Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2019
Resolution 2019-782 Board Meeting of September 10, 2019 ^o`05UFF0(.°O RESOLUTION 2019-782 ADOPTED DOC ID: 15547 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2019-782 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON SEPTEMBER 10,2019: RESOLVED that the Town Board of the Town of Southold hereby ratifies and approves the issuance of a fireworks permit by the Town Clerk to Peconic Landing at Southold, Inc. for a_fireworks display on September 1,2019 at 7:15PM (Rain Date: September 2, 2019 at 7:15 PM), on the Peconic Land'ing's property,at 1500 Brecknock Road, Greenport, New York,upon the payment of a single fee of$100 and subject to the applicant's compliance with the requirements of the Town's policy regarding the issuance of fireworks permits. • 9 Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: William P. Ruland, Councilman SECONDER:Louisa P. Evans, Justice AYES: Dinizio Jr, Ruland, Doherty, Ghosio, Evans, Russell Updated: 9/5/2019 9:23 AM by Elizabeth A. Neville Page 2 Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday, August 28, 2019 3:30 PM To: 'Jo-Anne Triolo'; 'Diane Radigan' Subject: Emailing: Fireworks Permit Peconic_20190828150815 Attachments: Fireworks Permit Peconic_20190828150815.pdf Attached, please find fireworks permit for Peconic Landing at Southold, Inc. event on September 1, 2019. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 Your message is ready to be sent with the following file or link attachments: Fireworks Permit Peconic 20190828150815 1 Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday, August 28, 2019 3.02 PM To: Duffy, Bill Subject: Emailing: Fireworks PeconicLanding_20190828150042 Attachments: Fireworks PeconicLanding_20190828150042.pdf Bill, This should have gone on yesterday's agenda for approval. I had been waiting from 8/2 until 8/23 to receive the approval of the Fire Marshall. I should have put it on yesterday's agenda, but it did not get on. I now have all of the approvals on the revision (attached). Is it OK for me to issue the permit to them today and put it on the next Town Board meeting? Your message is ready to be sent with the following file or link attachments: Fireworks PeconicLanding_20190828150042 Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 ELIZABETH A.NEVILLE,MMC Town Hall,53095 Main Road P.O.Box 1179 TOWN CLERK ,, �;, y Southold,New York 11971 CD REGISTRAR OF VITAL STATISTICS � Fax 631 765-6145 ''" Y ( ) MARRIAGE OFFICER "« "' Telephone(631)765=1800 ' � ` RECORDS MANAGEMENT OFFICER e Aw www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PERMIT for PUBLIC DISPLAY OF FIREWORKS I, ELIZABETH A. NEVILLE, Town Clerk of the Town of Southold, Suffolk County, New York, being an officer duly designated by the Town Board of the Town of Southold for this purpose, do hereby GRANT TO: PECONIC LANDING AT SOUTHOLD,INC. A PERMIT FOR THE PUBLIC DISPLAY OF FIREWORKS by said organization in accordance with the provisions of Section 405.00 of the Penal Law of the State of New York, on the time and place set forth in the application therefore, as follows: September 1, 2019 at 7:15 PM,(Rain Date: September 2,2019 at 7:15PNI) on Peeonic Landing's property located-at 1500 Brecknock load, Greenport,NY 11944 ON CONDITION THAT the bond (indemnity insurance) required shall continue in full force and effect in favor of the Town of Southold, and PROVIDED that the actual point at which the fireworks are to be fired shall be at least two hundred feet from the nearest building, public highway or railroad, or other means of travel, and at least fifty feet from the nearest above ground telephone or telegraph line, trees or other overhead obstruction; that the audience at such a display shall be restrained behind lines at least one hundred and fifty feet from the point at which the fireworks are discharged and only persons in active charge of the display shall be allowed inside these lines; that all fireworks that fire a projectile shall be so set up that the projectile will go into the air as nearby as possible in a vertical direction, unless such fireworks are to be fired from the shore or a lake or other large body of water, then they may be directed in such a manner that the falling residue from the deflagration will fall into such lake, or body of water; that any fireworks that remain unfired after the display is concluded shall be immediately disposed of in a way safe for the particular type of fireworks remaining; that no fireworks display shall be held during any wind storm in which the wind reaches a velocity of more than thirty miles per hour; that all persons in actual charge of firing the fireworks shall be over the age of eighteen years, competent and physically fit for the task, that there shall be at least two such operators constantly on duty during the discharge and that at least two soda-acid or other approved type fire extinguishers of at least two and one-half gallons capacity each shall be kept at such widely separated points as possible within the actual area of the display. s a Elizeth A. Neville, Town Clerk I Town of Southold Suffolk County,New York (TOWN SEAL) Date: August 2S,2019 THIS PERMIT IS NOT TRANSFERABLE Neville, Elizabeth From: Neville, Elizabeth Sent: Friday,August 23, 2019 9:44 AM To: Fisher, Robert; Neville, Elizabeth Subject: Re: Peconic Landing at Southold firework application for permit 9/1/19 Thank you Bob! Sent from my Verizon,Samsung Galaxy smartphone -------- Original message -------- From: "Fisher,Robert" <Robert Fisher(@tgW-.i.southcild.ny:us> Date: 8/23/ AM C{MT OS$ To: "Neville, Elizabeth" {E.Neville(irltown:sautholI v.us> Subject: RE: Peconic Landing at Southold firework application for permit 9/1/19 Betty have noroblem=Wit tbi� v A-as aR d.-DE* Bob har Fire JJkarshal, Town of Southold robert.fisher town.southold.ny.us (W) 631-765-1802 - (C)631-786.9180 P MIE6€D RIND C0NPXDfWTIA4 Z"CTr4fM N .MATRW C0DEMrrALrrY AVrr4F 7,is las #r onit msi!trrzrwvissim is intmded only far the am of the nidividua!or en0y to which it iv addressed and may contain confidentAQi informattm beioa-.gitzg to the Ba oder which&protected byprAIAVe.If yLv am wt the intended necipW,you am hereby aaatified Mat amay dis-cfosaare,-capyitV distrrbutiat+,or the taking of cny action in r rr�e/M ace os the cmtwts of M&information issh*tiy,arohfbited If you have mccfved Mis tmasmi,Wm in error, pkAm Rrooy the sandgr tmmr dratejybve-mail and dekta the original From: Neville, Elizabeth Sent:Thursday, August 08, 2019 1:29 PM To: Fisher, Robert<ftobert.Fisher town.southold.n .us> Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 1 Hi Bob, To date, I have not received your comments/approval on the revised fireworks permit application for Peconic Landing. Please advise. thank you. Betty Neville From: Neville, Elizabeth Sent: Friday, August 02, 2019 3:45 PM To: Burke, John; Duffy, Bill; Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun, Stacey; Spiro, Melissa; Dinizio, James; Doherty, Jill; Evans, Louisa; Ghosio, Bob; Ruland, William; Russell, Scott Cc: 'Jo-Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Please take into consideration the revision to this Fireworks Application. Elizabeth A. Neville, MMC Southold Town Clerk,Registrar of Vital Statistics Records Management Officer;FOIL Officer Marriage Officer PO Box 1179 Southold,NY 11971 Tel.631 765-1800,Ext.228 Fax 631 765-6145 Cell 631466-6064 From: Jo-Anne Triolo [maiito:joanne tWfireworks.com] Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc. dba Volt Live 999 South Oyster Bay Road, Suite 111, Bethpage,NY 11714 P: 516-597-5500 x14 F: 516-597-5507 ATTENTION: This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 2 Neville, Elizabeth From: Neville, Elizabeth Sent: Thursday, August 08, 2019 1:29 PM. To: Fisher, Robert Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Attachments: Peconic Landing (product revision) 9-1-19.pdf Hi Bob, To date, I,have not received your comments approval onmthe revised fireworks permit application for Peconic Landing. Please advise. thank you. Betty Neville From: Neville, Elizabeth Sent: Friday, August 02, 2019 3:45 PM To: Burke,John; Duffy, Bill; Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun, Stacey; Spiro, Melissa; Dinizio, James; Doherty, Jill; Evans, Louisa; Ghosio, Bob; Ruland, William; Russell, Scott Cc: 'Jo-Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Please take into consideration the revision to this Fireworks Application. Elizabeth A.Neville, MMC Southold Town Clerk,Registrar of Vital Statistics Records Management Officer;FOIL Officer Marriage Officer PO Box 1179 Southold,NY 11971 Tel.631 765-1800,Ext.228 Fax 631765-6145 Cell 631 466-6064 From: Jo-Anne Triolofmailto•loanne(abayfireworks.com] Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc:'l)iane'Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne Neville, Elizabeth From•. Pati@� Unrtin Sent: --- --St days,_Augpst-04r2019_7:a6:_P..M' To: Neville, Elizabeth Subject: �RE: Peconic Landing at Southold firework applicat�an.fpC;peCmit:9/1/,19 I have no objections to the permit to be issued Sent from Chief M. Flatley Mail for Windows 10 From: Neville, Elizabeth Sent: Friday,August 2,2019 3:44 PM To: Burke,John; Duffy, Bill; Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun,Stacey; Spiro, Melissa; Dinizio, James; Doherty,Jill; Evans, Louisa; Ghosio, B.ob; Ruland,William; Russell,Scott Cc: 'Jo-Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Please take into consideration the revision to this Fireworks Application. Elizabeth A. Neville, MMC Southold Town Clerk,Registrar of Vital Statistics Records Management Officer;FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel.631765-1800, Ext.228 Fax 631765-6145 Cell 631466-6064 From: Jo-Anne Triolo rmailto:ioanne@)bayfirewoi-ks.com Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. , Please confirm receipt.....thank you. Sincerely, Jo-Anne 1 Neville," Elizabeth From: n� � E3ill Sent: _KQnday wQ.41W 95,?019 8:42 AMS To: Neville, Elizabeth Subject: RE: Peconic Landing at Southold firework application for permit 9/1/19 7 nice action From: Neville,,Elizabeth Sent: Friday,August 02, 2019 3:44 PM To: Burke,John; Duffy, Bill; Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun, Stacey; Spiro, Melissa; Dinizio, James; Doherty,Jill; Evans, Louisa; Ghosio, Bob; Ruland, William; Russell,Scott Cc: 'Jo=Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Please take into consideration the revision to this Fireworks Application. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext.228 Fax 631765-6145 Cell 631466-6064 From:Jo-Anne Triolo Imailto:ioanrie bayfireworks.com Sent: Friday,August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc.display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc.dba Volt Live 999 South Oyster Bay Road,Suite 111, Bethpage, NY 11714 P: 516-597-5500 x14 F: 516-597-5507 ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 1 Neville, Elizabeth From: Diane Radigan <dradigan@peconiclanding.org> Sent: Thursday,August 22, 2019 1:31 PM To: Neville, Elizabeth;Jo-Anne Triolo Subject: RE: Peconic Landing at Southold fireworks 9/1/19 Thank you ladies, Weare down to the wire! Diane Radigan Director of Member Services Peconic Landing Tel:(631) 477-3800 x373 I Fax: (631)477-3900 dradigan@Oeconiclandin .ork www.peconielanding:org This message is confidential and the property of Peconic Landing. It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know by reply and then delete it from your system.You should not copy the message or disclose its contents to anyone.-----Original Message----- From: Neville, Elizabeth [mailto E Nei+ilietown.sduthoid.nyms] Sent:Thursday,August 22, 2019 1:20 PM To:Jo-Anne Triolo; Neville, Elizabeth Cc: Diane Radigan Subject: Re: Peconic Landing at Southold fireworks 9/1/19 [Outside Email] Jo-Ann, I am going to put a resolution on 8/27 TB meeting subject to approval of all involved departments, I am awaiting the approval of 1 department, I don't think there is a problem, but just an oversight of responding. Sent from my Verizon, Samsung Galaxy smartphone --------Original message-------- From:Jo-Anne Triolo > Date: 8/22/19 11:15 AM (GMT-05:00) To: "Neville, Elizabeth" <E`Neville townsodtliold.ny.ds> Cc: Diane Radigan > Subject: Peconic Landing at Southold fireworks 9/1/19 Good morning, Just a follow up on the approval for the Peconic Landing at Southold firework display scheduled for 9/1/19. Please let me know if the Board has approved the application. Thank you very much. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc.dba Volt Live 999 South Oyster Bay Road,Suite 111, Bethpage, NY 11714 P: 516-597-5500 x1,4 F: 516-597-5507 [http://www.voltlive.com/s/emaii.png] ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 7 Neville, Elizabeth From: Diane Radigan <dradigan@peconiclanding.org> Sent: Monday, August 05, 2019 8:39 AM To: Jo-Anne Triolo; Neville, Elizabeth Subject: RE: Peconic Landing at Southold firework application for permit 9/1/19 Hi Jo-Anne. I see you have already forwarded to Ms. Neville from Southold Town—thanks. Ms. Neville, is there anything more that you need from Peconic Landing? Diane Radigan Director of Member Services Tel-(631)-477=3800'x373.1 Fax: (631)477-3900 dradigan.Cfteconiclanding.org I www oeconiclanding.orct #WeArePL N N[9 This message is confidential and the property of Peconic Landing It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know by reply and then delete it from your system, You should not copy the message or disclose its contents to anyone, From: Jo-Anne Triolo [mailto_joanne a bayPireworks.corn] Sent: Friday, August 02, 2019 3:33 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 [Outside Email] Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc. dba Volt Live 999-South Oyster Bay Road, Suite 111, Bethpage,NY 11714 P: 516-597-5500 x14 F: 516-597-5507 m i Neville, Elizabeth From: Neville, Elizabeth Sent: Friday, August 23, 2019 9:44 AM To: Fisher, Robert; Neville, Elizabeth Subject: Re: Peconic Landing at Southold firework application for permit 9/1/19 Thank you Bob! Sent from my Verizon,Samsung Galaxy smartphone -------- Original message -------- From: "Fisher, Robert" <Robert.Fisher town.southold.n .us> Date: 8/23/19 9:40 AM (GMT-05:001 To: "Neville, Elizabeth" <E.Nevillegtown.southold.ny.us> Subject: RE: Peconic Landing at Southold firework application for permit 9/1/19 Betty / I have no problem with this event as nnnl* for_ / Bob 4 ry 5G Fire Marshal, Town of Southold N 1 robert,fisher town.sotuthold.ny.us (W) 631-765-1802 - (G) 631-786-9180 f'RMIE6ED AND CONFID&VTIAG G®rt9'MUIVECATr V COW70E IALr YNOrra 'his electronic mail trw=ission is intended only for the use of the m6viA&orentity to WbICh corrfr'dential tnformaMon belmVing to the sender which is protected by privilege.If you are not the intended rccfpfent.you are hereby notified that any discfosure copying distribution,or the taking of any actkn in reliance on the contents of the information is strictly pr ohibited..f f you have remived this transmission in error, please notify the sender imwe& tell by a-mail and delete the orig/nal message. From: Neville, Elizabeth Sent:Thursday, August 08, 2019 1:29 PM To: Fisher, Robert<Robert.Fisher@town.southold.nv.us> Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Hi Bob, To date, I have not received your comments/approval on the revised fireworks permit application for Peconic Landing. Please advise. thank you. Betty Neville From: Neville, Elizabeth Sent: Friday, August 02, 2019 3:45 PM To: Burke, John; Duffy, Bill; Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun, Stacey; Spiro, Melissa; Dinizio, James; Doherty, Jill; Evans, Louisa; Ghosio, Bob; Ruland, William; Russell, Scott Cc: 'Jo-Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Please take into consideration the revision to this Fireworks Application. Elizabeth A. Neville, MMC Southold Town Clerk,Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold,NY 11971 Tel.631765-1800,Ext.228 Fax 631765-6145 Cell 631466-6064 From: Jo-Anne Triolo [mailto:joanne(c)bayfireworks.com] Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc. dba Volt Live 999 South Oyster Bay Road, Suite 111, Bethpage,NY 11714 P: 516-597-5500 x14 F: 516-597-5507 ATTENTION: This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 2 Neville, Elizabeth From: Neville, Elizabeth Sent: Thursday, August 08, 2019 1:29 PM To: Fisher, Robert Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Attachments: Peconic Landing (product revision) 9-1-19.pdf Hi Bob, _To date, I have not received your comments/approval on the revised fireworks permit application for Peconic Landing. Please advise. thank you. Betty Neville From: Neville, Elizabeth Sent: Friday, August 02, 2019 3:45 PM To: Burke, John; Duffy, Bill; Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun, Stacey; Spiro, Melissa; Dinizio, James; Doherty, Jill; Evans, Louisa; Ghosio, Bob; Ruland, William; Russell, Scott Cc: 'Jo-Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Please take into consideration the revision to this Fireworks Application. Elizabeth A. Neville, MMC Southold Town Clerk,Registrar of Vital Statistics Records Management Officer;FOIL Officer Marriage Officer PO Box 1179 Southold,NY 11971 Tel.631765-1800,Ext.228 Fax 631 765-6145 Cell.631466-6064 From: Jo-Anne Triolo [mailto:joanne@bayfireworks.com] Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne i Neville, Elizabeth From: -F-} le�in , Sent: , To: Neville, Elizabeth Subject: RE: Peconic Landing at Southold firework application for p rmi�__ rg!i/1A I have no objections to the permit to be issued Sent from Chief M. Flatley Mail for Windows 10 From: Neville, Elizabeth Sent: Friday, August 2, 2019 3:44 PM To: Burke,John; Duffy, Bill; Fisher, Robert; Flatlet', Martin; Hagan, Damon; Norklun,Stacey,Spiro, Melissa; Dinizio, James; Doherty,Jill; Evans, Louisa; Ghosio, Bob; Ruland, William; Russell, Scott Cc: 'Jo-Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Please take into consideration the revision to this Fireworks Application. