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4.1 RACES&WALKS\Cerebral Palsy 5K—Glens Falls Elks—8-6-18 RESOLUTION AUTHORIZING GLENS FALLS ELKS LODGE #81 TO CONDUCT RACE FOR CEREBRAL PALSY 5K RESOLUTION NO.: ,2018 INTRODUCED BY: WHO MOVED ITS ADOPTION SECONDED BY: WHEREAS, the Glens Falls Elks Lodge 481 has requested permission to conduct its Race for Cerebral Palsy 5k within the Town of Queensbury as follows: SPONSOR: Glens Falls Elks Lodge 481 EVENT: Cerebral Palsy 5k Race (Information describing the event presented at this meeting) DATE/TIME: Saturday, October 20ffi, 2018 -Approximately 9:00 a.m. PLACE: Glens Falls Elks Lodge, 32 Cronin Road, Queensbury and WHEREAS, the applicant shall be responsible to obtain any other municipal agency's approval(s) as may be necessary for their event, NOW, THEREFORE, BE IT RESOLVED, that the Queensbury Town Board hereby acknowledges receipt of proof of insurance from the Glens Falls Elks Lodge 481 to conduct its Race for Cerebral Palsy 5k to be held on Saturday, October 20�1, 2018 within the Town of Queensbury, and BE IT FURTHER, RESOLVED, that the Town Board approves this event subject to approval by the Town Highway Superintendent which approval may be revoked due to concern for road conditions at any time up to the date and time of the event as well as other municipal agency's approval(s) as may be required. Duly adopted this 6ffi day of August, 2018,by the following vote: AYES NOES ABSENT: Town o,f Queensbiny David Duel] Highway Highway Superintendent Department 742 Bay Road—Queensbury,NY 12804 Mark Benware Phone: (518)761-8211 Deputy Highway Superintendent Fax: (518)745-4466 s TO: QUEENSBURY TOWN BOARD FROM: David Duell DATE: July 25, 2018 RE: October 2, 2018"Race for Cerebral Palsy" 5K I have reviewed the request of The Race for cerebral Palsy 5K being held by Glens Falls Elks Lodge #81 on Saturday October 20, 2018 at 9am. I hereby grant my approval for the race to be held on the following roadway that is under my jurisdiction: Cronin Road, Meadowbrook Road and Everts Ave.. All other roads that are not under my jurisdiction my need further approval from the County. Sincerely, David Duell Highway Superintendent ;j - =lexmis,Yeb y, WillMap & Direction xv Ma, N` GE7 D1R8CTIONS L Fy _ d �J l J l;oii?5 iriCrr?i15 - c Ccbblesrcre Cr r;.. s .,^cr gercp Csrlcsur� _ .rart4soY FI-t?D,rd° Iicssicanzial:ales C. d° Show all x ® a. 1 a "Race for Cerebral Palsy" 5K October20,2018 5K 9:00 AM 'itsIa Glens Falls Lodge#f81 Benevolent and Protective Order ojElks 32 Cronin Road, Queensbury,NY 12804 518-792-3434 First Name Last Name M/F Address City State Zip Phone ( ) Email Birthdate / / Age on Race Day Emergency Contact Phone Entry Fee —Pre-Registration$25.00 Must Register by October 19,2018 at 6:00 pm _Race Day Registration (until 8:30) $30.00 Shirts to the first 50 participants registered Adult S M L XL Release and Waiver(Please read and sign) In consideration of accepting this entry for myself or for the person that 1 am registering,1,the undersigned,intending to be legally bound hereby,for myself,my heirs,executors and administrators,waive and release any and all rights and claims for damages I may have against this event,the Glens Falls B.P.O.E.81 Elks Lodge,the event staging facilities,any sponsors,as well as any person involved with this event.I fully understand that 1,or the person 1 am responsible for,will be subject to roads and trails that may have uneven terrain,rocks,roots,and other obstacles,but that I am physically fit and have sufficiently prepared for this race.My physical condition has been verified by a licensed medical doctor.I hereby grant full permission for the event to use any photos,videos,or any other record of this event for any purpose whatsoever.I agree to the above waiver and attest that I am either the participant or the parent/legal guardian of the participant. Initial to agree to the waiver Signature of participant Date Signature of Parent/Guardian Date Mail