Koza, AnthonyFOR INTERNAL USE ONLY
Received by: Joseph P. P,aoloni f 1
Grace Robinson -j
Lori, McConologue
2021-05-13 .TPP
Town of Wappinger
Application for Hawkers
& Peddler's License
ec"e\
0 �-,
Date Received: o5 I
Serial #: Cw
The undersigned does hereby apply to the ToANf ` 6r Town Clerk for a
NEWX RENEWAL TEMPORARY
(1 weekend only)
License for Hawking and Peddling pursuant to Town of Wappinger Local Law No. 10 of 1
regulating Hawkers and Peddlers in the Town of Wappinger, and in con
application, does state the following:
1) Applicant:
NAME: Anthony Koza
AGE:
CURRENT ADDRESS:
7 W Cross St. Ste 7E Hawthorne
NY 10532
(St #) (Street) (City)
(State) (ZIP)
PHONE#
8474503082
PERMANENT ADDRESS (if different):
313 Washington st ingels Fox lake
IL 60041
(St #) (Street) (City)
(State) (ZIP)
If Applicant is an Agent or Employer:
Applicant's Employer APTIVE ENVIRONMENTAL LLC
Address of Employer 5122 N 200 WSte 150
Provo I JT 84
(St. #) (Street) (City) (State)
Proof of Employment (attach to application)
2) Nature of Business:
L Motor Vehicle (circle one): car truck van
I 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 Nurnber K200-0010-7178
1- Weights & Measures Certificate Certificate # N/A
I.- Dutchess County Health Dept Permit Pen -nit 9 NIA
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, Clarkstnwn
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: V V ... 2015 t �-
Wappingers Falls, N.Y.
Sworn to before me this
ay of 7t,-20
add W
N t ry Public
Lee A. Freno
Notary Public. State of New Yolk
No. 01 FR6327313
Qualified in Dutchess County
Cnmrnlssion Expires 7161 02
Signature of Applicant
'k 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 Dutcbess County Veterans Vendors License are -exempt from
the $200.00 fee, provided that a copy of saic.1��A,��^
Alexi GianflR0110
Limit- ApplY
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CERTIFICATE 4F LIABILITY INSURANCE
DATE (MMlDDlYYYY)
6/4/2025
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(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).
PRODUCER
Graham Company,
a Marsh &McLennan Agency, LLC company
30 S 15th Street, 20th Floor
CONTACT
NAME:
PHONEFAX
• 215-567-6300 (Ale,No :215.569-3025
A 013�ss; MMAEastGrahamHoldenUnit@marshmma..com
INSURERS AFFORDING COVERAGE NAIL#
Philadelphia PA 19102
INSURERA: Safety National Casualty Cor oration 15105
INSURED APTIENV-01
APTIVE ENVIRONMENTAL, LLC
5132 N 300 W. Ste 150
INSURERS : Evanston Insurance Company 35378
INsuRERc: Lexington Insurance Domparry 19437
INSURERD: Steadfast Insurance Company 26387
Provo, UT 84604
INSURER E:
INSURER F:
1'nVPRAr.l fLFRTIFICATF MIIhIllInR7A3RMW RFVISI(1N AIIIMRPR,
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 INSURANCEADDLSUBR
b
❑
POLICY NUMBER
POLICY EFF
Ml DJ YYYY
POLICY EXP
MMIDDIYYYY
LIMITS
C
X
COMMERCIAL GENERAL LIABILITY
Y
27734516
11/1/2024
1111/2025
EACH OCCURRENCE $1,000,000
CLAIMS -MADE FICCCUR
DAMAGE TO RENTED
PREMISES(Ea ocuu nce $300,000
MED EXP (Any one person) $
PERSONAL& ADV INJURY $ 1,000,000
GEN'L AGGREGATI; LIMIT APPLIES PER:
GENERAL AGGHEGATE $ 2,000,000
POLICY ❑PECTRO � LOC
J
PRODUCTS - COMP/OP AGG $ 2,000,000
$
OTHER:
A
AUTOMOBILE
LIABILITY
CA 8676643
1111/2024
1111/2025
Ea aacld � SINGLE LIMIT $ 3,000,000
BODILY INJURY (Per person) $
X
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accldent
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
D
UMBRELLA LAB
OCCUR
SXS 6439974-00
1111/2024
11/1/2025
EACH OCCURRENCE $ 2,000,000
AGGREGATE $
X
EXCESS LIAB
[I
CLAIMS -MADE
DED RETENTION $
$
A
A
WORKERSCOMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANYPROPRIETORlPARTNERIEXECUTIVE ❑
OFFICFHIMFMRERFXCLUl
NIA
LDS 4066513
PS 4068512
1111/2024
11!112024
11/1/2025X
11/1/2025
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE -EA EMPLOYEE $ 1,000,000
(Mandatary In NH)
It yes, desrribe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $ 1,000,000
s
C
Contractor's Pollution
Excess Liability
MKLV1 ENV104535
52114892
1111/2024
1111/2024
11/1/2025
11/5/2025
Fach PoWten
Gordlien UrnitlAgO: $5,000,000
Lmd: $3,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Sohedule, may he attached 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.
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.
>
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ACORD 25 (2015103) The ACORD name and Ingo are registered marks of ACORD