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel.631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 From: Jo-Anne Triolo [mailto:joanne(&bayfireworks.com] Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne i Neville, Elizabeth From: nf jl Sent: M_adgy. Auqust 05, 2019 8:42 AM To: Neville, Elizabeth Subject: RE: Peconic Landing at Southold firework application for permit 9/1/19 No Objection From: Neville, Elizabeth Sent: Friday, August 02, 2019 3:44 PM To: Burke,John; Duffy, Bill; Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun, Stacey; Spiro, Melissa; Dinizio, James; Doherty,Jill; Evans, Louisa; Ghosio, Bob; Ruland, William; Russell, Scott Cc: 'Jo-Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Please take into consideration the revision to this Fireworks Application. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 From:Jo-Anne Triolo [mailto:ioanne@bayfireworks.com] Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc. dba Volt Live 999 South Oyster Bay Road, Suite 111, Bethpage, NY 11714 P: 516-597-5500 x14 F: 516-597-5507 ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. Neville, Elizabeth From: Diane Radigan <dradigan@peconiclanding.org> Sent: Thursday,August 22, 2019 1:31 PM To: Neville, Elizabeth;Jo-Anne Triolo Subject: RE: Peconic Landing at Southold fireworks 9/1/19 Thank you ladies. We are down to the wirel Diane Radigan Director of Member Services Peconic Landing ' Tel: (631) 477-3800 x373 I Fax: (631)477-3900 dradigan@peconiclanding.org www.peconiclanding.org This message is confidential and the property of Peconic Landing. It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know by reply and then delete it from your system.You should not copy the message or disclose its contents to anyone.-----Original Message----- From: Neville, Elizabeth [mailto:E.Neville@town.southold.nv.us] Sent:Thursday, August 22, 2019 1:20 PM To:Jo-Anne Triolo; Neville, Elizabeth Cc: Diane Radigan Subject: Re: Peconic Landing at Southold fireworks 9/1/19 [Outside Email] Jo-Ann, I am going to put a resolution on 8/27 TB meeting subject to approval of all involved departments. I am awaiting the approval of 1 department. I don't think there is a problem, but just an oversight of responding. Sent from my Verizon, Samsung Galaxy smartphone --------Original message-------- From:_Jo-Anne Triolo<loanne@bayfireworks.com> Date: 8/22/19 11:15 AM (GMT-05:00) To: "Neville, Elizabeth" <E.Neville town.southold.ny.us> Cc: Diane Radigan <dradigan@peconicianding.org> Subject: Peconic Landing at Southold fireworks 9/1/19 Good morning, Just a follow up on the approval for the Peconic Landing at Southold firework display scheduled for 9/1/19. Please let me know if the Board has approved the application. , Thank you very much. 1 Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc. dba Volt Live 999 South Oyster Bay Road, Suite 111, Bethpage, NY 11714 P: 516-597-5500 x14 F: 516-597-5507 [http://www.voltlive.com/s/email.png] ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. z Neville, Elizabeth From: Diane Radigan <dradigan@peconiclanding.org> Sent: Monday, August 05, 2019 8:39 AM To: Jo-Anne Triolo; Neville, Elizabeth Subject: RE: Peconic Landing at Southold firework application for permit 9/1/19 Hi Jo-Anne. I see you have already forwarded to Ms. Neville from Southold Town—thanks. Ms. Neville, is there anything more that you need from Peconic Landing? Diane Radigan Director of member Services Tel. (631)477-3800 x373 I Fax- (631) 477-3900 0 w dradigan _peconlclanding org i www.peconiclanding.org #WeArePL This message is confidential and the property of Peconic Landing It may also be privileged and otherwise protected by woik product immunity or other legal rules If you have received it by mistake please let us know by reply and then delete it from your system You should not ropy the message or disclose its contents to anyone From: Jo-Anne Triolo [mailto:joanne@bayfireworks.com] Sent: Friday, August 02, 2019 3:33 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 [Outside Email] Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc. dba Volt Live 999 South Oyster Bay Road, Suite 111, Bethpage,NY 11714 P: 516-597-5500 x14 F: 516-597-5507 i Neville, Elizabeth From: Neville, Elizabeth Sent: Friday, August 02, 2019 3:45 PM To: Burke,John; DL\&!1il1; Fisher, Robert; Fla , Martin; Hagan, Damon; Norklun, Stacey; Spiro, Melissa; Dinizio, James; Doherty,Jill; Evans, Louisa; Ghosio, Bob; Ruland,William; Russell, Scott Cc: 'Jo-Anne Triolo' Subject: FW: Peconic Landing at Southold firework application for permit 9/1/19 Attachments: Peconic Landing (product revision) 9-1-19.pdf Please take into consideration the revision to this Fireworks Application. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer;FOIL Officer Marriage Officer PO Box 1179 Southold,NY 11971 Tel.631765-1800,Ext.228 Fax 631 765-6145 Cell 631466-6064 From: 3o-Anne Triolo [mailto:joanne('Obayfireworks.com] Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon, Attached is a revision to the number of fireworks on the Peconic Landing At Southold Inc. display scheduled for September 1st. Please confirm receipt.....thank you. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc. dba Volt Live 999 South Oyster Bay Road, Suite 111, Bethpage,NY 11714 P: 516-597-5500 x14 F: 516-597-5507 i f Neville, Elizabeth From: Neville, Elizabeth Sent: Friday, August 02 2019 3 45 PM To: Burke, John; Duffy, Bill, Fisher, Robert; Flatley, Martin, Hagan, Damon, Norklun, Stacey; Spiro, Melissa, Dinizio, James; Doherty, Jill; Evans, Louisa; Ghosio, Bob; Ruland,William; Russell, Scott Cc: 'Jo-Anne Triolo' Subject: FW Peconic Landing at Southold firework application for permit 9/1/19 Attachments: Peconic Landing (product revision) 9-1-19.pdf Please take into consideration the revision to this Fireworks Application. Elizabeth A. Ncvi!le. fVEIVIC Southold Town Clcrl;. of Viiai Staltriws Records Managenient Offccr• FOIL Officer Marriage Officei PO Box 1 179 Southold, NY 119-1 Tel, 631 765-18001, Elt, 228 Fax 631 765-614- Cell 631 466-6061 From: Jo-Anne Triolo [Ma Htojoannebay_fireworks.com] Sent: Friday, August 02, 2019 3:34 PM To: Neville, Elizabeth Cc: Diane Radigan Subject: Peconic Landing at Southold firework application for permit 9/1/19 Good afternoon. Attached is a revision to (lie number ol'fiireworks on the Peconic Landing At Southold Inc. display scheduled for September Please confirm receipt ....thank you. Sincerely, Jo-Anne Jo-Anne Triolo Pyro Engineering Inc. dba Volt Live ,999 South Oyster Bay Road, Suite 11 1, Bethpage, NY 11714 P: 516-597-5500 x 14 F: 516-597-5507 t c ' ATTENTION: This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. z ELIZABETH A. NEVILLE,14[NC pb� ,� � �� Town Hall,53095 Main Road TOWN CLERK — ��A P.O.Box 1179 Co Southold,New York 11971 REGISTRAR OF`TITAL STKPISTICS " Fax(631)765-6145 MARRIAGE OFFICER ��� Telephone(631)765-1800 RECORDS OF MANAGEMENT OFFICERd southoldtown.northfork.net FREEDOM OF INF0RmATION OFF icER OFFICE OF THE TOWN CLERK TOWN�IgOF SOUTH�OLD AP LICA'TIO7 PERIV11T TO DISPLAY FIREWORKS APPLICATION IS HEREBY MADE, pursuant to the provisions of Section 405.00 of the Penal Law of the State of New York,for a permit to display fireworks as hereinafter specified: DISPLAY IS TO BE SPONSORED BY Peconic Landing at Southold Inc. PRINCIPAL OFFICE AT 1500 Brecknock Road, Greenport, IVY 11944 HATE& TIME, OF D1srLAY 9/1/19 at 7 15 pm EXACT 1,6CATION OF DISPLAY Peconic Landing property near Brecknock Hall SUFFOLK COUNTYTAX MAP NUMBER FOR SITE RAIN DATE &TIME 9/2/19 at 7.15pm The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition Robert Mardorf 45 yrs. 1 yrs. Health Excellent (Additional names and information may be submitted on an attached sheet Number and type of fireworks is as follows: • 1.3G Fireworks. rirrn-i-nremr--�32�-1-3--s�-�-e--2-:5--� �-�-n--d-iax�-e-r--Irl-�3�1-�-i-��a3,�-o��s., 2.575--3' 720, cakes=22. Manner and place of storage of fireworlo prior to display: Delivery will be day of display. Attached hereto and made a part of hereof is a diagram of the grounds on which the display is to be held. Also attached is a Certificate or policy of insurance coverage. NOTICE: Written permission, with signature of the Property Owner,must.be submitted with the- Application. FEE. $100 Name of Organization See policy for additional information By Printed Name o f pp scant Signature of Applicant e-mail address: Telephone Number Date of Application 5. All applications for a fireworks permit shall be subject to an application fee in an amount of$100.00,together with a processing fee in an amount to be detennined by the Town Board to cover the Town's costs for monitoring and enforcing compliance with the Penal Law. (The above instructions are in accordance with the Penal Law, Article 405 - Licensing and other provisions relating to fireworks.) ®rovFfat/(,, ELIZABETH A. NEVILLE, MMIC: ��O � Town Hall,53095 Main Road TOWN CLERK RO. Box 1179 Southold,New fork 11971 REGISTRAR OF VITAL STATISTICS ® Fax(631)765-6145 MARRIAGE OFFICER �� ��bt' Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE `I'OWlel CLERK TOWN OF SOUTHOLD POL C-Y fog• the Issuance of Fireworks Permits 1. The Town may grant a permit for the display of fireworks by municipalities, fair associations, amusement parks,persons or organizations of individuals. Penal Law Section 405.00(2), 2. An "organization of individuals" is a religious, civic,or comparable organization.Op. Atty. Gen No. 2007-3. 3. Fireworks permits shall indicate that the display must be concluded by 10:00 p.m. if held Sunday-Thursday, 11.00 p.m. if held Friday or Saturday, and there shall be no time restriction if held on July 4. 4. No person shall engage in or allow the manufacture, assembly, storage or display of any fireworks or pyrotechnics display without first obtaining a permit issued by the Town Clerk. A completed application for display of fireworks must be received by the Town Cleric a minianum of 30 days prior to the date of display. The permit application for any fireworks or pyrotechnics display shall be accompanied by the following: a copy of a valid certificate of competency as a pyrotechnician for the individual supervising the firing of the display; ' Certificate of Insurance naming the Town of Southold as additional insured with coverage limits of$2,000,000 for public liability and$2,000,000 for property damage; Detailed diagram showing location of fireworks discharge and minimum separation distances in accordance with the applicable requirements of Penal Law Section 405(2); 4r (d) A copy of the contract with fireworks display company; and (e) All applications shall require the approval of the Fire Chief of the District in which the display will take place and the Fire Marshal before being presented for approval by the Town Board. t o � ELIZABETH A. NEVILLE,MMC �.� y Town Hall,53095 Main Road TOWN CLERK ® P 0.Box 1179 en Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Fax(631)765-6145 MARRIAGE OFFICER � ®�' Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.soutlioldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD t INSTRUCTIONS FOR DISPLAY OF FIRE,WORKS 1. Name of body sponsoring fireworks display. 2. The date and time of day at which the fireworks display is to be held. 3. The exact location planned for the fireworks display,including TAX MAP NUMBER. 4. The age, experience and physical characteristics of the persons who are to do the actual discharging of the fireworks. 5. The number and kind of fireworks to be discharged. 6. The manner and place of storage of such fireworks prior to the display. 7. A diagram of the grounds on which the display is to be held, showing the point at which the fireworks are to be discharged, the location of all buildings, highways and other lines of communication, the lines behind which the audience will be restrained and location of all nearby trees, telegraph or telephone lines or other overhead obstructions. 8. Such other information as the Southold Town Clerk may deem necessary to protect persons and property. Written permission of the property owner is required. 9. An indemnity insurance policy with liability coverage and indemnity protection of$1,000,000.00 per person for bodily injury;$1,000,000.00 per accident; $1,000,000.00 property damage. 10. The Town Clerk of the Town of Southold must have the insurance policy in her possession before the fireworks permit is issued. The named insured must read: TOWN OF SOUTHOLD. Thirty (30)Town of Southold POLICY 11. Application for a fireworks permit must be made at least f dEs in advance of the date of the fireworks display. (The above instructions are in accordance with the Penal Law, Article 405 - Licensing and other provisions relating to fireworks.) NO ADM t7ANCE S p IECO NYC. IDING LAK IGTH q AN14NIVERSARY 3" MAX SIZE SHELLS 4istf 210 RAIDUS Cl- e4 41 07 6 72 21 47.03 W FIREWORKS Federal Explosives l,icellse/Permit U.S.ncpatYmrgt ur.lusticc p 1_fo cau of Alcohol•Tobacco;Firearms an4 E%plostves (18 US.C Chapter 4 0) [ttttEitife:lied fti3^33961.ftII6.f$t39 In accotd£uur IAith the prav lions orTil c X1,Orgatimcd Crime Control Act ref•1970,and the rcgulLtions?,sued!ince t under 127 C i721' ri »:i),)ou mat engage ut the activity specified zSl flus litxnse Qr permit within the litnilations of Chaplcr 40.'i'ttic IS.Unitel.l States C'r:dc and the rc2ulzuto 1,issued tluneundi:%unlet the t xPiratian dale shntstt. '1 HIS I-WENSE IS fivf)'f"i I3 t Sl l;Et\B1 I Lt-Nk See-V,1ARNP4GS":Ind 'N101ICE.S"on£cvenr e, Direct ATF ATT-Chief.FRI. ~Ltucnsc Pcritut �r,T, u„ r 4''1J 6 • Cvreslxmdcn.:r To 4-1 rlcrdl'Road Nuntbur Mattut56urg,WV 25.1((3 M31 Ch;c1'.1'cdctall:•iia;ivcsi.icans7ngC�•Ttter(I�II ,..,,•m,r;->tzGi;^, •mr^^�- n rl i {{ �:..6'"'.'� isvlstralson ,*. 1 •�"-� t lf,�-f� ,�• u:te ;;�,fir,''„r; �1�1���'`�'��r,�� a 0 -- BAY FIREWORKS & INTIL PYRO IMPORTERS Premises Address(ChangcO Nastl\the FELC at le-LA 10(!eiy,tn;hxc thn rnoNO 999 SOUTH OYSTER BAY RD SUITE 11'1 — BETHPAGE NY 11714- 1'vpe of License or Permit 51-IMP0R1'ER OF EXPI_C)SIVES Purchasing ecnisic:atron stt wnirret ivfniling Addr4•a,�(Cirinkc;i' Ncuu;•ilio I-El ('of any uhangcs) Trie limmscc or pLanince naTned above ftill lust a copti of thrt:license or?pipit to tt5 w a tralisl.a•tx or 0%T10'sivei III verify the ikulily and the h4erincd s1lctus of the liw1wc tw pmniticca�prn:tdcdm27CtrftPaAStt, 'T1Trxis�tttvecr�rl��4g:yttttz.�tktu:c:sttin,sl PYRO ENG1NE1=RINGING .t initzad A faxetl..c uinai w c-mail:d u< ry ufthe ficrn�e ar prnnit ttr9t a n}�,stur. smmdedtolio:ut:xtgrnslsi(,aiarurarsutx:;it9lixl,. '111csi�tattrnttrttsiht lhaturthctredcsal BA`!FIREWORKS & IiVTL PYRO IMPORTERS [splustw%Licensee(FE1.)Ora rSpMlaiblrPei sntofthe F'El- 1c'e4iliacthlsist4ince 999 SOUT14OYS1-E R NAY RD SUITE 111 ,opy,N:t li.rxa>,s::.n jwwuh is wcd 4a,the licatsox or palni:tce amncd atJocc to entla}?,e in the BETH PAGE, NY 1 1714- haran, cx t per Slttilia sp zsf i KI L1Tt+ve under”I`)'p<of I.ic�xc c u Prrini[" 1.leer?se< 1'4rttlriteZl2�.,p<?