Registration to: Lodge#81 BPOE 32 Cronin Rd.Queensbury,NY 12804 Drop off at Glens Falls Lodge#81 32 Cronin Rd.Queensbury,NY 12804 Register online at active.com Questions: email tinademarshl@yahoo.com BPOE816-01 KBOLLER ACORO' DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/16/2018 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()es)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). ME PRODUCER NONTACT Loomis&LaPann,Inc. PHONE FAX 228 Glen Street,PO Box 2158 (AIC,No,Ext:(800)666-6479 A/c,No:(518)792-3426 Glens Falls,NY 12801 AUNAESS- INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:U S Specialty Insurance Co INSURED INSURER 8: BPOE#81 5K Run INSURER C: 32 Cronin Rd INSURERD: Queensbury,NY 12804 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS L INSD D MM A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE [X OCCUR 333129727 06/29/2018 10/22/2018 DAMAGE TO IE RENTED re $ 300,000 MED EXP(Any oneperson) S PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JPEROT- LOC PRODUCTS-COMPIOP AGG $ 1,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT gde.,I S ANY AUTO BODILY INJURY Perperson) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident S AUTOS ONLY AUTOS ONLYY PPe�PER 'dentDAMAGE $ 3 UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE [--] E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? N!A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) BPOE#81 5K run,1 012 0-2 112 0 1 8 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Queensbury Highway Dept. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN rY 5 Y p ACCORDANCE WITH THE POLICY PROVISIONS. 842 Bay Rd. Queensbury,NY 12804 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Form 990 Return of Organization Exempt From Income:Tax OMB No.1545-0047 Under section 501(c),527,or 4947(a)(1)of the Internal Revenue Code(except privati:foundations) RO 17 Dep to-Do not enter social security numbers on this form as it may be made public. • • - • • artment of the Treasury Internal Revenue service ►Go to wwwJrs gov1Form990 for instructions and the.latest information. •' • A For the 2017 calendar year,or tax year beginning Apr 1 ,2017,and ending Mar 31 - ,2018 B Check if applicable: C Name of organization GLENS FALLS LODGE NO.81 BPOE D Employer identification number ❑ Address change Doing business as 14—0 6 9 612 3 ❑ Name change Number and street(or P.O.box if mail is not delivered to street address) Room/suite E Telephone number ❑ Initial return 32 CRONIN ROAD 1 (518)792-3434 ❑ Final return/terminated City or town,state or province,country,and ZIP or foreign postal code ❑ Amended return QUEENSBURY, NY 12804 G Gross receipts S ❑ Application pending F Name"and address of principal officer. Hie)Is this a group relum forsuborcrinates?❑Yes N No MICHAEL DUBRAY 32 CRONIN ROAD QUEENSBURY NY 12804 H(b)Are all subordinates included?❑Yes El No I Tax-exempt status: ❑501 c 3 0 501 c 8 insert no.) ❑4947 a 1 or ❑527 If"No,"attach a list.(see instructions) J Website: ► N/A H(c)Group exemption number► 115 6 K Form of organization:X❑Corporation[]Trust ❑Association❑Other► L Year of formation: 19 3 91 M State of legal domicile:NY Summary 1 Briefly describe the organization's mission or most significant activities: A_FRATERNAL_ORGANIZATION_ __________ DEDICATED TO THE CHARITABLE PRINCIPLE OF THE-BENEVOLENT & PROTECTIVE --------------------------------------------------------------------------------------------------------------------------------------------------------------- c ORDER OF ELKS,____AS-SUCHt -LOCAL_COMMUNITY-ENRICHMENT-IS FOSTERED. POLICY NUMBER: 333129727 SE DS 01 02 10 SPECIAL EVENT LIABILITY DECLARATIONS U.S. Specialty Insurance Company HCC Specialty Underwriters, Inc. 13403 Northwest Freeway 401 Edgewater Place, Suite 400 Houston, TX 77040 Wakefield, MA 01880 ph. (713) 462-1000 ph. (781) 994-6000 NAMED INSURED: BPOE#81 5K Run MAILING ADDRESS: 32 Cronin Rd.,Queensbury, NY 12804 POLICY PERIOD: FROM Jun 29,2018 TO Oct 22, 