jone, Wappingers Falls, N.Y. Sworn to before me this eAday of�, 20'9 o aty Public 202KJ bo�=� AA i Signature of Appl an Lee A. Freno Notary Public, State of New York No. 01 FR6327313 Qualified in Dutchess County Cornrnission Expires 7/J 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�� y] 7 0 ASR` CERTIFICATE OF LIABILITY INSURANCE ATE (MM1DDlYYYY) F 614,2025 -D 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 INSUREII AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) muss 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 Ileu of such endorsement(s), PRODUCER Graham Company, a Marsh & McLennan Agency, LLC company 30 S 15th Street, 20th Floor Philadelphia PA 19102 CONTACT NAME: PHONEFAX e Ext)- 215-567-6300arc No ; 215-569-3025 (AJC, No_ E-MAILSS: MMAEastGrahamHDldenUnit marshmma.com -ADDRESS: INSUREI AFFORDING COVERAGE NAIL# INSURER : Safety National Casualty Corporation 15105 11!112024 INSURED APTIENV-91 APTIVE ENVIRONMENTAL, LLC 5132 N 300 W. Ste 150 INSURERB: Evanston Insurance Company 35378 wsuRERc: Lexington insuranceCompany 19437 INSuRERD: Steadfast insurance Company 26387 Provo, UT 84604 INSURER E: DAMAGE TO RENTED 300,000 PREMISES Ea occurrence $ MED EXP (Any oneperson) S INSURER F : ('0VFRIlC;FS f'FRTIFIC:ATF NI lhhRFR•9nR7dRRflrlq RPVICIt'1N NIIIRARFR• 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. [NSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF UWDDfYYYY POLICY EXP MMIDDIYYYY LIMITS C X COMMERCIAL GENERAL LIABILITY Y 27734516 11!112024 11/1/2025 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR DAMAGE TO RENTED 300,000 PREMISES Ea occurrence $ MED EXP (Any oneperson) S PERSONAL &ADV INJURY $1,004,000 GEl AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PROJECT LOC PRODUCTS - COMPIOP AGG $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY CA 6676643 11!1!2024 1111/2025 00 RINEDISINGLE LIMIT , 3,000,000 BODILY INJURY (Pcr person) $ X ANY AUTO OWNED SCHEDULED AUTOS ON LY ALTOS BODILY INJURY (Peraocident) $ HAH❑ NON -OWNED AUTOS ONLY AUTOS ONLY r PROPERTY DAMAGE $ Per accident $ I D UMBRELLALIAB X OCCUR 3XS6439974-00 1111/2024 1111/2025 EACH OCCURRENCE $2,000,000 X EXCESS LIAB CLAIMS -MADE AGGREGATE $ PHD F RETENTION $ $ A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1 N ANYPROPRIETORIPARTNEFVEXECUTIVE OFFICER+MEMBEREXCLUDED? NIR 14068513 PS 4068512 11/1!2024 1111/2024 1111/2025 11!112025 X PER PRH 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 C Contraclofe Pollution Excess Uahility MKLVIENV104535 52114892 11/1/2024 11/1/2024 1111/2025 11!1!2025 Each Pollution Condition UnilllAgg: $5,000,000 Limit: $3,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS) VEHICLES (ACORD 1.01, Additional Remarks Schedule, may he attached If more space is required) The Excess Liability policy referenced above with Steadfast Insurance Company provides limits in excess ofthe 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. [li.lflliiL-7-111Ai0L*JM■J-1a Town of Wappinger, NY 20 Middlebush Road Wappingers Falls NY 12590 ACORD 25 (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. - u `- ©1988-2015 A The ACORD name and logo are registered marks of ACORD CORPORATION. All riahts rase