£taiblcPcrwtt Signaturc Position, itis 11631 led Name DRIC .l k !,■nt A,It W SAh1 t,Pan I P•c:wc• UIJT.01i•s'ArM N1111 M'Vilkw*111tg("Ml: mem i;•_w,rdn,-•3s21uI Federal Fxplosivrs L ceinc(FLL)C'unlwntr Ser,ice Inrurinaliott federal t•epiosiveb I,iccilsmg Centcr IirL-1c) NAI-frec'Cctepltaate Number, (5771283.3352 A'[I•I lomepago tt,tu etf gcly 24.1 Nccc Reind Fox Numb-r• f3(;4)616-1401 Lsertmbburg.WV 2540-9431 l-"-mail 1'L1Gmatt:lav Change or,Addrm (27."1.7?5a5,5-1fa)r1p Liccw;ct•s or perinittecs may durun;the teor of' current h.e,i>c Or t+cnnu r int've their bin mica or nt,crationctrt u Slow locauoa ut tthiclr thew•attend regularly to carry on such himincss or ciperatirtn4 The 1wenwe OI pw_irnitlec iv required In cn e rlt+:ilicat•t+n at'thc net+local5t,ii of ilio business of operattofts not Icssthun 10 da}'s poor to such rcint-wal ttith the Chicf,Fcdcral l.NpIof ives ucenshig Centel )'he Iiiewit:or periml will he valid for tllc rentaindw of the lima of the ongenul liccntie ar pennit• ('I'he Chief,>:E1,C•,shall,if the ticensi or Permittrr is riot yuallfied,rcfcr t1w request for atnended ifcence or pertrrit to the lXtrector of ludustry Operations for dental in accordance?Sidi Q 555.S4.) Ri0he or Succee fon (27CIrR 35S.59j, (v)Ccriain persons oth than the licensee or permittee 111,1 ?enure ilio trgl[t to cu:ry art the:Mime evplosn•c•:natcmals bu:,irtars or operations rut Ilio same addttsss shown on.and for the reminder ofthe tern(it'.£1 cuiliew lieCiliC OT[)cillii tii.1;11 pc.--Z—AIS arc i I)'Chiu wul vit ulg spausa or child.of executur,adntinistratnr,or othcr legal reprcSciit£ltil"C ora deccased liccrt-tx or prrmatec:and(2):t rcccitcr w it usrc:in h ink-rupicN.or n assig;lce for bcnetil of crediiors- (b)Ln order to secure the right providtxl iii this seelinn,the prrson or pawn-conliumn?!the austltcs,of of<t ?coils shall furw%fi clic tivem c err permit liir lbr that hltsnte4s or operntions forendorwilew of such Succe.ision tothe(:hies,I i.l,(',within 31)(lin•,from clic dntc oil til hich the Nucecsxx bcgiustn cam'on the business or cirvatime �1'nNivMcii ani✓C'VQrSf`Jrie, CUL Here:'C Federal Explosives Liceuseilretmit(FEL)Inforniittiott Curd i License-Permit Name:PYRO ENGINEERING 11`4C t t I t - I 1 13usirccssNante. BAY FIREWORKS&INTL PYRO IMPORTERS I t I i icensc'Pcnnit Number:ti•NY-059-5'!-OE-00129 j t i Liccusc•F'cmul T}pc:.51•fMPORTER OF EXPLOSIVES i t i I lt�puati<Jii: May 1,2020 1 I I Please utile: Nkx Valid lir the Sale or CXher Di%p ittan of----------------------------------- Eeplbsiva.. I t q ��® CERTIFICA,rE OF LIABILITY INSURANCE DATE A s�r2o19YYY) 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 ODES 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 arid conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in heu of such endorsement(s). PRODUCER CONTACT Arthur J.Gallagher Risk Management Services, Inc, -P Ho E- ------ --- ---- ;FAX – 677 Broadway 4th Floor (Arc,No,Ext);518-869-3535_ _,(Arc,No)_518-869.3.580 E-MAIL Albany NY 12207 -ADDRESS', INSURER(S)AFFORDING COVERAGE_ NAIC# wSURERA:James River Insurance Company 12203 INSURED PN ROENG 07 _ B_Lexin ton Insurance Com an 19437 Pyre Engineering, Inc dba Volt Live INSURER 9----- -- - p y- ----- - -- 999 S.Oyster Bay Rd INSURER C Bethpage NY 11714 INSURERO' - __ INSURER F t COVERAGES CERTIFICATE NUMBER:2113450827 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 REOUIREMENI, TL-RPA 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 iNSRI - ;AODL'SUBR1 - - - --- POLI'CYEFF I -POLICY EXP i LIMITS - - LTR TYPE OF INSURANCE pr ylY-Q-- POLICI NUMBER MMIDDIYYYY I MMIDOIYYYY A , X i COMMERCIAL GENERAL LIABILITY Y 000891360 2115/2019 I 2/15/2020 EACH OCCURRENCE 'S 1,000,000 CLAIt.iS-MADE X OCCUR DAMAGE TO RENTED - _. i. 4 4 PREMISES(Ea gccuirence) S 100,000 _ _ I MED"EXP(Any one person) i S Excluded PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER a I GENERAL AGGREGATE s2,000, 0 X POLICY I PRO-JECT LOC ' PRODUCTS-COMP/OPAGG :S2.000,000 ` - I OTHER; _ _ _ I Arno 'S 1.000,000 A AUTOMOBILE LIABILITY 000891360 • 2/15/2019 S 2115/2020 COMBINED O BINEDtSINGLE LIMIT '51,000.000 1 I ANY AUTO I BODILY INJURY(Per person) t S OWNED SCHEDULED -- - r AUTOS ONLY AUTOS s BODILY It4JURY(Por accident);S HIRED NOM-OWNED ` X X PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY i{Per-accident) I S - B I X I UMBRELLALIAB 1 X OCCUR 023627359 211512019 I 2/15/2020 1 EACH OCCURRENCE 1$9,000,000 EXCESS LIAR + CLAIMS-MADE' 'AGGREGATE !S 9,000,000 I DED X "RETENTIONS E - _ nn 's WORKERS COMPENSATION ' ( PER OTH. ' AND EMPLOYERS'LIABILITY Y i N ___ STATUTE ER ANYPROPRIEIOPJPARTNENEXcCUTiVE r--I ' I E L.EACH ACCIDENT_ f S OFFICER/MEMBEREXCLUDED? L_ I NIA I .- 3-- (Mandatory In NH) ' E.L DISEASE_EA EMPLOYEE S Ir es,describe under i "'- — - - -- -- -- -- DESCRIPTION OF OPERATIONS hot w, _ _ E.L.DISEASE-POLICY LIMIT(S I I DESCRIPTION of OPERATIONS!LOCAI IONS/VEHICLES (ACORO 101,Additional Remarks Schedule,maybe attached it more space Is required) General Liability Form Number FPS201-0112 Additional Insured-Automatic Status When Required by Written Contract-includes Primary and Non-Contributory when reoulred by written contract General Liability Forin Number FP-1001-11 17 Common Conditions and Definitions-includes Waiver of Subrogation when required by written-contract 'Location of Display Peconic landing at Southold Greenport,NY 'Date of Display September 1,2019 -See Attached... 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. Peconic Landing 1500 Brecknock Road Greenport NY 11944 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: PYROENG-01 _ LOC#: ®® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Arthur J Gallagher Risk Management Services,Inc. Pyro Engineering, Inc dba Volt Live 999 S Oyster Bay Rd POLICY NUMBER Bethpage NY 1 1714 CARRIER NAIC CODE EFFECTIVE DATE ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Rain Date:September 2,2019 Peconic Landing at Souhtol Inc.:Brecknock Hall Foundation Inc;Peconic Landing Housing Association Cooperative,Inc.,1 he Shores at Peconic Landing Assisted Living Residence,Inc.;Peconic Landing Home Health Services,Inc,Town of SOUthOlo are Additional Insured as required by written contract ACORD 101 (2008101) G 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INISU D-AUTOMATIC STATUS WHEN REQUIRED BY VVRITTEN CONTRACT OR WRITTEN AGREEMENT This endorsement modifies insum nce provided by the Coverage Part(s)checked below: ❑ All Coverage Parts or j Only the following checked Coverage Part(s) X COVERAGE PART A- COMMERCIAL GENERAL LIABILITY N/A COVERAGE PART B - CONTRACTOR'S POLLUTION LIABILITY N/A COVERAGE PART B - CONTRACTOR'S POLLUTION LIABILITY—LIMITED N/A COVERAGE PART C- PROFESSIONAL LIABILITY N/A COVERAGE PART D-SITE ENVIRONMENTAL LIABILITY N/A COVERAGE PARTE -PRODUCTS POLLUTION LIABILITY ❑ COVERAGE PART F-PRODUCTS/COMPLETED OPERATIONS LIABILITY N/A COVERAGE PART G -OTHER Solely with respect to coverage afforded by the Coverage Part(s) checked above- SECTION II--Who Is An Insured is amended to include as an additional insured any person or organization you are required to include as an additional insured on this Policy by written contract or written agreement in effect during this "policy period" and executed prior to the"occurrence"of any"bodily injury"or, "property damage" but only with respect to liability for"bodily injury" or"property damage" caused, in whole or in part, by, 1 Your acts or omissions, or 2 The acts or omissions of those acting on your behalf Liability for the above acts or omissions includes the liability you are required to assume in a written contract or written agreement with an additional insured that is specifically related to"your work", provided that assumption of the additional insured's liability is permitted by law. The insurance provided to the additional insured(s) under this endorsement is limited as follows: 1. In the event that the Limits of Insurance provided by this Policy exceed the Limits of Insurance required by the written contract or written agreement, the insurance provided by this endorsement shall be limited to the Limits of Insurance required by the written contract or written agreement This endorsement shall not increase the Limits of Insurance stated in the Declarations 2 Any coverage provided by this endorsement to an additional insured(s)shall be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. 3 With respect to the insurance afforded to the additional insured(s), the following additional exclusions apply This insurance does not apply to"bodily injury"or"property damage"occurring after: a All work, including materials, parts or equipment furnished in connection with such work, (other than service, maintenance or repairs) on the project to be performed by FP5201 01-12 Page 1 of 2 or on behalf of the additional insured(s)at the location of the covered operations, has been completed, or b. That portion of"your work"out of which the"bodily injury"or"property damage" arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project; provided that item 3.a. and 3.b.above shall not apply if such coverage is required by written contract or written agreement in effect during this"policy period" and executed prior to the "occurrence"of any"bodily injury"or"property damage", ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. Includes copyrighted material of Insurance Services Office, Inc , with its permission FP5201 01-12 Page 2 of 2 �a New V ork St2te Insurance Fund {3�a kers COl)1pL+nC(1!(011 & 1)(sr Gild,Benefits Specialists Since 1914 8 CORPORATE CENTER DR,2ND FLR,MELVILLE,NEW YORK 11747-3166 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE R0 i4 'C7 ^^"^"^ 753044987 ARTHUR J GALLAGHER &CO 677 BROADWAY 4TH FLOOR �� ;�- ALBANY NY 12207 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER PYRO ENGINEERING INC PECONIC LANDING AT DBA BAY FIREWORKS SOUTHOLD INC 999 S.OYSTER BAY RD, STE 111 1500 BRECKNOCK ROAD BETHPAGE NY 11714 GREENPORT NY 11944 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H2437 559-4 6907 02/15/2019 TO 02/15/2020 616!2019 THIS IS TO CERTIFY 1 HAT THE POLICYHOI DER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO 2437 559-4, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY, IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/IWWW.NYSIF.COM/CERT/CERTVAL,ASP.THE NEW YORK STATE INSURANCE FUND IS NOl LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THE POLICY INCLUDES A WAIVkR OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION FO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSA_I ION AND/OR NIEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. THIS CERTIFICATE IS ISSUED AS A NIAFTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POI ICY NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER. 5960,18512 U-26.3 YORK Workers' CERTIFICATE OF INSURANCE COVERAGE S ICompensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAYS! PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Narne 8 Address of Insured(use street address only) 1b.Business Telephone Number of Insured PYRO ENGINEERING INC (516)597-5500 999 SOUTH OYSTER BAY RD STE 111 BETHPAGE,NY 11714 1c,Federal Employer Idonlification Number of Insured or Social Security Work Location of Insured(Only required dcoverage is specifically limited to Number certain locations in New York State,i e.,a Wrap-Up Policy) 753.04-4987 2.Name and Address of Entity Requesting Proof of Coverade 3a Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) PECONIC LANDING AT SOUTHOLD,INC. 1500 BRECKNOCK ROAD 3b Policy Number of Enitty Listed in Box"l a" GREENPORT,'NY 11444 DBL 5213 59-1 3c,Policy effective period 01/04/2003 to 01/04/2020 4 Policy provides the following benefits. Z A Both disability and paid family leave benefits B Disability benefits only [] C.Paid family leave benefits only 5.Policy covers: ® A All of the employers employees eligible under the NYS Disability and Paid Family Leave Benefits Laws B.Only the following class or classes of employer's employees. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of(he insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date Signed 111512019 By (51gnature of insurance carrier's authorized representative or NYS Lionised Insurance Agent of that Insurance carrier) Telephone Number (866)6974332 Name and Title Melissa Jensen,Acting Head of Disability Insurance Unit IMPORTANT: If Box 4A and 5A are checked,and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate Is COMPLETE Mail it directly to the certificate holder. If Box 46,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220, Subd 8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the WorKers'Compensation Board, I DB Plans Acceptance Unit, PO Box 5200,Binghamton,NY 13902-5200 PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box 4C or 5B of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board, the above-reamed employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compen%alwn Board Employee) Telephone Number Name and Title Please Nofe:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed Insurance agents of those insurance carriers are authorized to issue Form OB-120.1. Insurance brokers are NOT authorized to issue this form D8-120,1 (10-17) Certificate Number 530946 M'-#Y'•;4�YC;f�>r A,:�r�,���a;`F-=r;,57,iiv"Y �.•;^ "�'a 3'�N ��sjt„�j•�°3�n•�:,�,'XIt^r��S'fit,��'�h�Y. �pc�,vc'vy'^ '-� n �1`id - .`��-•"'7r""``� 1,Yy��`t.�.',�,1�'-'�.i`�q,�, �n�l^�`fi7i'�< ��� •'+' xY _ �t n �Sks• ,�;�,2R';�ik�^,� 1°t"r't. ;.r �f n..o,•:Yr-,c' v �'� Ct '2k� fz ��t "` L ,.,may¢��r�jcc.�{%•r,;t,,��' j,•!'s,�';.h•„ryy�y; i�' �,�'.��`y,� Z'7' 51Iti``�n�• l; 'iMo-1 3 �Yr't• �.-K"..nC(�jF"�-/'hM'1:�' •lA 'J'•lYl=1yY. ��. --0 �3:•'4:a`$,nr,r,�i"1t,'Y��'""�'`-�e�r��� '"r.�'- �'� ��: ,?•'� _ .y :' �xit?�;:.'�` �aifarfy":k��F'=cy�]�3,�t,�'+.y�,.::;k`•�-',;t�,`4��a',`�,�' ,,: ,-Ys�`�T��k j`+:a��jis`.• 3 1 r�lf{,t�.,��� �A;� Y. <�` ,.�L.ai s v `,"i az" �"�-it 7 t?,yt,-,x '7rhR �lSar_, Saa,r�' .�. G•,rr, , �{ t.xT.,:'i 6 ♦iL'1".-".,"74Y"t',cX}, �fi,�"?' 1 ITY"I"En>.�7, n 2'n t d"� ,ti;r,.�`!vr• `d}', $ ! E�' n •i'`• Yj `i rt t;%i...t” Z,�ii..�+`,1•�s�ll�i-.l��Mf`t�t >t� "a., ,��'» <�s'�;;�g, rr 4:.�;,,�%.'moi ,!:=.• � � rt ',s �ti. ' �" ��.,?;.„rt`rf�'r7,r- p2,n'C;jFgtr��,�'-. y�,J,z�F7ri 4`C'�•��f '.x'�ii ,� �., I; :f .� �,�,����k=3,il Y��:C'?`�,�'v+t}�s'��.rg;_v_a�.4 +r"E-dp't`ai'�..�.;�'e�ca�•�."r`3?� 1•,..<,.s' '�'�, _ �` 'i s *%t?„3 A 1,y +Zfi:pp41'`'y�7''N „✓ 1: '�lr vQ•,'f'•{ lam` •v!� f '1.Yf"L,"t 'Y t, �l }, f `�7•Y1v;a �yytt i [��, �h,'n�• 4, µ� „r ; e.-y -.!f°` ��}��;��«,,'iq`:';:-•r.��ry 4,-,� •r';�' -F, '"'���€;�>�ir'�•rr�y'� �,"'.�yF`S-'��t,«�:r�,�' c}�;� t' ji'1�2+�� t"�itln;�,y, � �ey�.;�: � � �'�,'� , �YaT d��';�' _ ti 'ri r ,,,�.�y� o-;�•`�S`x.j•�I=ar> t 3��ir�?`�"{�r,�ji;� "P� ���dtf� ,� .C �'��,`v-�kdkt�F+ '1`t"a�.,1�;`3c•f Cn;�:t".?., t, �.'vy'"tcr �sr y}�'•:t��,r. �mr a �t!'r 4 e�'�(��F2^"i.fi��Y�;}";E�k�•'+"` � t.tJS,�+!°"•+ �� ?�., 1(,S'-.!1,1 v�c't:�' '.%<i•i �9-fiC4i k`:� qd�' 2a,,`{ .. s�,3M1`j���t"`'� rs r'�ait✓;._��,a';e fi";�w it^'� ti .,,,�r ul, �'" }"'i+ r L •"' O-T149 ( ��>1�'•' „r� :- k,cS'�r' D''•,•j,z nS°k Y,cb. p +.y .u:i3-vZ=r5�}-°k;'<.�;�-.},r°; ,.•, �` 43rt;1{�' S�'+�r ._£•,•r•�,� ':�s'M1 1•r V,t.. r<, {xFs �' � � 7�X'`a 9 u ,•. _ ,fit, .?x ;.ysf •` „✓"C'ifi�/° >•Y`;� +';}t%Zat'z•�,X ',b;,k^' y^};j'4y,.V tt' y� �}, ,��` 'A'��� `�`p'?Kri'i�'�:f 1` fi 4 ,� 1,n.f���1f,1�4�P'�"rk'y6�'3.y�,'y'� 7•.. �, d' (•y>. p.,,,,y�i t4k, ti';-`C'M1,;:e s�,'��'r��Y:�`2�b1��'�O�'rtcJ'UE�`•1'YT 1"''t4° d�''14 �r- x�� d:.4^' Yfw �;,.��,`<}e„ �FY trr.,, �•,��,•rf:,•s< r�, •, �F _ °F •' ,-`�".�.��7,. ��i`��y o''t�''r 5 v+ fit. t1'-Ad^'��•i'%�e'' •v'� '. )�.'+''�y�' u"F. b �:-lS;.i,.�},'•�,. �,}'K'i.Y` �{d2+..�:.!�rr,•,2tl� ,X ��. " F S`l� 4'^ 5�'F•r��'ft =t'f: )`S 9e� �,Y.:.�"-1 �£:}Y�'3rJ t, _,.y;' ^'pvF.,•�,< r{�7d;:}leeS<yr 'i.x�•Fn'<j-�L •s ,,,p,�� !_ n V4' ��. �°•�ghl.'x-'�ytc,Yi:,,j �,t,`, 1F..'^,r"rl �,i "', Tit7^z 7''�`g`e.f,'r ,.u.'Y,� . J7�y[`.•,-'7v, <� %:.Y.'�kF'S+7.",ryr'hsl,^i��: tyr?, l,�'+'w� Y., }S�"'�^>�"��.P ` �, g 4�Y` f;,,k.,�,�y�, v•', r,`r. ,s�r'^,n,t•�,.,;q>' �y'�"�,;$a 1'3}he, -ars �� �f�:� l�u.>rr�h�"x}�,,,;, � c,. �s• ,fzr,�;�t�'N�i'��-t''�,a i�X 3� � �a4 =�Ln ,.'-... R"-+�,�:��k .,.'tYc:�t V'-;l��Ert` t��^�•v+ �Y�?�>pl,.` ,� � "`+ ••, �!*r` ?- 3;, .AN, ,X.b-^A'..,tt," v >E.,kt..,� •R. e' Nr 'v�. c, w' .t;"••4�,,..i r.., t'n',,,.4-•(:^�"A k�' ,„, �r �"'� r :Y71�1fp��s'i 7S�_ � .�Yr tF�(T7,.2'<S 1r���'�-�'!��:�liw.�.:y:�:''.1�...•.-:�..1 r,..+.�� 1 3' i '+u..f'-.? "^� 'r ''`';Qt'd�. '£wl.t"t.,:"•`,:k<^.t�.�, ..:�.��.. a 'yy�t E'»'` ,j�'.� S Icy: P( 7'JA� A k �•1,Y".'.,,., . ~1i�-I' rfj`1 LR�2 1'' I_ �Ai~}��3.\.a/• " ,..JI i_•rt-7�, T N-c- , ....( _ 0 B '.,,,,, t, IF CLASS., B '���il�k,r '(t(ate ,�I!`r;..,.•��E,r�., -' '4� . ^rH <, Yi��1�,�`rj��ttZa•�i�+�a�le4.rr' „�r�7 kyr 1 _ AT ROX 1. - IS,- CARD w� �K.a�L s'�'�.,{f3{.'y' -va•ii.;. �S?i'""�%�4. -_ _ r, BE '�L�.ral=�v V.� T�gp,'7F<�ry�YtA•��'c,1.4 {j' .' 