2018 AT 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. LIMITS OF INSURANCE EACH OCCURRENCE LIMIT $ $1,000,000.00 DAMAGE TO PREMISES RENTED TO YOU LIMIT $ $300,000.00 Any one premises MEDICAL EXPENSE LIMIT $ $0.00 Any one person PERSONAL&ADVERTISING INJURY LIMIT $ $1,000,000.00 Any one person or organization GENERAL AGGREGATE LIMIT $ $2,000,000.00 PRODUCTS/COMPLETED OPERATIONS AGGREGATE LIMIT $ $1,000,000.00 DESCRIPTION OF BUSINESS FORM OF BUSINESS: ❑ INDIVIDUAL ❑ PARTNERSHIP ❑JOINT VENTURE ❑TRUST ❑ LIMITED LIABILITY COMPANY ❑ ORGANIZATION, INCLUDING A CORPORATION (BUT NOT INCLUDING A PARTNERSHIP, JOINT VENTURE OR LIMITED LIABILITY COMPANY) BUSINESS DESCRIPTION: BPOE#81 5K Run to be held 10/20/2018- 10/21/2018 at Elks Club, Queensbury, NY 12804 SE DS 01 02 10 Page 1 of 2 2-14141 ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective 12:01 a.m. Jun 29,2018 forms a part of Policy No. 333129727 Issued to BPOE#81 5K Run By U.S. Specialty Insurance Company ATTENDANCE LIMITATION EXCLUSION ENDORSEMENT This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Number of Admissions 100.00 The following exclusion is added to both Paragraph 2. Exclusions of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I — COVERAGES) and Paragraph 2. Exclusions of COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY (SECTION I— COVERAGES): This insurance does not apply to"bodily injury","property damage", or"personal and advertising injury"arising out of any event in which the attendance or capacity ofthe designated venue for such event exceeds the Number of Admissions shown in the Schedule to this Attendance Limitation Exclusion Endorsement. However,this exclusion does not apply if the attendance or capacity of the designated venue for such event is otherwise approved by us in writing. All other terms,conditions and exclusions of the policy remain unchanged. Authorized Representative SE 1010 02 10 Page 1of 1 2-14141 POLICY NUMBER: 333129727 SE DS 05 0210 COMMON POLICY DECLARATIONS U.S. Specialty Insurance Company HCC Specialty Underwriters, Inc. 13403 Northwest Freeway 401 Edgewater Place, Suite-400. Houston, TX 77040 Wakefield, MA 01880 ph. (713) 462-1000 ph. (781) 994-6000 NAMED INSURED: BPOE#81 5K Run MAILING ADDRESS: 32 Cronin Rd., Queensbury, NY 12804 POLICY PERIOD: FROM Jun 29,2018 TO Oct 22, 2018 AT 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE BUSINESS DESCRIPTION BPOE#81 5K Run to be held 10/20/2018- 10/21/2018 at Elks Club, Queensbury, NY 12804 IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM COMMERCIAL AUTOMOBILE COVERAGE PART $ $0.00 COMMERCIAL GENERAL LIABILITY COVERAGE PART $ $200.00 COMMERCIAL INLAND MARINE COVERAGE PART $ $0.00 COMMERCIAL LIABILITY UMBRELLA $ COMMERCIAL PROPERTY COVERAGE PART $ N/A CRIME AND FIDELITY COVERAGE PART $ EMPLOYMENT-RELATED PRACTICES LIABILITY COVERAGE PART $ EQUIPMENT BREAKDOWN COVERAGE PART $ FARM COVERAGE PART $ LIQUOR LIABILITY COVERAGE PART $ .$0.00 MEDICAL PROFESSIONAL LIABILITY COVERAGE PART $ POLLUTION LIABILITY COVERAGE PART $ TRIA $ $2.00 TOTAL: $ $202.00 Premium shown is payable: $ $202.00 at inception. $ SE DS 05 02 10 2-14141 ALL PREMISES YOU OWN, RENT OR OCCUPY LOCATION NUMBER ADDRESS OF ALL PREMISES YOU OWN, RENT OR OCCUPY Elks Club/ 32 Cronin Rd Queensbury, NY 12804 CLASSIFICATION AND PREMIUM LOCATION CLASSIFICATION CODE PREMIUM RATE ADVANCE PREMIUM NUMBER NO. BASE Prem/ Prod/Comp Prem/ Prod/Comp O s O s O s O s Marathon 100.00 N/A $100.00 STATE TAX OR OTHER(if applicable) $ TOTAL PREMIUM(SUBJECT TO AUDIT) $ $202.00 PREMIUM SHOWN IS PAYABLE: AT INCEPTION $ $202.00 AT EACH ANNIVERSARY $ (IF POLICY PERIOD IS MORE THAN ONE YEAR AND PREMIUM IS PAID IN ANNUAL INSTALLMENTS) AUDIT PERIOD(IF APPLICABLE) ❑ANNUALLY 0 SEMI-ANNUALLY 0 QUARTERLY 0 MONTHLY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY: THESE DECLARATIONS, TOGETHER WITH THE COVERAGE FORM(S) AND ANY ENDORSEMENT(S) SHOWN ABOVE,COMPLETE THE ABOVE NUMBERED POLICY. Page 2 of 2 SE DS 01 02 10 2-14141