2 rJ ' VV,H' SIN _ . "'�y'::n,�,t s :;�„',s fik "x�� •�;,r •;'�,.n, q,.F:..,yaE`•i 7,�•, ..,; v, :`_', r ,',,s z _ yyf {,r`" �. �...�...,.� .,a.-.... _- M, .. -:�,.,.. -^ - „ut>1ry;:.-+a�i,.:^.:� �✓•.:r-..'^' ""'4t.N*nam. - IS„'�tf��'^•�'� tS��� l`1�i�t/'\� t �'kE1,.^�� r„�-� jN < ��,..- _ ;-^ -_ ”- '- -_ --_ __ -•:�� ., __ - �`# 't t .oF 'f,i`� .',t:.- -p-• _ t. .tr_d, - - - ., _- ",'.. � ', 'i �i� ,.s"��*�a '-�", °ha�t�-� �` �4,` ��x, _ _ .',�xr,,.,;.`,xrv�.<•Y�,,,n., .��:�:k;:s;F,_ t�,' `1��:��"�4aai3,i��i�i,!'�'i.,�>�'�, .t- �4cr'rri`�i,. ',t;-. - ",�.i i( - ,`' Vit' _ -`:5.,!''p'il,i 'h,.r+.?f ,4f.a?- .d•�>T'i>.� o•�.. _ ..ai'R-", 1€�F}'1."f; ,7: tijt�'. r�i, _ •,F.,, y:a'.,, - � r�y 4vt-" ,A)d .iR�,V,ii,c'{�i s„t' - ,Y �� _-i w^ •:7,.,, - ,. - _;'j3,e=�, �ti .*Ss,'L$c,., '",�iea;�.,`-q',4'_�, _ _ i'` '1.-y. Jin^ -dr't'' _ .. tM1; ,`2.h.^'.,,'it?.iiir, xr'2.�A.•+ `�si;�,`�A'vy�_.`lt'Y 4� ,!> �4- i� a„<°�3 ^. ,_ !{+„i"�.�,y,:C�-;.,t,. 'S�SF�„4., `��;,.is�,•.,3.c , ..,��-+,.},r!'7 7 `Y7 - :,"ft ^ - _ _ '•-':t"' ,:l fi_"tike: h-'" _ - p �`�','„ f�, _�,,� '��r L° ,t'1'r�' - �Yr�r, �Ye ` ?"^' - '^'t'+`+,r•''`-`��!�'j,. S:e'�'�C;''t t.-¢�wYi^S'„ly` <'�ie.,,.�'•=m d''i'� -;s� `a �d'3� :d'� -.,+. - .. `��s'� `�', -r_,'!',k;+,,ry�, ;d�,t'4.w..:�`,'T3;�1 ..�. �”"•' � .• i;,, - "' '' '3 -'!' ,. I •''`! •;r"tiR,6�r;�<,,, ;,,`.4``�,art Y.`!•," -, J '�+,-'rr;.�e 1 - - - .t"+'•.\`k-�,,'(.,(..y.`-„i.-.i �M1 t�v'�„��- •"ti. ,_i,-'r?"� A`�i. -- w•, i`i'i""�:?r'���,,.,t Vit' ;�.., *; -�: 1+�•'f> ,,' �'; :-„^'--"" >- - - _ h�`.k`y�f�,i77 P�.��`,,ry',''S 7.-�:K,:”' ;', ��" nI�4,.•'6.j`t""�"� .aY' 'gd�'t�ta - ,f,h, •'*, ,- '..�_,�, ^�a�,'_, .1.1;cy,Sva��ti;e"�A�.y �<`[:r, _ oi, .},y '.x.. � r• '';. - , - �.vF"-'•�d,�;`4,+t'^,' .,t, _,._�,�` - ,,;;��'' 1•�",;.,:ip}? y ,:ii•`�1, i,• •�r,� ,'�: �dns7�^�� _ - ,q,..• - �:y ,, .��.'e _ <.•' tic;: °S,•a,' qL.x:;;,,,Y;,; n �';i -�-f,'�c', i.l, �' '..f. � h',�*•.. 'riV hz>��?"' - td��` V�-;r•�ki~` '�� F�' sfr. _ 4i ,1 � ? a;<;,I:i.�+.9.tre..__ -- -...,�._•,.", - »,..�.-.,....«e.--..�.:::a,....,.._.,.ce. Y�-. '.,',;:, ,.,:- �4'.�sf.91 y `n t-" i+'` •- .-,..dr' FAA/Air Traffic Organization 1 701 COIUinbia Avenue Eastern Service Center College Park GA 3033% U S. Deportment of Tronsportat:on Federal Aviation Administration Dear Firc%vorks Proponent: FAA-Peconic Landing 2019 Thank you for informing us of your proposed firewol ks display. Although there are currently no federal regulations specific to 1 iruworks displays, the Federal Aviation Administration(PAA) has been tasked with regulating the sale and cflicicnt use of' the navigable airspace (49 U.S.C.§ 40103). In recognition of'this role in promoting aviation safety, many jurisdictions require notice to the FAA as a condition ofapproval of a fireworks permit. We acknowledge your notification and have no objection to the Cr c%voi ks display provided it is conducted in a manner that does not create a hazard to other persons. or their property. To enhance the safety of your event, we recommend the lollowln;actions; + Fireworks staff should remain vigilant to ensure that no atrciall ate in the area prior to beginning the fireworks display. + If vour event is within 5 miles of a public use airport, or if'thc display will exceed 500 feet Above Ground Level (AGL). contact L.etdos Plight Sc:r\,lcc at I-877-4-1fS-NfIvIS (1-877-487-6867) at least 24 hours (but not more than 72 I10Urs) in advance to request a Notice to Airman (NOTAM). You \N,ill need to provide the following information. o Name and address of the person filing the NOTAfvl L o Date, time(s), and event location (City. State, and locmion in refelence to the airport) o Maximum altitude of the display This letter should not be construed as superseding or lnvaltdatinL, any e:;isting rules or tegtilations promulgated by any other federal, state; county, oi- municipal govenunent which may be required for this display. If you have any questions regarding this information, please contact our off ice at(404) 305- 5570 or 9-ATO-PSA-OSG-Fireworks<ii)f ia.ttov. Sincerely, Ryan W. Almasy Manager, Operations Support Group Eastern Service Center,Air Traffic Organization Neville, Elizabeth From: Neville, Elizabeth Sent: Thursday,July 25, 2g19 3:32 PM To: Burke,John; Du , Bill, Fisher, Robert; FlaV, Martin; Hagan, Damon; Norklun, Stacey; Sp\pe, Melissa; Baylinson, Lester Cc: Doherty, Jill; Doroski, Bonnie; Ghosio, Bob;James Dinizio; Lauren Standish; Louisa Evans; Neville, Elizabeth; Noncarrow, Denis; Rudder, Lynda (lynda.rudder@town southold.ny.us); Russell, Scott; Silleck, Mary, Tomaszewski, Michelle; William Ruland Subject: Emailing: Referral Fireworks Pecon_20190725152633 Attachments: Referral Fireworks Pecon_20190725152633.pdf Importance: High Good Afternoon, Attached, please find a Fireworks Application of Peconic Landing for a fireworks display on September 1, 2019 Rain Date: September 2, 2019. Please review and send me your comments and recommendation. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 Your message is ready to be sent with the following file or link attachments: Referral Fireworks Pecon 20190725152633 Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. J 1 Neville, Elizabeth From: Neville, Elizabeth Sent: Thursday, July 25, 2019 3:36 PM To: Greenport Fire Department (gfdfire@optonline.net) Subject: Fireworks Applic Peconic Landing Attachments: Referral Fireworks Pecon_20190725152633.pdf Good Afternoon, Attached is the Fireworks Permit Application of Peconic Landing for a fireworks display on September 1, 2019 at 7:15 P.M.; rain date:September 2,'2019 at 7:15P.M. Please review and if you approve send me a letter stating your approval of this event and your pledge of support and coverage with fire engines, ambulance and any additional apparatus as needed. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk,Registrar of Vital Statistics Records Management Officer;FOIL Officer Marriage Officer PO Box 1179 Southold,NY 11971 Tel.631765-1800,Ext.228 Fax 631765-6145 Cell 631466-6064 i Neville, Elizabeth From: Neville, Elizabeth Sent: Friday, July 26, 2019 9:47 AM To: _ Duffy, Bill Subject: RE: Emailing: Referral Fireworks Pecon_20190725152633 Thank you, Bill! -----Original Message----- From: Duffy, Bill Sent: Friday,July 26, 2019 9:00 AM To: Neville, Elizabeth Subject: RE: Emailing: Referral Fireworks Pecon_20190725152633 No objection -----Original Message----- From: Neville, Elizabeth<E.Neville@town.southold.ny.us> Sent:Thursday,July 25, 2019 3:32 PM To: Burke,John<iohnbu@southoldtownny.gov>; Duffy, Bill <billd@southoldtownny.gov>; Fisher, Robert <Robert.Fisher@town.southoId.ny.us>; Flatley, Martin<mflatley@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Norklun, Stacey<Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.nv.us>; Baylinson, Lester<lesterb@southoldtownny.gov> Cc: Doherty,Jill <fill.doherty@town.southold.nv.us>; Doroski, Bonnie <Bonnie.Doroski@town.southold.ny.us>; Ghosio, Bob<bob.ghosio@town.southold.nv.us>;Jim Dinizio<iim@jamesdinizio.com>; Standish, Lauren <Lauren.Standish@town.southold.nv.us>; Louisa Evans<pevans06390@gmail.com>; Neville, Elizabeth <E.Nevil le@town.southold.ny.us>; Noncarrow, Denis<denisn@southoldtownny.gov>; Rudder, Lynda <lynda.rudder@town.southold.nv.us>; Russell, Scott<scottr@southoldtownny.gov>; Silleck, Mary <marvs@town.southold.nv.us>;Tomaszewski, Michelle <michellet@town.southold.nv.us>; William Ruland <rulandfarm@vahoo.com> Subject: Emailing: Referral Fireworks Pecon_20190725152633 Importance: High Good Afternoon, Attached, please find a Fireworks Application of Peconic Landing for a fireworks display on September 1, 2019 Rain Date: September 2, 2019. Please review and send me your comments and recommendation. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 Your message is ready to be sent with the following file or link attachments: Referral Fireworks Pecon 20190725152633 1 Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. z Neville, Elizabeth From: Flatley. Martin . Sent: Thursday, July 25, 2019 3:38 PM To: Neville, Elizabeth Subject: RE: Emailing: Referral Fireworks Pecon_20190725152633 I have no objections to this display taking place Martin Flatley, Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 -----Original Message----- From: Neville, Elizabeth Sent:Thursday,July 25, 2019 3:32 PM To: Burke,John<iohnbu@southoldtownny.gov>; Duffy, Bill<billd@southoldtownny.gov>; Fisher, Robert <Robert.Fisher@town.southold.ny.us>; Flatley, Martin <mflatlev@town.southold.nv.us>; Hagan, Damon <damonh@southoldtownny.gov>; Norklun,Stacey<Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.nv.us>; Baylinson, Lester<lesterb@southoldtownny.gov> Cc: Doherty,Jill <fill.dohertv@town.southold.nv.us>; Doroski, Bonnie <Bonnie.Doroski@town.southold.nv.us>; Ghosio, Bob<bob.ghosio@town.southold.nv.us>;Jim Dinizio<iim@jamesdinizio.com>; Standish, Lauren <Lauren.Standish@town.southold.ny.us>; Louisa Evans<Ipevans06390@gmail.com>; Neville, Elizabeth <E.Neville@town.southold.nv.us>; Noncarrow, Denis<denisn@southoldtownny.gov>; Rudder, Lynda <Ivnda.rudder@town.southold.nv.us>; Russell, Scott<scottr@southoldtownny.gov>; Silleck, Mary <marvs@town.southold.nv.us>;Tomaszewski, Michelle <michellet@town.southold.nv.us>; William Ruland <rulandfarm@vahoo.com> Subject: Emailing: Referral Fireworks Pecon_20190725152633 Importance: High Good Afternoon, Attached, please find a Fireworks Application of Peconic Landing for a fireworks display on September 1, 2019 Rain Date:September 2, 2019. Please review and send me your comments and recommendation. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 Your message is ready to be sent with the following file or link attachments: Referral Fireworks Pecon 20190725152633 1 Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 2 1 Neville, Elizabeth From: Spiro, Melissa Sent: Thursday,July 25, 2019 3.38 PM To: Neville, Elizabeth; Burke,John; Duffy, Bill, Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun, Stacey; Baylinson, Lester Cc: Doherty,Jill; Doroski, Bonnie; Ghosio, Bob;Jim Dinizio; Standish, Lauren; Louisa Evans; Noncarrow, Denis; Rudder, Lynda, Russell, Scott, Silleck, Mary;Tomaszewski, Michelle; William Ruland Subject: RE: Emailing: Referral Fireworks Pecon_20190725152633 This is not Town Preserved land. Melissa -----Original Message----- From: Neville, Elizabeth Sent:Thursday,July 25, 2019 3:32 PM To: Burke,John<johnbu@southoldtownny.gov>; Duffy, Bill<billd@southoldtownny.gov>; Fisher, Robert <Robert.Fisher@to wn.southold.ny.us>; Flatley, Martin <mflatlev@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Norklun, Stacey<Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.nv.us>; Baylinson, Lester<lesterb@southoldtownny.Rov> Cc: Doherty,Jill <fill.doherty@town.southold.nv.us>; Doroski, Bonnie <Bonnie.Doroski @town.southold.nv.us>; Ghosio, Bob<bob.ghosio@town.southold.nv.us>;Jim Dinizio<iim@iamesdinizio.com>; Standish, Lauren <Lauren.Standish@town.southold.nv.us>; Louisa Evans<Ipevans06390@Rmail.com>; Neville, Elizabeth <E.Neville@town.southold.ny.us>; Noncarrow, Denis<denisn@southoldtownny.gov>; Rudder, Lynda <lynda.rudder@town.southold.nv.us>; Russell, Scott<scottr@southoldtownny. ov>; Silleck, Mary <marys@town.southold.nv.us>;Tomaszewski, Michelle<michellet@town.southold.ny.us>; William Ruland <rulandfarm @ya hoo.com> Subject: Emailing: Referral Fireworks Pecon_20190725152633 Importance: High Good Afternoon, Attached, please find a Fireworks Application of Peconic Landing for a fireworks display on September 1, 2019 Rain Date: September 2, 2019. Please review and send me your comments and recommendation. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 Your message is ready to be sent with the following file or link attachments: Referral Fireworks Pecon 20190725152633 Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. i r , RECIVE V JUL 2 5 2019 o��S11FF0���vG -� • ELIZA MMA.NEVMLE,MMC ? Tow .Q 'own Clerk TOWN CLERK - � Z Southold,New or REGISTRAR OF VITAL STATISTICS d ,� Fax(633)765-6145 MARRIAGE OI+,FICER �'� �' Telephone(631)765-1800 RECORDS OF MANAGENLM OFFICER FREEDOM OF INFORMATION OFFICER southoldtown nortbfork.net OFFICE OF THE,TOWN CIMR TOWN OF SOUTHOLD APPLICATION PERMIT TO DISPLAY FIREWORKS r` APPLICATION IS HEREBY MADE, pursuant to the provisions of Section 405,00 of the Penal Law of the State of New York,for a permit to display fireworks as hereinafter specified: DISPLAY IS TO BE SPONSORED BY Peconic Landing at Southold Inc. ) PRINCIPAL OFFICE AT 1500 Brecknock Road, Greenport, NY 11944 DATE&TIME OF.DISPLAY 9/1/19 at 7:15 pm EXACT LOCATION•OF DISPLAY Peconic Landing property near Brecknock Hall SUFFOLK COUNTY TAX MAP NUMBER FOR SITE SGT�M I®DID"3 rt n-` :'�j RAIN DATE&TIME 9/2/19 at 7:15pm The following persons are to be in charge of the actual shooting of the firewoirks: Name Age Experience Physical Condition Robert Mardorf 45 yrs. 1 yrs. Health Excellent (Additional names and information may be submitted on an attached sheet Number and type of fireworks is as follows; � 1.3G Fireworks: , maximum shell size 2.5 inches in diameter plus illuminations Manner and place of storage of fireworks prior to display: Delivery will be day of display. Attached hereto and made.a part of hereof is a diagram of the groands on,which the display is to be held. Also attached is a certificate or policy of insurance coverage. " NOTICE .Written permission,with signature of-the Property Owner.must bersuhmitted-with.the Application:. Q- Yt I e t_'0 Aa 6qfi lXt SO L4& (C�r fie, FEE;, $100' Name o£Organization See policy-460 additional information tl be-r+ T. 5�i ro n By .,PrintedName o . Applicant Sig atureofAppli ant e-mail address: 5�/r9 r} /�P.CoN I L 1�t1(�(r�/tt�SCM k 7 1 19, Telephone Number C i-`f 7a - 3$®o J7(kk/ d Date of Appli tion Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 07/25/19 Receipt#: 258405 Quantity Transactions Reference Subtotal 1 Fireworks 9/2019 $10000 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#89018 $100.00 Peconic, Landing Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Peconic, Landing P. O Box 430 1500 Brecknock Rd Greenport, NY 11944 Clerk ID: BONNIED Internal ID 9/2019 Ka µP""�'�nf 999 South Oyster Bay Road,Suite 111 i 8ethpagz,NY,New York 11714 ® United Slates L 1 V E 516-597-5500 www voltlive com America's World Class Fireworks Leader Display Date:September 1,2019 PREWORKS DISPLAY AGREEMENT AGREEMENT made June-4,2019 by,and between Pyro Engineering, Inc.d/b/a Volt Live,whose address is 999 South Oyster Bay Road,Suite 111, Bethpage, NY 11714(hereinafter"VOLT'); and Peconic Landing 1500 Brecknock Road, Greenport, NY 11944 (hereinafter"SPONSOR"): WHEREAS;VOLT-designs,,produces,and conducts fireworks displays;and WHEREAS;SPONSOR wishes to engage VOLT to design,produce and perform a fireworks display on the terms and conditions'hereinaftee setiforth; NOW,THEREFORE,in�conslderatton of the terms,conditions and covenants hereinafter set forth,the parties hereto do mutually agree as follows: 1.FIREWORKS DISPLAY.: On,September 1,2019(hereinafter"the Display Date"),VOLT shall provide the fireworks and equipment for the display at the Fireworks Display location.The display will be under the supervision of a VOLT trained technician.It is agreed that VOLT shall be the sole fireworks supplier and producer for the event contracted for herein. (Note: The actual start and stop time of the.display will,be determined by.the_govemmental authorities having jurisdiction over the display). ALTERNATE DATE: September 2,2019 2. COS.T AND PAYMENTS: FIREWORKS DISPL" PRICE: $8,000.00 I The-total(Fireworks"Oisplay'Pnce°plus all•other applicable charges)sum of8a� ,000.00 shall be due and payable as follows. a.The sum of: $4,000.00 upon execution and delivery of this contract ,b:The•Balance:of $4,000,00(which includes any taxes that may be applied to this sale) shall be paid by Official Check made payable'to Pyro Engineering,Inc.not later than fifteen(15)days prior to the.Display Date. Please Notd: SPONSOR,ls responsible'for the payment of all governmental fees and taxes, including, but not limited to, sales, use;excise,license,permit;,enWrildinment,or-other fees,taxes or"surcharges imposed or otherwise applied to this exhibition. Also, please's9e Section`16(c)-betaw, 3. POSTPONEMENT/RESCHEDULfNG:If the display of the fireworks is postponed/rescheduled by reason of inclement weather or by determination by the governmental authority having jurisdiction,or for any.other reason beyond the control of VOLT,same shall be re- scheduled to the Alternate Date set forth above. In the event a postpone ment/rescheduhng is necessary due to inclement weather or by determination by the governmental authority having jurisdiction,or for any other reason beyond the control of VOLT a postponement/rescheduling fey will be based on the table below. Description I %of Fireworks Display Price Additional Costs If notified by 12:01 AM'orf 813112019' 5% An 3"Party Vendor Expenses If notified after 12:01 AM on 813112019 15% An 3r0 Pa Vendor Ex enses When fireworks tech arrives on site 20% An aro 'arty Vendor Expenses Any request made by SPUNSOt%'fdr rescheduling/canceling shall be directed to help@voltlive.com or by phone(516)426-0334. It is understood and-agreed that VOLT shall have no obligation to reschedule a display except as required by inclement weather or reasons beyond the control'of VOLT. 4.SPONSOR'S AGENT:Diane Radidan CELL PHONE: �O-1-91`/.X shall be designated as SPONSOR'S agent to whom all questions and inquiries shall be relayed. Sponsor's agent shall be the only agent of SPONSOR authorized to make decisions on behalf of SPONSORor to request rescheduling of the fireworks display on the part of SPONSOR. Please initial each page. Initial here- _/`l j- Spa r rA 5. EXHIBITION PLANNER CHECKLIST: It is understood and agreed by the parties hereto that the Fireworks Display shall be contingent upon the strict compliance by SPONSOR with all items specified on the Exhibition Planner Checklist(EPC)which is annexed hereto and made a part hereof. Failure on the part of SPONSOR to comply with all requirements set forth in the EPC to the satisfaction of VOLT within the time limits therein set forth shall be deemed to be an event of default of SPONSOR'S obligations hereunder 6.SECURITY/SAFETY: SPONSOR shall provide and maintain sufficient Security before,during and after the Fireworks Display until the pyrotechnician in charge declares the area clear. Security shall be deemed to include,but not limited to,be all security lines,police protection, snow fencing,rope lines,barricades orany other item deemed necessary by the local government or by VOLT.SPONSOR shall also provide and maintain an area clear of any buildings cars and spectators with a minimum radius as specified by current edition of NFPA Code 1123, as a Fire Safety Zone(FSZ)during the entire period commencing from the time the fireworks are delivered to the site until the area is declared clear by the pyrotechnician. It is understood and agreed that VOLT will cease all fireworks discharge due to any security breach of the FSZ VOLT shall not be responsible for personal,injury,vehicle or property damage occurring within the FSZ as a result of the SPONSOR's failure to maintain the FSZ in accordance with'lhe standards of current edition of NFPA 1123 which, incidentally,are only minimum standards of distances. SPONSOR acknowledges and agrees that VOLTs responsibilities are limited to the Fireworks Display and that VOLT is relying on SPONSOR to maintain the aforementioned FSZ and to comply with all Federal,State,municipal and local laws,orders,regulations and ordinances pertaining to the implementation of any and all security measures at the site of the Fireworks Display.Any site visits made during the display-setup-by or on-behalf-of SP_ONSOR.shalLbe in. accordance with the current edition of NFPA 1123-and under the direct supervision of the VOLT technician in charge.Any such inspection shall not in any way interfere with the safety,setup or schedule of the preparation for and disassembly after the Fireworks Display.The VOLT technician in charge may,at his discretion,cancel any inspection that in his sole opinion may compromise the safety of the setup or the Fireworks Display or the setup schedule, The VOLT technician mayat•anytime temporarily_disconUr ue the discharge of fireworks for any reason 7. CREDITS: As a material inducement to VOLT agreeing to enter into this Agreement,SPONSOR shall give VOLT program credit,as sole fireworks supplier and producer in all press releases,advertising,and any other program announcements,printed or otherwise. 8.INABILITY to DELIVER or CONDUCT FIREWORKS DiSPLAWFORCE MAJEURE. VOLT shall not incur any liability for any loss or for any failure to perform any obligation hereunder due to causes beyond its reasonable control including without limitation legal or regulatory restrictions, labor disputes of whatever nature, power loss, telecommunications failure, acts of God, or any other`cause beyond its reasonable control. In the event VOLT Is unable to deliver the Fireworks Display on the Delivery'Date this cofitract will remain in full force and effect and the Fireworks Display will be performed on the-Altemate Date or if no Alternate Date is stated then on such other date as may be agreed upon by the parties. 9.CONTRACT SUBJECT TO GOVERNMENT REGULATION. This Agreement and VOLTs obligations hereunder are subject,to all applicable Federal,State,Municipal and local laws,rules,ordinances,.regulations and codes,now or hereinafter in effect,and to.the conditions and limitations contained in the permits required to be obtained by SPONSOR prior to the Fireworks Display. In the event any Federal, State,municipal or local law,rule,regulation or ordinance shall be enacted which in any way-prohibits,limits or restricts the sale,performance or operation of the exhibition of the Fireworks Display or in the event SPONSOR'S permit in any way limits or restricts the sale,performance or operation of said exhibition,VOLT shall limit or restrict its performance or the Fireworks Display so as to comply with such law, rule,regulation or ordinance or limitation or restriction of SPONSOR'S permit.SPONSOR acknowledges that any such limit or restriction-placed on the performance or operation of the Fireworks Display shall,in no way result in or entitle SPONSOR to a reduction or abatement in the full contract price 10. GENERAL PROVISIONS: a) This agreement constitutes the entire agreement between the parties relating to the subject matter hereof,and may not be changed,modified, renewed or extended except by a written agreement,signed by both parties. SPONSOR acknowledges and agrees that VOLT has not made any representations or warranties except those specifically set forth in this contract. Should any clause,section,or part of this,agreement be held or declared to be void or illegal for any reason,all other clauses,sections, or parts of this agreement which can be effected without such illegal clause,section,or part shall nevertheless continue in full force and effect b) SPONSOR is responsible for removal of paper debris associated with the Fireworks Display. c) VOLT is not responsible for procuring any marine services associated with the production of SPONSOR'S event. Should SPONSOR require these services,VOLT may,upon written request,assist SPONSOR in the location and contracting of such services. All additional costs and fees associated with marine services are the responsibility of the SPONSOR. It is specifically understood and agreed that VOLT shall not be responsible in any way if any third party service with which SPONSOR has contracted for service fails to perform and the display cannot proceed as planned. d) SPONSOR is responsible for any additional marine costs and fees,city permit/escort fees,County IState/PD/FDIFM fees, local town permit fees, etc. e) In the event SPONSOR cancels the Fireworks Display the full contract price as set forth herein shall become immediately due and payable. SPONSOR will have up to 30 days from the date of cancellation to request VOLT to reschedule the Fireworks Display. Fireworks Display shall take place no later than six months from originally scheduled Fireworks Display Please initial each page. Initial here- Spo i-lyjl� f) VOLT agrees to procure liability insurance on behalf of SPONSOR,and to indemnify SPONSOR,to the extent thereof,for all claims arising out of VOLT's negligence. Any additional insurance that is required that incurs a cost,will be the SPONSOR'S responsibility. 11.SPONSOR'S DEFAULT: in the event SPONSOR shall fail to pay any sum when due under the terms of this contract,SPONSOR shall pay,In addition to such amount,inter'est`at-the P6te of 1:5%per month on the unpaid amount from the original due date SPONSOR,does further agree that it shall,pay VOLT reasonable attorney fees and other costs in the event VOLT shall commence any proceeding(Arbitration or any other,proceeding)or incur fees to compel SPONSOR to pay any sums due hereunder or otherwise as a result of SPONSOR'S default of any of We terms and provisions herein contained. 12.UQUJDATED DAMAGES: It is agreed by and between the parties hereto that in the event of SPONSOR'S default hereunder VOLT shall be entitled to receive the entire contract price and same shall be considered"liquidated damages"based upon an understanding between the parties hereto that VOLT will have suffered damages due to Sponsor's default.The damages suffered by VOLT as a result of Sponsors default will be substantial,but incapable of determination with mathematical precision.It is,therefore,agreed by the parties that the amount due VOLT is not a penalty,but rather a mutually beneficial and reasonable estimate of the damages suffered by VOLT 13,SUBSTITUTIONS: VOLT shall have the right,at its discretion,to substitute any fireworks it deems necessary provided same does not detract from the aesthetic value-oequalityof the program:This includes,but is not-limited to,shell sizes,quantities,types and brand names. Any substitutions shall in no way result in or entitle SPONSOR to a reduction or abatement of the full contract price 14.ARBITRATION: Any and all disputes,differences,or any other type of controversy arising out of or in relation to this Agreement, including as to the meaning or interpretation of any provision hereof,shall be resolved by arbitration in Nassau County, New York, pursuant to the commercial ruies.then obtaining of the American Arbitration Association:Only one(1)arbitrator shall'be required,and the arbitrator may award attorneys'Yees.The avA4 of the arbitrator shall be final and binding and judgment may be entered thereon in any court of competent jurisdiction.The arbitrator sitting,in such controversy shall have no power to alter or modify any express provision of this Agreement, nor to make any award vlhicti bjils terms effects any such alteration or modification. Either party may seek from the court of competent jurisdiction any provisional remedy in aid of arbitration,including,but not limited to,injunction, attachment or replevin, pending the determination of any claim or controversy in arbitration. Any and all disputes,controversies, actions,claims,causes,of;action,or proceedings arising under,out of,or in connection with or relating to the terms of this contract,and any amendment thereof,commenced by,between or against-any of the parties of this contr"act'shall be deemed to have arisen from a transaction of business in New York;-and shall be resolved by-application of the,substantive laws of the State of New York. 15.BINDING EFFECT., This contract shall not be binding on VOLT until executed by SPONSOR and VOLT and VOLT is in receipt of the downpayment required hereunder. 16. EXHIBITION PLANNER CHECKLIST(EPC): a. FIREWORKS-DISPLAY PERMIT: (Note: The actual start and stop time of the display will be determined by the governmental authorities having jurisdiction over the display). 'SPONSOR'S RESPONSIBILITY: It is Sponsor's.responsibility to call your State,City, County,Town, Borough,or Village Fire Marshai,oe other,appropriate authority to.frle;for olid obtaln'the Fireworks Display permit VOLT will prepare the paperwork for the permit,application on SPONOR'S_,behalf: Upon receipt of your permit you must send the permit to our office for our records no iaterthan 36 days nribi to vo&'displav date Failure to do so could seriously,leopardize your disolay ,You must obtain information on: 1. Filing application deadline and fees. 2. Local and state requirements for fireworks license for transportation and/or display. If a license is required,fax all forms immediately to us. 3. Fire Marshal's requirements for security of fireworks truck upon arrival,and the security of the fire zone before and during the display. 4. Federal.regulations require that we carry an accurate route plan to the display site Fax us a copy of the route instructions from the.,nearest US,Interstate to the display area(approved by the fire marshal or other authority,if necessary) 5. Notify FAA on day of your display,according to the instructions in the FAA Letter of Approval,which will be forwarded to you prior to your display. b,COAST GUARD PERMITS(where-reciiuiredl: 1. if the fireworks are to be displayed,on or near,the water,the following may be required: (Requests for permits must be filed at least 60 days prior to the Display Date(135 days prior for 4th of July events). Please initial each page. 9 Initial here: ' sor VOLT 2. 'Coast Guard Application and Permit to Handle Hazardous Materials. 3 Coast Guard Marine Event Permit, c,SPONSOR RESPONSIBILITIES AND EXPENSES(The following services need to be provided and paid for by the SPONSOR in addition to the Fireworks Display Price. I ',SECURITY:-,-, MU$TBE PROVIDED-,FOR.,FIREWOR'KS.-'TR'QiC rjlJ'�O`MAINTAK THE,�IFIAE,9AFETY26KE'AT K!�) , i i ' � ' THIS, STAGING AREA FROM DOART.UREVVHICH-,MI�*'814,FOL,�,LOWING THE REQUIRED FIRST LIGHT DUD SEARCt4bN-T"HE-^ MING AFTER THE DISPLAY: - 2) Sand: Please provide_0_yards of sand. 3) Laborer(s): 0 laborers to arrive at fireworks site on (They Will not handle fireworks). 4) Hotel Room(s):—0 hotel rooms(within 10 miles of show site). 5) Vehicle(s); Four-wheel_drive vehicle for movement on.qand.:.Yqs_No. XX—, 6) If you have ordered a set piece(s),you are responsible for erecting the scaffolding and It 'must be ready When the r.rew arrives d.RADIO SIMULCAST EXPENSES(if applicable): 1) Set up and staff a fireworks simulcast command center on,sfte,c6j-l.'Qb PM on the display date. 2) Provide broadcast relay to VOLT Firing Center. Call our office fbFddtails. 3) Speaker system for VIP viewing stands. e.INSURANCE: Please list below the additional insured,as they should appear on the insurance certificate: 1. Peconic Lanclinq(df Souhti6Mric.; Brecknock 3. Hall Foundation Inc.; 'PeconiLl-Landing Housing Association Cooperative, Inc.; The Shores at Peconic Landing Assisted Living Residence, Inc.; Peconic Landing Home Health Services,Inc.:Town of Southold. 2. 14 La/,,4 E vt.A�M I �-Z (I? Name of Sponsor J Date Nolt Live,Signat Date BY: YVJ Ji Si ped�y 9�!bqhajf pf Spbrinsor(Signature) Print Name- LIf Title of authorize &eraative of Sponsor Tide ATQ, ...................................................................................... State of 0 W Q County of ,-4A On the 12-day ofjEAL-1 in the year A19 before me,the undersigned,a Notary Public in and for said State,personally appeared Q6btr-A7a,- sgirpr) ,personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s)whose name(s) is(are)subscribed l to the within instrument and acknowledged to me that he/she/they executed the same in hisitherldi-eir cipacity(ies), and that by his/her/their signature(s)on the instrument,the individual(s),or the person upon behalf of which the individual(s acted,'executed the instrument. .Its&AA kt Signature and Office of individual Allison M.Latham taking ackno%sledgraeritry Public,State of Now York Iseal] NotaReg.No-OILA6380165 otiented in Suffolk county commission Expires September 4,2022 Please initial each page Initial here. �Sp- IV OLT PYRE ENGINEERING, INC. d/b/a Volt Live DISPLAY SITE PLAN QUESTIONNAIRE All iterns listed below are subject to all governing Federal,State,Municipal and local laws,rules,ordinances,regulations and codes,now or hereinafter in effect,and'to the conditions and limitations contained in the permits required or to be obtained by Sponsor SPONSOR, Peconic Landing apt c; 15 Display,Ddte ��+ Rain Date' c) '.�a i Budget: Display Location: A N-) ci4- Aj—A Time of Display: (Note: The actual start and stop time of the displ'a9�Vil I b-e' determined by the governmental authorities having jurisdiction over the display). IMPORTANT. PLEASE PROVIDE A SITE PLAN FOR YOUR EVENT LOCATION, INDICATING WITH AN X THE EXACT SPOT WHERE FIREWORKS ARE To BE so--up. Local Fire Maishal: Telephone No: Ch jo--L r-, Cell Phone No: Crew Contact Person: Telephone No: Cell Phone No: The Following Information is necessary in order for us to provide your community or organization with a display that conforms with fireworks safety 2gulations and for the-issuance of your insurance certificate. DISTANCES,IN FEET, FROM THE FIRING AREA TO THE FOLLOWING: FEET SPECTATORS,AUDIENCE OR PARKED CARS................................................... OCCUPIED BUILDINGS (HOMES,APARTMENTS,ETC.)..................................... PUBLIC BUILDINGS(SCHOOLS, HOSPITALS,CHURCHES, ETC.)...................... TEMPORARY EVENT SET-UOS (CONCESSIONS,TENTS,ETC.)........................... MAIN PARKING AREAS............................................... .................................. HIGHWAYS OR ROADS.................................................................................. OVERHEAD OBJECTS(POWER LINES, LIGHTIPOLES,TREES, ETC..................... FUELSTORAGE.......... .................................................................................. PLEASE PROVIDE DIRECTIONS FROM NEAREST INTERSTATE TO DISPLAY SITE. A MAP WOULD ALSO BE HELPFUL. Local Motels/Hotels: Telephone Nos. -/21 Signature - /-� Title: /V Date Please iftal each page. .Initial here: AVZL--- SPOFF �OAL r i i �oeS1�FFOL C ELIZABETH A.NEVILLE,MMC ��O �y Town Hall,53095 Main Road TOWN CLERIC P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS `gyp • Fax(631)765-6145 MARRIAGE OFFICER Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER �0.1_ �►a www,south61dtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN, CLERK TOWN OF SOUTHOLD POLICY for the Issuance of Fireworks Permits 1. The Town may grant a permit for the display of fireworks by municipalities,fair , associations,amusement parks, erp sons or organizations of individuals. Penal Law Section 405.00(2). 2. An'organization of individuals"is a religious,civic,or comparable organization.Op. Atty. Gen No.2007-3. r 3. Fireworks permits shall indicate that the display must be concluded by 10:00 p.m.if held Sunday-Thursday, 11:00 p.m.if held Friday or Saturday,and there shall be no time restriction if held on July 4. 4. No person shall engage in or allow the manufacture,assembly,storage or display of any fireworks or pyrotechnics display without first obtaining a permit issued by the Town Clerk. A completed application for display of fireworks must be received by the Torun Clerk a minimum of 30 days prior to the date of display. The permit application for any fireworks or pyrotechnics display shall be accompanied by the following: ray a copy of a valid certificate of competency as a pyrotechnician for the individual supervising the firing of the display; Certificate of Insurance naming the Town of Southold as additional insured with coverage limits of$2,000,000 for public liability and$2,000,000 for property damage; �.} Detailed diagram showing location of fireworks discharge and minimum separation distances in accordance with the applicable requirements of Penal Law Section 405(2); (d) A copy of the contract with fireworks display company; and (ems) All applications shall require the approval of the Fire Chief of the District in which the display will take place and the Fire Marshal before being presented for re approval by the Town Board. J Qv®��FFOL � ELIZABETH A.NEVILLE,MMC ,y. a Town Hall,53095 Main Road TOWN CLERK -P.O.Box 1I79 C4 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p Fax(631)765-6145 1 MARRIAGE OFFICER Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER ©.` �►Q www.soDtholdtowany.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD INSTRUCTIONS FOR DISPLAY OF FIREWORKS 1. Name of body sponsoring fireworks display. 2. The date and time of day at which the fireworks display is to beheld. 3. The exact location planned for the fireworks display,including TAX MAP NUMBER 4.' The age,experience and physical characteristics of the persons who are to do the actual discharging of the fireworks. 5. The number and kind of fireworks to be discharged. 6. The,manner and place of storage of such fireworks prior to the display. 7. A diagram of the grounds on which the display is to be held,showing the point at which the fireworks are to be discharged, the location of all buildings,-highways and other lines of communication, the lines behind which the audience will be restrained and location of all nearby trees,telegraph or telephone lines or other overhead obstructions. t 8. Such other information as the Southold Town Clerk may deem necessary to protect persons and property. Written permission of the properly owner is required. 9. An indemnity insurance policy with liability coverage and indemnity protection of $1,000,000.00'per person for bodily injury; $1,000,000.00 per accident;$1,000,000.00 property damage. 10. The Town Cleric of the Town of Southold must have the insurance policy in her possession before the fireworks permit is issued. The named insured must read:TOWN OF SOUTHOLD. Thirty (30)Town of Southold POLICY 11. Application for a fireworks permit must be made at least fr&-days in'advance of the date of the fireworks display. (The above instructions are in accordance with the Penal Law, Article 4051- Licensing and other provisions relating to fireworks.) b 5. _ All applications for a,fireworks permit shall be subject to an application fee in an-amount of-$100.00;together with a processing fee in aft amount to be determined by the Town Board to cover the Town's costs for monitoring and enforcing compliance with the Penal Law. (The.above instructions are in accordance with the Penal Law,Article 405-Licensing and other provisions relating`to fireworks.) r ' r 1 P11712-- ; :.. :'`.�,\\\`+>F .c`5 ,'"'\\,'°` *\.tea`` a \e` `�. `�... " `a �ceL >., z_ `\ a\� " `.� .:\cc .r''��`.�,x. ��.�5.a..:.u��a,,��:.> :.. '�., .,��s_.>^>�\��` i:`aY•.\il` `P.\Yl :sS 1.��X� -_a`�\\\1K'w"ut _ \:m ;.e�a \:�T,n w "`i,> ..'\\a\." w. >.?o a .;,• \JR:,y .'�a'.`\`<• L?`:'�.•a: �;..� >:>ti.°;, a>\o..` �,��`��\�...` ��;.=..aha• "a ;"`�\..'.,'a.�F `�F� a. P, .\. :c � \ .> a a.@. w �a�w;";.°`aa�., .e.. �� \\a: :�.. � a•:a @. .,y n \�yaaaL: \tee"`S\ .,a•.s ��i. .��< ".\.�., p`O'��" a a\\l"':. �u� ` _ \�,•`•'. •s: - �?a $\zF�x\:.:ti,.�'3, .�.\•\ �'�'", .�.� .�>\\�'k�: .�.8\F,.,<F.�' _�.\\,,\. .�e�v\"aaw. 3,,..,.�..,, a. :e\`�a.: :a'x � ><P. 'L.>, .a'\.`z :p\\ s.\,.'3`',•,'a��< `�,a \ \�a� �ya"':Y�.. A. ..w�< <:.. ,x^: a, W.`�`•• .:iw" e\,.M`Vj,i .\ NO ADMMA �.F=.�?a,\,•w @. .e .\., o tae � 7' �^4.'• dn, :'4. :,,;.. lQI .:,.r: �F. :;������ti.�:�.: ��,�'�F��`• g\\ ,�a��..v �ni.,�a<'•,*��:,tti, off, �' a'.i..;y�; �>��'��*'. "�.a.„ .a`\,a`�ah.,• ,`a ��:.. ,<a„.a a. gid.. va.`.`a a»";``.v`.`,} Wig• .�.o"tea ..r��`.' �\i\�:e .Fn*`\.� �'\�Y."; 'yd' .y °S\� a :. fid^ M \\. x` ^ \ :' \ay\"a <. \yC'Y \��\a\a.. :: .F>^`' \. E xa " \_, a� �3.x. ,.\aA` a.,,. �.3.`:'• �;\, " �,<`. .<.. \ x, ^'`AS'aa s\, ac`s` ,• l ..` �, r'%%`>\",a: a`,;,q. \;�. ..�>..x.,.`�.r' Z: �\ >'.<,� 'r�'w�`\:.\. ��a. � ?�,a. =i�\rF'�:a:: ,� _•�Fx =s a\a`.qq':�"��:x .5.,' .a\�!'a•�\�`��,.�� `\ \ ..a...,�..` ate;: :�"� •" � a.<aa ?';� .,,.Yom, \x >a�' � `,��x ��as, <a�� g.•�t, d 1.,'8F^��,a�� .\\.. :�°ti�`a .\i `: � ^r• .a„, ti\�� _ � ;a':� ar .^`..4<•=P„ 'a.. "`.• '� / .,,a .A, `a :.<r`\�.a`,aax u”w<+a::a %• \,a2.., ..��:• .�.:.:�v�� x C..�.._ "."k F, ,:,•"t„�.�`•" a. \ x 44, ... aL '•\'``.3#,:`1 'aw. gfh%, `.. a\. @' ,$.\av Ly•a\. -<�,. ti �>,`�.. F`.` �v„� °• 2{ ,may„ .•. - <" Z ` (.�.`x•.: i,?P.... `.av v.=,� ^< \:�` r. ` u *` _ 3' .kyr • :Z.. if .a x�.m,: f .\r F�:w3;�. ?� „':x` :" :•„.o„ate ..�kx. ,:•., ate. y r.. 'irt�.. ,,;` ;: '�x`,\Y s � e Al F' `axLF �a�° �. F�"=;.a.:•�a .. .R\"'> <�.,a.,w �. �\ w>: .s .o..; t„ V s^>:c. '�.,.3g \�` v <. hLL �:,•w\\N' an��? P ,y<t 'fir \. '�:' PECOMIC > x. ?•\\ ., '`•<=;°pa• �'c•est �a�'. �,�.pg � �<� :��. :.i� ,�a :•i•. ��a. ?. ,,��. baa <.� .tsar. `•..q.•\4°\ .L\\.\ fi�> tia^Fe```vl' "` F:a\a'"'dF, .d,..:\@ •1 �`^ x:� � .`�> fix: ��Za `:� Pie uaC..4�.' xL�vi\.o��.. .x4” •yF' x, a.�. Fy ”. OTH 94, u use '. ANNIVERSARY =�.�'aa` - ��•s�" -%•\ ,�: \ 'fie,, e�aa. ..\\\>,e:` a�.er`' ,.��i: ':.,; �„ �.. \.�\ SIZE- )A, PF�,i: R ..'�.y. 4a`.��•a` t a F <�a� y �x R � .tea,. ;\ a ,�a + ?4P:i ,Y >.2�\`�,e� ��C�'a"u V1 •2''\ <as.aw'_ �' a p aYc "Z.<C , a��,! ,� \, .,.� \ 3 i a\a"F - �. .ea<.\:„ `:\iia `�� .\ •i�e` \sa. '.:Ga �`. �,a\>> da �j� w �?'P r , E:�:@,\", "�` � e.s� `>F ^.i' :@x:"a�• a,? \�. > ,Y .`R,�'\`�':A'a:.a:":Wa`�@�\,P.,�..;av.�`;.'.^'.a::.>"„�a`<..Va`Fa\.:`:�.\ta\\�'"\�.�'.fr<,ad`�y\..;s�v�i`\at:a�.;,".a<:.;`o'”'aaC.-�,'a,L..?\.\,�\.fi,,>wr\t\a_e\.:ti;F..':�.;�^��v,k�a,\a\tG-ko°�S.\�..�\oa\�\\a''oF�F\\°aaR'a.e`r.^a="fi;`a`•ea•a.`'��p..a•0:\�\:il.\��;".3\,.\�e`a>c`'.�:t`�1n`.�..�;a\;\*`,w'a`,�x•"c..\a''`w'`a.�ai\,.;;.<.:,,`a*:,,..\\\..vr\*ae•'''`>`\<.'a`'.,:.::i.`s>�^aa,g.a.�..�.:,.\_�>.^;�,�:.�F`\s�.',=.�A.>?x:�4?..>\',e^.,„\`.'S\\',^".�`�\�"'m"'a<i„.�.Saa.:"„.'.`�^.e�i'.'iCiv`"e�`�a&x.c:.`�;.'aa:�-�`e��dv`1�"••..A���.-�.xe'�.�aa.'\„a,ag�^,\a�°',o_t�.a�rc.Z:\:'"�_,,x��.!�Y.”'�.v,�'o\,°se`v`va.�Y`"�a1,i\a:�`\,1\.:�.Saa*en'.w,¢�m,\>�.e,,�yi•a�d'>>L��r`..>"'i="+,a'S\�`..�:,.. .,\<•.'Va:,a,\`*\..�,',``>'',e`,•y�:�'..F.�=:a;°u,,:s.>".;`�"at��`,\`:\�:,:.,:.�:`^,.\'D.,�u!a:S:4-M<•.^.-.a : 210 RAIDUS ^NP ppffit ^ :4M, :Mr� a\`c• �z �.. „ vt �\\ , <mz ta a , .Sra. : , `:• e as `,�, ex �\\>,: .: S.�t�• ��\�,. E� a .�,XPW 4 ..�: �'�a� .� a,`o <.ca".. .,tea ��C,a• �<,. u \ \ �'"\� �.'`,�,., > c -." oS� c \,.•. aAxF:�:�v� .�,.. l• •<� Ry�Hc:�^;`1"\a.':`a �'�6z I,.a .Sl ,a. :\ Via. :BeP, ; `�.ac .<,` Ylv. :��•_\ \.: •`i! e\$:^;te.. �,\, _ '" `a•. x,`,`\\ a ;i \,xa..\k, `.. `?°°\, oP\@.`�:. :. 'NP `• ?`\." ``', `\a \:r< �' \.^�\a.•^"\\`��<��' A:�'. Qom\ `b ,.F.�Y,. + �..,.x '`, ,1... ,' :.\��E.",.-x•' .: ..„.` o., Y\a >`..s `;a,:`;."'a°;x>ra`i. ::Z'ua`3..- `,`,' "\\`\.•:..%,„;b.. -y.i`t `xA�.i•�:;> <, �< .�. .�ia,' �,a.a y> ,'s' ..a:. ;_ �\3 ;� .„."��;@ .\'.,`yah\ . - NKM rr Q a�..u. �` >v\ ZXIa:a �}� \ \� O✓ >:�' \\``.%`«�''\`�'.���"'�`�e Via`,` .?aC�:�ir aC:.�S 8, VMl j ,. •S ^,'io "c €F,\o` „ .. ^ a , \ x �.. °:9%Y. aY: '::` .`�`..'a\•a`,e^. <�C' ,. %" `�, Z >.•� ;�\..a .a,a•� ay� d ,�: .`@\v,,. `�L. .e= �:x\`�"..La\,�..�^a `�.\. :a ;�\,s may` \o�„ .= \ti. \.. �. :\ a\� ti:�, �a §h9At 8��\ �.,x��a�,� 6rm:' a .` (( F•R: a '°A• .Aa:.\�' „ ���as<,. \C?aa,.` aP\ a a.< �<a., u ..fix.^! :.a,.. e":. Ya, :,\\ ..A,, av � ,...,a.• \ .\•, :.�`F."F":Y."a�a= 3e\\ 743 W `�. ""t, - '>, �.aa�CY _�.�'=t��'�.,M� a` `>a..sgt� .:`�..`�\`\\."\,�.,.•� �:?�``` �:� :zE��?y, '�� v� �.. a„. \ `",ax.. o=.'t„> •:aab'., m\ ��a'C\\,,:` x.o, t. 3 ,car '^ ."Y��' \\..•,�.z�"- ^;�.q �”"'oxo, P* U.S.Department of Justice Federal Explosives License/Permit Bureau of Alcohol,Tobacco,Fiareantts rand Explosives (18 U,S.C. Chapter 40) l a #;trt3r��ttirtK=ASR7 In 71CCn7C1:niC4 1�'11h the]rUvisioals of•I'dlc XI,Organucd Crime Conirol Act of 1970,and the,regulations Issued IhcrvundeT(27 CFR Pan 555),you niny engage in the acimity specified all this licen.w or ivrtril Within tate lttnlia(iLnh o Cb.ipler.10.•('tile 18,Unitcd Stales Codc and the resaulat:ons issued thereunder,until the expiration Jatc shotin, l!tIS LICENSE IS NO't Ji R NS�,�rt,t i3%K ZJ`vtll,it 2 C It fti5.f11 $cc"WARINTINGS"and"NOTICES"oa feNvse. Dircct A IT A'lT.Chief:FELL � I,tcnnsePcrnnt t onVhNrWk1lcCT(I 244 Needy Road Nurriver Marthwbttrg.WV 254tis5-94:1 Cit:cf,Fcda ereI�.•llasivos,Liu:nfiiItg Center ri-1J. P Expindion j }late Name (�I BAY FIREWORKS& 1NTL PYRO IMPORTERS f r'emiLws Address ttyzaagcs? Notefy the FLLC Yt leat i(1 dayr N-Twe the ITIAw i 999 SOUTH OYSTER BAY RD SUITE 111 BETHPAGE, NY 11714- 14pe of License or hermit 51-MMPORTER OF EXPLOSIVES Piuchasini3 Certific,'nion Statsntvnt Marling Address(Changcs'l dow'>•rhe FEELC of:itit uh(inL:s.; The lwinl!4c or penvira9 nursed ahcrc•c stroll use a Lily csi'thut ticalse of P,min to*";.Y a trunsfer-m 4Ir cxpltnir es to N erif the idal;ity and the lw4lwd slatux of die Iteassce or Pcrt)itt a as prtn-idcd lrn 37 CSPort 555- 71re siwoure iNk rxcli gars i itvd be t;:t>+-+eirml PYRO ENGINEERING tide xioi,iltlrg A I;+xcd.'lv,aulVJ or L-ruaiiai etgn'of file i LVW at pamill with A&[Iaialurs^ uutt+dcd to bean cxir,Tnal wrg))mure is i aN)tnhl,: 71w sig;7dture inim be gild ofti7c T�Ylan] BAY FIREWORKS 8t tlifTL PYRO IMPORTERS l r+atosivev Livalscc(1 nil_)v a respxtKihic pa cn ofthc l l:I. i cye(46 that thin iv tl true 999 SOUTH OYSTER 13AY AD SUIT=111 ,:Vpylit8tX1t'u7n4ilWedlathe kzcus O[pctnrtoeisuiiedlthtacelwimageInthe gB1l1pAQE, NY 1171�i- huvmcs�a npcKatsarti sP:Ldiad ahova under"T){lc i 1'I.i�Znxc or P<rmit'• l.icen,ec'YLitttittex J{cspt?c7si1)la 1'arwn Signature Position,'Fitla Printed flame Dflit A l V I am AUri 1.`410!i i 1'an i t;e:f.�t:�k'1SIttC�i et�XrF�>1C P'PitlfJlitt>1NG A;�H IClrealeSt to MR 1v Pmtkrlalm a M121V4 t,"mI alm-GIN anWa r�vlxJlttatc Clltl Federal Uxplosives License(FliI}CusttnnerSerr'ice information Fcderill'NriosiicsLicensing Cc717cr{r'};.l.(.'i M1-frceTelephoneNwnbLn (877)28_1-3352 ATI liomcpaye a+rtii.atf:gati' 2-1-1Ncc.h Road I-cmN11111bel: £304)016'4401 Martinsburg.V6`1i 25405-9431 E-maul• FELUalttl.gov Cturnge or.'lddrrss {2%CP%!t_f33.31{u)t Irt- T.iccn+ces ar pe,7litrccs may during the telco taftheir Current licell'o Or permit remove their businevv or operation,;In a ncit kxation at which''ihLy intend reguhrrly in cam-on well business rroperations The licenxee of permittee;is required 10 akc nolification of the new lccatian oftlie business of opL attons nut 1Lss thult 14 da}s prior t<7'ugh rcmm'al)viii the Ch"tci:Federal F.xplo-ivca Li-.vasing Center. The tic ei ne err Permit will he ti slid£ur the tentainder vi,he lu nl lit the ump)nal IicensL or permn. (The Otier,FELL,sliall,If the(icunwe or perntittee is not yustlified,rerer tate request for antmded license Or perritit to the Director of industry Operation%furdenial in accordance with§ Right of Succettsion (.7 f FR 555-59}• (a)Cc"in per5mis rather titan the Ikcnscx or pcnnitiec tray:peon;the right to cttm on the l inlc ckp,1ostvc matcnais bumilass or operations ill the�amc address sliamit on.and for the remainder ofthe team tri;a ctmcat litrn'a or lxrtnil. Such prrso7ls are: t t 5 The survb trig:;laou C or i:hild.or executor.adminisiratol,I)r n;llcr lcg,tl rt prescnl7thl'G al a deccascd tiocrisce or permittee.and(2)A weeiver or Inislea In liaril.TvpleN,ur an'migalcc for bLnctit of auditors (b)In order to secure til=e right luon idLd hs this section,tele person or N-nons wli intang the.busaless or operatiotis'Miall Airmsh the hucrlw or pormil Jor fiat that Rosiness or operoliolls for endorsement of stich suee cssioll to the Chief.1:1-I.c.within.10 duyl,t rom the dale on ultch Illc stv"cssor begins to carry on the business Or operations �'gl7rialli Ckr on revei-se y Ilei Cut herr X 1 --------------------------------- Federal -------- ---------- --- — —Federal Explosives Liceim-Metmht(FEL)Intonnation Card � ( Liecii.w-'<lertrtt Name:PYRO ENGINEERING INC i 1 g 1 i I BusincssNamc_ SAY FIREWORKS&INTL PYRO IMPORTERS i I I.aecnhc'retm'st lh`umbetr:O-NY-059-51-OE-00129 It I I J icm3c;,Penna 1•ypc.51-IMPOSTER OF EXPLOSIVES 1 i Expautioll. May 1,2020 t 1 Il1ca�Nene, \cl Valid I'm thr Sala kir Ckhet 1)i_spmiti n of L"T]o4ves.---------------------------------- 1 t i r>' L r ''2._,"'i'",����^`y^Tx€' i a x-+.r"�..0 �_ r - .s::� 45 ;-. �q ,i-i;�,{Y 3F�. r`w rc ;�a�'7'N -.''�; kyt <y?5'"t^�;.i5"'.a.,y }. .. r.+ aX,'i*'.:,.z, -(�C,v'"....:�"a �'w:, xye�:k..� e"�t' .»F. �.. �^.r v' _ r- �M E.may,-y,.�.r}1�.�w F.er:. -,<k 1 +�r^`. +�+�1`�. ,: ,�....,...� '� r "E fir" _ ie� +. ��Ct'�'.c:�'� s'k -sra a' '�,y cy; �".- - .. -�"� .c:',c�s{ r r .zf.< .�.' yrs y,Y3rxy��lz..i,Ar t a s s �s r t .r," - A *v . !y. 4 t '0'xfl w,rY'N+' } -:: 4.,�Yf o7yfr ; `kc fit' 'Kt �.�+^Z� i aY,?:_s .µ.'^. 7 �1'y a'x s' y,at '. 'ts if,Rc,, a �' b; r 4' "1 k"�-i`>'c^t"..r„ ..T rt-.:a 4g_°'� F�E •7 fmg:�`tYt*i r.•qa'k `. 'F� f^ 4�c c err+ <xr+ro 1+.Yv ,,,v, ,-k N r yti S�z y 7 L. dew m ��Q ✓ c ti ti wy ay , ,U,.:..:yxW,�.<f��r '�s'"•M�k�t�.'^�`.s✓`4 s',,•? �F.�,^l r °' -r.'L.ra A s+`nr i rnj..>ec .h1 +s"'r..,._ .'. r`.,3 rti i u ,,y. ,,. Nks �. _a'' A `5..7: ice' -;" .5:*? 1 -:.t o a,a,., ut r a..z r y me. ., w�t�k T R .'�fi ^�' �r r Xs ce''`E>• w '# f dgcY'" f_. a.. 'J r "sa.,.�;. s<ttkf q.,. ,s�- Yy>4 --�iL^ "`'"{. �ri4.4\ fi: ,a�?,:tr; .xy('s?,d. Cr rT '� r 4'Ts :,i�''" ,, .'''- 'c; r '� w X r s rx In p „� :.:.. ,,, 4 Yet• k a' 'x t4 a.! F) ,*s k. .r,� .....s st�'�'� ' y' r� -f�a'� FrS: S rias 1` -" i.,..cnr C.:y ,C`.t"L.k r y-3.. f Y 4 S Y h ♦..CY 1" .0 '.l nn�r 3� fi-' M ,�3 f'e i..f- C yr_ 't 1 f { `S 3. . . 'k e *>,'°`^w�� .£r`.z`ia{ � �� r: '��.�:.-:�. �?k�i�e, g �i,s.C�r:'F�,d v�:��" ��';._,a„'ii.><ry'r��--L v��' '€s`„�-�,. .:: t,� , a' i+�..�r `�5'�j ;.,,, "�• VigMIN y U-J x4 a d q, m <S p€3f T r M a s ar i y UP k v 5 h t9 �v 'ei,W`4 .""a.+4i�iW..Tsa v -, y zr' v„Yr;W t"y '^4yt�'s< ,;4&`'t ..mrt ns5 - d' ?�''" a�,w._,'* +aa-.'.'i;,..'R''t { # :x '1-e. r �`4n' < E., ,. .arS-.z "c tr+.*dT"w+ru- k "'Y`%� `r a _ .. 4'' .tt ^'.�+ ts" .+-, a..{.sr" .g< ) '" ..� t...�-a < ti-s - .yf' ' " 3, ."F„ fµ Y... +'Y Y..o-,7 Y p s, �✓ 7.y:.{ t''u.i `�i,4r.^4,Si.he i 5Y Sy yV_:.v3, 9 `r"f-.yy'F^� ��,rF.w .1 fr„ �►r. '"2.r .r ,.W;,.a C7 �t1.':."'%� 'S" ,1* J ; 3 s �'� 'f," ''c",-}' r 'k ;a.^ ��`st°.Lr "s 5. .Tr y;y\s's,'sp m 'v,,.c ! �*a 5¢ 5 ,) �"'?,k '4 3 '� vt �. .�+-'� � L � r �. �z c 2' .`-•�.^r k r ^�. k^...'3'" t�"w, ',r ;µ M t MC G a -"`' „y3"Y:. N' -R# ,,..-eSK -` s �k„_:4 ti� >* .+t• �' '.}�' ri : d �t "G�s+. � rwW sy��'�' 7 �•✓.-.� �` .,n. ,ne fir':r�„ P is :- 4t>6i- �ap'1 '�}v1a .1 t t;�.+",� �� �, � y> .,�� :..:.+c y, µ s`c -h a'?.:w� 6�S'ti 's'"' a'rtr�?"� s :��`3< �� n � "��t a ,. � x � }mx•S� -: "t. a r}J�.a �, �,''_ ,� P t' � .� `<^r t�ai;�i�`='� S✓�'.�'�'y�,<'r� �-,�.>• ..: �y��-9,,.."l^,5s-'` ,,. �3 Rl�H;. t^'<. psis �*3 s'Fzy3�`' r":'� s >•� ?;.: ,.x. 3 `y.y �}� .,,,,. .i3TM.d... Yf y"'."f.,,,'�,y s1.�: n^tA„.X, v'ii" 4'kz% e >„f sts-"r.:" ci. '�*nSxs,a- ^•�,"�.Y?fe �..7k`y'._' ,``' F {cyt'_e : Sce OV t�*t'E,tr',Y 6e`?., : aC 'i ':.':•^'f` {, r p :'^?ias"'v .."€ y r i 9 l..- :._ 7 §` tz;, y�.axn fr. 'tY d3• nS s' ' 1 +4a ,a", 'eS .�r" } �'',w3, ,r..t'+� _':7 �,$s Y;• t��;pt4k+,' j. r Mem a 3 3' dt *err d nt ,x "'�` f" 3 nx 1 w p 0., y, �. �,/K' t.. d`M! {'7 �` . Je l pq .75.txr. 'L:•.' err✓.� t a *'E N w'1 La.�- R7•'^+- r � r�x•s:xz."'x" cF •^" > JX t rt 4 r er �' :^iaa w �Y'zr^,` ?�R-,..+^ 7 u 7 A tctz � r r t As ' ,v.t^. £< .,�. w r ,,,t 'h 3. i __r rytr wr "ir a�' s '{,S� 3 7 e (€. i.'» ,. v d' ;{'� °`r" tf s �n d ,yyk; ,. ay`4r;:Y X' ; r<ns �yq,• k!L Y. s.. T`_yrt x -pr 41ok .# Lx. .�c, ,z r:-,`�) �1it5 4 )' x�.;,�" l €r• 'Y7 Y M 'a'r't a �i �x r t �$t E ti .r{ � .Y'� " .FW 'c ,s.,r<...n.::, f a Fir e�"'�1' °c. �) L Th ;,.a r � fj 7•y. :r } ar%i §" � r� tS ;+. 5x.1:r^+`3 ��` x' fQl.R 4 i Sxn ra'LS/lµ` 9A51 +Z� F F� . NOnj..r 7 IQ 4%ffiggp, V.tri.; .�.`,��4�x 4 .6"�`F'��ru,�`xy 7�'+++�-� 7 ,� \5'24t,4.0 I•• ��e CC 4 f r�1..��ry�'�^� yry�t � $ � •'x�Sy�rv35X�yY }� x.r. L 7 gSSSooU0ys�,Bay�oudSuUn1�1 -A 8ethpage.NY.New York 1171^ ��� ��, �� ��p�== �� United States �� O� � �� � 5182597'5500 == ~ ~ ~. www ooiU/waoom America's World Class Fireworks Leader Display Date:September 1'2019 FIREWORKS DISPLAYAGREEMENT AGREEMENT made June 4,2819byand between PyroEngineering, address is eo9South o Road,Suite i11 Bethpage, NY 11714 (hereinafter"VOLT"); and Peconic Landing, 1500 Brecknock Road, Greenport, NY 11944 (hereinafter"SpONSOR' . WHEREAS,VOLT denign* pmduoao.amdcondu�s8mwmrkn�sp�yu;onu WHEREAS,SPONSOR v�s�eotnengage VOLT Vodesign.produce and perform efireworks display onthe terms and conditions hereinafter set forth; NOW,THEREFORE,in consideration of the terms,conditions and covenants hereinafter set forth,the parties hereto do mutually agree mmfollows: 1. i e� 1h Display Date"),VOLTshallpmmdeNofimwmrkeundequipmeot for the FIREWORKS �lay at the Fireworks Displ ay location.The display will be under the nofaVOLT\/a|nedtechnician.k/nagreed that VOLT shall be,themdofinmvorhsouppherundprmduoarfonthaoventconkraotedforhore|n. (Note: The actual start and stop time of the display will be determined by the governmental authorities having jurisdiction over the display). 4LTERIVAT2DATE. 2. COST^lND PAYMENTS: I FIREWORKS DISPLAY PRICE: $8,o00.00 The total(Fireworks Display Price plus all other applicable sum of shall bndue and payable unfollows. a.The sum of: L4,000.00 upon execution and delivery ofthis contract b.The Balance ny; {may be applied to this sale) vho|\be paid byOfficial_Check made payable*oPXnoEngineering,Inc.not later than fifteen(16)days prior to the Display Date. Please Note: SPONSOR Is ' uib| forth , mntofm(| Qovammenta| feaamnd1axeo. indudlng, but not limited to, sales, use,excise,license,permit,entertainment,or other fees,taxes or surcharges imposed or otherwise applied to this exhibition. Also, please see Section 10(c)hm|mw. 3 pOSTpOx&EME07IVESCH£2DUi0VG, |fthe d|op| nfthe fireworks inpootponed�excheduiodbyreason ofin�ementweather urhy determinationbythegooemme�alouUhn�yhdvin8' `*dkctNn.orforenyothermasunbayundthocontro|oyV8LT.eameuhaUbere' scn»du|od«mthoAhammhaDahanaYforthobove. In the event a postponement/rescheduling is necessary due to inclement weather or by determination by the governmental authority having jurisdiction,or for any other reason beyond the control of VOLT a poutponomnntiraochodu\m8fee will b*based onthe table below. Description I %of Fireworks Di��Pricee_ Additional Costs if notified by 12:01 AM on 8131/2019 Z% Any 3 d Party Vendor Expenses If notified after 12:01 AM an 813112019 15% Any 31d P rty Vendor Expenses When fireworks tech arrives on sitE 20% Any 31d Party Vendor Expenses Any request made hy SPONSOR for rescheduling/canceling mba||bodirectedmho|p@voNive-cunnorbyphona(6{G)42$'V334. !�ItisunemtondondageedthatVOLTsha8havenoob|igubootonauoheduieodisp|aynxoepianp,qvimadbymdament*eoUheroreeouno beyond the control ofVOLT. / 4.SPONSOR'S AGEAM,Diane Radician CELL PHONE; be designated as SPONSOR'S agent to whom all questions and inquiries shall Sponsor's agent shall bethe only agent of SPONSOR authorized tomake decisions on behalf ufSPONSOR orborequest rescheduling nfthe fireworks display unthe part ufSPONSOR. Please initial each Initial here: 5. EXHIBITION PLANNER CHECKLIST: It is understood and agreed by the parties hereto that the Fireworks Display shall be contingent upon the strict compliance by SPONSOR with all items specified on the Exhibition Planner Checklist(EPC)which is annexed hereto and made a part hereof. Failure on the part of SPONSOR to comply with all requirements sefforth in the EPC to the satisfaction of VOLT within the time limits therein set forth shall be deemed to be an event of default of SPONSOR'S obligations hereunder. 6.SECURITYISAFETY: SPONSOR shall provide and maintain sufficient Security before,during and after the Fireworks Display until the pyrotechnician in charge declares the area clear. Security shall be deemed to include,but not limited to,be ail security lines,police protection,snow fencing,rope lines,barricades or any,other item deemed necessary by the local government or by VOLT.SPONSOR shall also provide and maintain an area clear of any buildings cars and spectators with a minimum radius as specified by current edition of NFPA Code 1123, as a Fire Safety Zone(FSZ)during the entire period commencing from the time the fireworks are delivered to the site until the area is declared clear by the pyrotechnician. It is understood and agreed that VOLT will cease all fireworks discharge due to any security breach of the FSZ VOLT shall not be responsible for personal injury,vehicle or property damage occurring within the FSZ as a result of the SPONSOR's failure to maintain the FSZ in accordance with the standards of current edition of NFPA 1123 which, incidentally,are only minimum standards of distances. SPONSOR acknowledges and agrees that VOLT's responsibilities'are limited to the Fireworks Display and that VOLT is relying on SPONSOR to maintain the aforementioned FSZ and to comply with all Federal, State, municipal and local laws,orders,regulations and ordinances pertaining to the implementation of any and all security measures at the site of the Fireworks Display.Any site visits made during the display setup by or on behalf of SPONSOR shall be in accordance with the current edition of NFPA 1123-and under the direct supervision of the VOLT technician in charge.Any such inspection shall not in any way interfere with the safety, setup or schedule of the preparation for and disassembly after the Fireworks Display.The VOLT technician in charge may,at his discretion,cancel any inspection that,in his sole opinion may compromise the safety of the setup or the Fireworks Display or the setup schedule. The VOLT technician may at any time temporarily discontinue the discharge of fireworks for any reason. 7.CREDITS: As a material inducement to VOLT agreeing to enter into this Agreement,SPONSOR-shall give VOLT program credit as sole fireworks supplier and producer in all press releases,advertising,and any other program announcements,printed or otherwise. 8. INABILITY to DELIVER or CONDUCT FIREWORKS DISPLAWFORCE MAJEURE. VOLT shall not incur any liability for any loss or for any failure to perform any obligation hereunder due to causes beyond its reasonable control including without limitation legal or regulatory restrictions, labor disputes of whatever nature, power loss, telecommunications failure, acts of God, or any other cause beyond its reasonable control. In the event VOLT is unable to deliver the Fireworks Display on the Delivery Date this contract will remain in full force and effect and the Fireworks Display will be performed on the Alternate Date or if no Alternate Date is stated then on such other date as may be agreed upon by the parties. 9.CONTRACT SUBJECT TO GOVERNMENT REGULATION: This Agreement and VOLT's obligations hereunder are subject to all applicable Federal,State,Municipal and local laws,rules,ordinances,regulations and codes,now or hereinafter in effect;and to the conditions and limitations contained in the permits required to be obtained by SPONSOR prior to the Fireworks Display. In the event any Federal,State,municipal or local law,rule,regulation or ordinance shall be enacted which in any way prohibits,limits or restricts the sale,performance or operation of the exhibition of the Fireworks Display or in the event SPONSOR'S permit in any way limits or restricts the sale, performance or operation of said exhibition,VOLT shall limit or restrict its performance or tbe�Fireworks Display so as to comply with such law,rule,regulation or ordinance or limitation or restriction of SPONSOR'S permit.SPONSOR acknowledges that any such limit or restriction placed on the performance or operation of the Fireworks Display,shall in no way result in or entitle SPONSOR to a reduction or abatement in the full contract price. 10. GENERAL PROVISiONS: a) This agreement constitutes the entire agreement between the parties relating to the subject matter hereof,and may not be changed,modified, renewed or extended except by a written agreement,signed by both parties. SPONSOR acknowledges and agrees that VOLT has not made any representations or warranties except those specifically set forth in this contract. Should any clause,section,or part of this agreement be held or declared to be void or illegal for any reason,all other clauses,sections, or parts of this agreement which can be effected without such illegal clause,section,or part shall nevertheless continue in full force and effect. b) SPONSOR is responsible for removal of paper debris associated with the Fireworks Display. c) VOLT is not responsible for procuring any marine services associated with the production of SPONSOR'S event. Should SPONSOR require these services.VOLT may,upon written request,assist SPONSOR in the location and contracting of such services. All additional costs and fees associated with marine services are the responsibility of the SPONSOR. It is specifically understood and agreed that VOLT shall not be responsible in any way if any third party service with which SPONSOR has contracted for service fails to perform and the display cannot proceed as planned. d) SPONSOR is responsible for any additional marine costs and fees,city permit(escort fees,.County 1StatetPD/FDIFM fees, local town permit fees, etc. e) In the event SPONSOR cancels the Fireworks Display the full contract price as set forth herein shall become immediately due and payable. SPONSOR will have up to 30 days from the date of cancellation to request VOLT to reschedule the Fireworks Display. Fireworks Display shall take place no later than six months from originally scheduled Fireworks Display Please initiai each page /f� Initial here- /' ' ' � f spons )QL f) VOLT agrees to procure liability insurance on behalf of SPONSOR,and to indemnify SPONSOR,to the extent thereof,for all claims arising out of VOLT's negligence. Any additional insurance that is required that incurs a cost,will be the SPONSOR'S responsibility. 11.SPONSOR'S DEFAULT. In the eventSPONSOR shall fail to pay any sum when due under the terms of this contract,SPONSOR shall pay,in addition to such amount,interest'st the rate of 1:5%per month on the unpaid amount from the original due date. SPONSOR does further agree that it shall pay VOLT reasonable attorney fees and other costs in the event VOLT shall commence any proceeding(Arbitration or any other proceeding)or incur fees to compel SPONSOR to pay any sums due hereunder or otherwise as a result of SPONSOR'S default of any of the terms and provisions herein contained. 12.LIQUIDATED DAMAGES: It is agreed by and between the parties hereto that in the event of SPONSOR'S default hereunder VOLT shall be entitled to receive the entire contract price and same shall be considered"liquidated damages"based upon an understanding between the parties hereto that VOLT will have suffered damages due to Sponsor's default.The damages suffered by VOLT as a result of Sponsors default will be substantial,but incapable of determination with mathematical precision.It is,therefore,agreed by the parties that the amount due VOLT is not a penalty,but rather a mutually beneficial and reasonable estimate of the damages suffered by VOLT 13.SUBSTITUTIONS; VOLT shall have the right,at Its discretion,to substitute any fireworks it deems necessary provided same does not detract from the aesthetic value or quality of the program.This includes,but is not limited to,shell sizes,quantities,types and brand names. Any substitutions shall in no way result in or entitle SPONSOR to a reduction or abatement of the full contract price 14.ARBITRAVON. Any and,all disputes,differences,or any other type or controversy arising out of or in relation to this Agreement, including as to the meaning or interpretation of any provision hereof,shall be resolved by arbitration in Nassau County, New York, pursuant to the commercial rules then obtaining of the American Arbitration Association, Only one(1)arbitrator shall be required,and the arbitrator may award attorneys'fees.The award of the arbitrator shall be final and binding and judgment may be entered thereon in any court of competent jurisdiction.The arbitrator sitting in such controversy shall have no power to alter or modify any express provision of this Agreement, nor to make any award which by its terms effects any such alteration or modification Either partymay seek from the court ofcompetent jurisdiction any,provisional remedy in aid of arbitration,including,but not limited to,injunction, attachment or replevin, pending the determination of any claim or controversy in arbitration. Any and all disputes,controversies, actions,claims,causes of action,or proceedings arising under,out of,or in connection with or relating to the terms of this contract,and any amendment thereof,commenced by,between or against any of the parties of this contract shall be deemed to have arisen from a transaction of business in New York,and shall be resolved by application of the substantive laws of the State of New York. 15.BINDING EFFECT., This contract shall not be binding on VOLT until executed by SPONSOR and VOLT and VOLT is in receipt of the downpayment required hereunder. 16. EXHIBITION PLANNER CHECKLIST(EPC): a. FIREWORKS DISPLAY PERMIT: (Note: The actual start and stop time of the display will be determined by the governmental authorities having jurisdiction over the display). SPONSOR'S RESPONSIBILITY: It is Sponsor's responsibility to call your State,City,County,Town, Borough,or Village Fire Marshal or other appropriate authority to file for and obtain the Fireworks Display permit. VOLT will prepare the paperwork for the permit-application on SPONOR'S behalf. Upon receipt of your permit you must send the permit to our office for our records no later than 30 days prior to your display date Failure to do so could seriously ieopardize your display. You must obtain information on: 1. Filing application deadline and fees. 2. Local and state requirements for fireworks license for transportation and/or display. If a license is required,fax all forms immediately to us. 3. Fire,Marshai's requirements for security of fireworks truck upon arrival,and the security of the fire zone before and during the display. 4. Federal regulations require that we carry an accurate route plan to the display site. Fax us a copy of the route instructions from the nearest US Interstate to the display area(approved by the fire marshal or other authority,if necessary). 5. Notify FAA on day of your display,according to the instructions in the FAA Letter of Approval,which will be forwarded to you prior to your display. b,COAST GUARD PERMITS(where required): 1, if the fireworks are to be displayed on or near the water,the following may be required. (Requests for permits must be filed at least 60 days prior to the Display Date(135 days prior for 4th of July events). Please initial each page. Initial here: r t sir VOLT z Coast Guard Application and Permit mHandle Hazardous Materials. u Coast Guard Marine Event Permit. c.SPONSOR RrESPONSIBILITIES AND EXPENSES(The following services need to be provided and paid-for by the SPONSOR in addition to the Fireworks Display Price. 1) SECURITY: MUST BE PROVIDED,FOR FIREWORKS,TRUCK S) AND'TO'MAINTAIN THE 1=1RE SAFETY ZONE AT STAGING AREA FROM.FIREvvbRKS TRUCR(S)ARRIVAL�UNT112,TRUCK-DEPARTURE'WHICH MAY BE FOLLOWINGI THE REdUIRED FIRST LIGHT DUD SEARCH ON'THE MORNING AFTER THE-Dl;sPLAY. 2> Sand: Please provide__0__yards v[sand. 3) Laborer(s):_0 _laborers toarrive atfireworks site on (They will not handle fireworks). 4) Hotel Ronm(s):_-0hotel rooms(within 1Omiles o(show mite). 5> Vehicle(s): Four-wheel drive vehicle for movement posand:Yes NcL__XX____ 0> If you have ordered a set piece(s),you are responsible for erecting the scaffolding and It must be ready when the rpewarriveo u.RADIO SIMULCAST EXPENSES(If agpricablel: Setup and staff a fireworks simulcast command center on site by 1:00 PM on the display date. 2) Provide broadcast relay ioVOLT Firing Center. Call our office for details. u> Speaker system for VIP viewing stands. e INS! R Please list below the additional insured,as they should appear on the insurance certificate: � 1. Peconic Landing 0 Souhfoi*,Inc.; Brecknock 3. Hall Foundation Inc.;-PeFtonic' Landing Housing Association Cooperative, Inc.; The Shores at Peconic Landing Assisted Living Residence, Inc.; Peconic Landing Home Health Services,Inc.:Town of Southold. 4. Name of Sponsor ] Date 'Yolt Live Sicinatutef I I Date Title of atithorizeg,&pRr-esentative,of Sponsor Title State of A -1 county0ft On the Ry ofaML—,in the year%q before ine, the undersigned,a Notary Public in and for said State,personally appeared Qoob�- UrDyl persorrilly known to me or proved to me on the basis of satisfactory evidence to be the individual(s)'whosc name(s) is(are)subscribedl to the within instrument and acknowledged to me that he/she/they executed the same in hWher/th eir capacity(ies),and that by his/heritheir signature(s)on the instrument,the individual(s),or the person upon behalf of which the individual(s)acted.exccuted'dic-instrument. S ignatuie and Office of individual Allison M.Latharfl taking acknowledgment [seal] j4ot-ary Public,state of Now York Reg.No.oll-ArS380155 Quelified in Suffol,,,county commission r-.),pires September 4,20?2 ' Please initial each page Initial here. Neville, Elizabeth From: General Code Client Services <ersupp@generalcode.com> Sent: Thursday, July 25, 2019 8:55 AM To: Neville, Elizabeth Subject: Important! Your Code is due to be updated IMPORTANT: Your help is needed to�ensu e your Code is properly updated Hello Elizabeth, The Code for Southold is scheduled for a supplement in the upcoming month. In an effort to make this process as simple as possible for you and your staff, we wanted to verify that we have received all enacted legislation necessary to begin your supplement. Please indicate where you currently are in the process by clicking the appropriate link below: • General Code has received all enacted legislation. Nothing else is expected at this time. Please proceed with the supplement. • We are attaching additional legislation that has been enacted to be included in the supplement. Please proceed with the supplement. • We still have legislation pehdinq and will send it to General Code upon adoption. Please do not process the supplement until you receive the additional legislation. • We have not passed any new legislation since the last supplement. There is no need for a Code update at this time. Clients with eCode360® can view the legislation that has already been sent 'to General Code in the New Laws section of their eCode. Once legislation is codified and integrated into the Code, it will be listed instead in your eCode's Disposition List and history. To ensure that Southold's Code is supplemented as soon as possible, we urge you to click the appropriate link now. Thank you for being a General Code client and for your help in keeping your Code up-to-date and enforceable. 1 Sincerely, Generae's Client Service Team Genera0 Code A Member of the ICC Family of Companies generalcode.com 1800.836.8834 ATTENTION.This email came from an external source Do not open attachments or click on links from unknown senders or unexpected emails 2 guFFOL,� ELIZABETH A.NEVILLE,MMC 0� c® Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Southold,New York 11971 coo REGISTRAR OF VITAL STATISTICS • Fax(631)765-6145 MARRIAGE OFFICER A �. Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER ®( �`� www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PERMIT for PUBLIC DISPLAY OF FIREWORKS I, ELIZABETH A. NEVILLE, Town Clerk of the Town of Southold, Suffolk County, New York, being an officer duly designated by the Town Board of the Town of Southold for this purpose, do hereby GRANT TO: PECONIC LANDING AT SOUTHOLD, INC. A PERMIT FOR THE PUBLIC DISPLAY OF FIREWORKS by said organization in accordance with the provisions of Section 405.00 of the Penal Law of the State of New York, on the time and place set forth in the application therefore, as follows: September 1, 2019 at 7:15 PM (Rain Date: September 2, 2019 at 7:15PM) on Peconic Landing's property located at 1500 Brecknock Road, Greenport,NY 11944 ON CONDITION THAT the bond (indemnity insurance) required shall continue in full force and effect in favor of the Town of Southold, and PROVIDED that the actual point at which the fireworks are to be fired shall be at least two hundred feet from the nearest building, public highway or railroad, or other means of travel, and at least fifty feet from the nearest above ground telephone or telegraph line, trees or other overhead obstruction; that the audience at such a display shall be restrained behind lines at least one hundred and fifty feet from the point at which the fireworks are discharged and only persons in active charge of the display shall be allowed inside these lines; that all fireworks that fire a projectile shall be so set up that the projectile will go into the air as nearby as possible in a vertical direction, unless such fireworks are to be fired from the shore or a lake or other large body of water, then they may be directed in such a manner that the falling residue from the deflagration will fall into such lake, or body of water; that any fireworks that remain unfired after the display is concluded shall be immediately disposed of in a way safe for the particular type of fireworks remaining; that no fireworks display shall be held during any wind storm in which the wind reaches a velocity of more than thirty miles per hour; that all persons in actual charge of firing the fireworks shall be over the age of eighteen years, competent and physically fit for the task, that there shall be at least two such operators constantly on duty during the discharge and that at least two soda-acid or other approved type fire extinguishers of at least two and one-half gallons capacity each shall be kept at such widely separated points as possible within the actual area of the,display. Eliz eth A. Neville, Town Clerk Town of Southold Suffolk County,New York (TOWN SEAL) Date: August 28,2019 THIS PERMIT IS NOT TRANSFERABLE AGENCY CUSTOMER ID: PYROENG-01 _ LOC#: ACCP V ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Arthur J.Gallagher Risk Management Services,Inc. Pyro Engineering,Inc.dba Volt Live 999 S,Oyster Bay Rd POLICY NUMBER Bethpage NY 11714 CARRIER NAIL CODE EFFECTIVE DATE. ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Rain Date:September 2,2019 Peconic Landing at Souhtol Inc;Brecknock Hall Foundation Inc.,Peconic Landing Housing Association Cooperative,Inc.;The Shores at Peconic Landing Assisted Living Residence,Inc.;Peconic Landing Home Health Services,Inc Town of Southold are Additional Insured as reouired by written contract. ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TE WDDMYY moo® CERTIFICATE OF LIABILITY INSURANCE DA sn2ols i 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 CONTACT NAME:._ Arthur J.Gallagher Risk Management Services,Inc, PHONE FAX _ 677 Broadway 4th Floor AIPc to,.Ext),518-869-3535 _;Lac,Nei 518-869 3580 EMAIL Albany NY 12207 1NSURER(S)AFFORDING COVERAGE NAIC d INSURERA:James River Insurance Company 12203 INSURED PYR6ENG•01 INSURER B:LeX�ton InSUfance Company 19437 Pyro Engineering,Inc.dba Volt Live —` 999 S.Oyster Bay Rd INSURERC_ Bethpage NY 11714 INSURER D_. INSURER E: INSURER F• ' COVERAGES CERTIFICATE NUMBER:2113450827 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_P_AID CLAIMS. INS I TYPEOFINSURANCE Y iADOLSUBRI 1 POLICY EFF -POLICY EXP I I POLICY NUMBER ( MM1DD I MMIDOIYYYY I LIMITS A I X ,COMMERCIAL GENERAL LIABILITY : Y ' I , i0891360 2/15!2019 2!1512020 EACH OCCURRENCE 51,000,OD0 _ ; X OCCUR CLAIMS-MADE I I `'O'AMAGETbRENiEO : i t..__.J i l i PREMISES(Ea occulrenw)_ ;S 100,000 MED EXP(Any one person) S Excluded PERSONAL&AOV INJURY I S 1,000,000 GEN'LAGGREGATE LIMIT APPLIESPER, I i I t GENERAL AGG-•- REGATE_ 52,000,000 r t PRO- J i ( -- x 'POLICY ;JECT i LOC I I ! PRODUCTS-COMPIOPAGG ,52,000,000 OTHER: I I 'Auto i S 1,000,000 A l AUTOMOBILE LIABILITY 1000691360 1 211512019 2/15/2020 _COMBINED SINGLE LIMIT {S 1,000,000 ANY AUTO i 1 i BODILY INJURY(Per person) ;S f 'OWNED i 'SCHEDULEDI -"„"- AUTOS ONLY '_ _AUTOS I I i BODILY INJURY(Per accident)l$ X HIRED � )( 'NON-OWNED I t PROPERTY OHMAGE S I AUTOS ONLY ;..__,AUTOS ONLY I I i (Per aaidenl)__ l i 5 B X £UMBRELLA LIAB X!OCCUR I 1023627359 I 7/1512019 21151202/) •'EACH OCCURRENCE $9,000,000 /IAB � Y EXCESS , _ _ . _ CLAIMS-MADEi ( ( , _ =AGGREGATE [$9,0_ 00,000 t OED i X I RETENTIONS I nnn S 'WORKERS COMPENSATION t , 'PER t OTH- AND EMPLOYERS'LIABILITY YIN I STATUTE I ER IANYPROPRIETOR/PARTNERMXECUnVE ' - EL EACH ACCIDENT s •OFFICERIMEMBEREXCLUDED? E]INIA� (Mandatory In NH) J 1EE^L DISEASE-EA EMPLOYEEi S Ir yes,desc6be under - - 1 DESCRIPTION OF OPERATIONS below I I I E L.DISEASE-POLICY LIMIT i S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) General Liability Form Number FP5201-0112 Additional Insured-Automatic Status When Required by Written Contract-Includes Primary and Non-Contributory when required by written contract General Liability Form Number FP4001-1117 Common Conditions and Definitions-includes Waiver Of Subrogation when required by written contract Location of Display,Peconic Landing at Southold,Greenport,NY Date of Display:September 1,2019 See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Peconic Landing ACCORDANCE WITH THE POLICY PROVISIONS. 1500 Brecknock Road Greenport NY 11944 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-AUTOMATIC STATUS WHEN REQUIRED BY WRITTEN CONTRACT OR WRITTEN AGREEMENT This endorsement modifies insurance provided by the Coverage Part(s)checked below: ❑All Coverage Parts or ® Only the following checked Coverage Part(s) ® COVERAGE PART A-COMMERCIAL GENERAL LIABILITY NIA COVERAGE PART B-CONTRACTOR'S POLLUTION LIABILITY NIA COVERAGE PART B-CONTRACTOR'S POLLUTION LIABILITY—LIMITED NIA COVERAGE PART C-PROFESSIONAL LIABILITY NIA COVERAGE PART D-SITE ENVIRONMENTAL LIABILITY NIA COVERAGE PART E-PRODUCTS POLLUTION LIABILITY ❑ COVERAGE PART F-PRODUCTSICOMPLETED OPERATIONS LIABILITY NIA COVERAGE PART G-OTHER Solely with respect to coverage afforded by the Coverage Part(s)checked above: SECTION II—Who is An Insured is amended to include as an additional insured any person or organization you are required to include as an additional insured on this Policy by written contract or written agreement in effect during this"policy period"and executed prior to the"occurrence"of any"bodily injury"or,"property damage"but only with respect to liability for"bodily injury"or"property damage" caused, in whole or in part, by: 1. Your acts or omissions,or 2. The acts or omissions of those acting on your behalf. Liability for the above acts or omissions includes the liability you are required to assume in a written contract or written agreement with an additional insured that is specifically related to"your work", provided that assumption of the additional insured's liability is permitted by law, The insurance provided to the additional Insured(s) under this endorsement is limited as follows: 1. in the event that the Limits of Insurance provided by this Policy exceed the Limits of Insurance required by the written contract or written agreement,the insurance provided by this endorsement shall be limited to the Limits of Insurance required by the written contract or written agreement.This endorsement shall not increase the Limits of Insurance stated in the Declarations. 2. Any coverage provided by this endorsement to an additional[nsured(s)shall be excess over any other valid and collectible insurance available to the additional insured whether primary, excess,contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. 3. With respect to the insurance afforded to the additional insured(s), the following additional exclusions apply: This insurance does not apply to"bodily injury"or"property damage"occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, (other than service, maintenance or repairs)on the project to be performed by FP5201 01-12 Page 1 of 2 or on behalf of the additional insured(s)at the location of the covered operations, has been completed;or b. That portion of"your work"out of which the"bodily injury"or"property damage" arises has been put to its intended use by any person or,organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project; provided that item 3.a,and 3.b.above shall not apply if such coverage is required by written contract or written agreement in effect during this"policy period"and executed prior to the "occurrence"of any"bodily injury"or"property damage". ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. Includes copyrighted material of Insurance Services Office, Inc.,with its permission. FP5201 01-12 Page 2 of 2 New York State Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR.2ND FLR,MELVILLE,NEW YORK 11747-3166 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE R. 'm AAAAAA 753044987 ARTHUR J GALLAGHER&CO 677 BROADWAY 4TH FLOOR ALBANY NY 12207 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER PYRO ENGINEERING INC PECONIC LANDING AT DBA BAY FIREWORKS SOUTHOLD INC 999 S.OYSTER BAY RD, STE 111 1500 BRECKNOCK ROAD BETHPAGE NY 11714 GREENPORT NY 11944 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE H2437 559-4 6907 02/15/2019 TO 02/15/2020 6/6/2019 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2437 559-4, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/IWWW.NYSIF.COMICERTICERTVAL.ASP,THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION ANDIOR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY, I NEW YORK STATE INSURANCE FUND DIRECTOR.INSURANCE FUND UNDERWRITING VALIDATION NUMBER:596048512 U-26.3 Y"o K Workers' CERTIFICATE OF INSURANCE COVERAGE srATE Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured PYRO ENGINEERING INC (516)597-5500 999 SOUTH OYSTER BAY RD STE 111 BETHPAGE,NY 11714 j 1c.Federal Employer Identification Number of Insured or Social Security I Work Location of insured(Onlyrequired)fcoverageisspecificallylimdedto Number certain locations in New York State,i.e.,a Wrap-Up Policy) 753-04-4987 2 Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State insurance Fund(NYSIF) PECONIC LANDING AT SOUTHOLD,INC. 1500 BRECKNOCK ROAD 3b.Policy Number of Entity Listed in Box"la" GREENPORT,NY 11944 DBL 5213 59-1 3c Policy effective period 01104/2003 to 01104/2020 4.Policy provides the following benefits- ® A.Both disability and paid family leave benefits [] B.Disability benefits only F] C.Paid family leave benefits only 5.Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law B.Only the following class or classes of employer's employees- Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Data Signed 1/1512019 By (Signature of insurance carriers authorized representative or NYS Licensed insurance Agent of that insurance carrier) Telephone Number (866)697-4332 Name and Title Melissa Jensen,Acting Head of Disability Insurance Unit J IMPORTANT: If Box 4A and 5A are checked,and this form is signed by the insurance carnet's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE.Mad it directly to the certificate holder. If Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law.It must be mailed for completion to the Workers'Compensation Board, DS Plans Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200 PART 2.To be completed by the NYS Workers'Compensation Board(only if Box 4C or 513 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. f Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to Issue this form. DB-120.1 (10-17) Certificate Number 530946 0