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Home My WebLink About2021 Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday,June 16, 202110:41 PM To: '(nail@ northforkcc.com'; 'kelly@santorefirework$.com' Cc: Rudder, Lynda Subject: Emailing: Corrected time Fireworks Permit#2021-3_20210616223736 Attachments: Fireworks Permit#2021-3_20210616223736.pdf My apologies. Attached, please find corrected permit and resolution on display time of 9:OOPM for 9/5/21. Elizabeth A. Neville 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#2021-320210616223736 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. ELIZABETH A.NEVILLE,MMC Town Hall,53095 Main Road TOWN CLERK . .„ P.O.Box 1179 Southold,New York 11971 REGISTRAR,OF VITAL STATISTICS '�"" °` ', ��°, A ,��. •�� Fax(631)765-6145 MARRIAGE OFFICER " • " ` Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER ''r FREEDOM OF INFORMATION OFFICER www.southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD TERMIT#•-2021 -3• for - PUBLIC DISPLAY-ORFIREWORKS { 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: SANTORE'S FIREWORKS ON BEHALF OF NORTH FORK COUNTRY CLUB 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 Saturday;•,MVl,,`3, 2021 at 9,.15 P.M. - Rain,Date:-.Sunda Sg tember�5 -2021-at 9:00-P.M- •located-at,2b342-Main Road Cutebo ue New Yor the time and place set forth in the application therefore, 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, This This,ver-mit is subiect-to the-applicants,compliance,with,any Executive Orders issued by the Governor and im 'tlae:alri�lrcarits t i i li€1ri A it i iV '�ci irli b s 'and all e+ iaie� i tits:of the. a s.mioliey_r6#iirdiiia_1he; �assi�i�aic+e-of�fire•��i�l+:s:�,e�z�►its. ' Eli,' eth A.Neville,Town Ierk Town of Southold Suffolk County,New York (TOWN SEAL) Dated June 16, 2021 THIS PERMIT IS NOT TRANSFERABLE RESOLUTION 2021-504 ADOPTED DOC ID: 17154 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2021-504 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JUNE 15,2021: RESOLVED that the Town Board of the Town of Sputhold hereby approves the issuance of a Fireworks Permit by the Town Clerk to Santore's Fireworks on behalf of the North Fork Country Club, for a fireworks display on Saturday, July 3, 2021 at 9:15 PM(Rain Date: Sunday, September 5, at 9:OOPM) at 26342 Main Road, Cutchogue,New York upon payment of a single fee of$100.00 and subject to the applicant's compliance with any Executive Orders of the Governor and compliance with any conditions and requirements of the Town of Southold policy regarding the issuance of fireworks permits. _. _ f 1 Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Sarah E. Nappa, Councilwoman SECONDER:Louisa P. Evans, Justice AYES: Nappa, Dinizio Jr, Doherty, Ghosio, Evans ABSENT: Scott A. Russell JIFF ELIZABETH ELIZABETH A.NEVILLE,MMC �� G,f, Town Hall, 53095 Main Road TOWN CLERK ® P.O.Box 1179 CA Z Southold,New York 11971 REGISTRAR OF VITAL STATISTICS We • Fax(631)765-6145 MARRIAGE OFFICER �'� ®� Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER www.southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PERMIT#2021 -3 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: SANTORE'S FIREWORKS ON BEHALF OF NORTH FORK COUNTRY CLUB 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 Saturday, July 3, 2021 at 9:15 P.M. (Rain Date: Sunday, September 5, 2021 at 9:00 P.M) located at 26342 Main Road, Cutchme, New York,the time and place set forth in the application therefore, 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, This This permit is subiect to the applicants compliance with any Executive Orders issued by the Governor and to the applicants compliance with any conditions and all requirements of the Towns policy regarding the issuance of fireworks permits. yl Eli eth A. Neville, Town Jerk Town of Southold Suffolk County,New York (TOWN SEAL) Dated June 16, 2021 THIS PERMIT IS NOT TRANSFERABLE RESOLUTION 2021-504 ADOPTED DOC ID: 17154 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2021-504 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JUNE 15, 2021: RESOLVED that the Town Board of the Town of Southold hereby approves the issuance of a Fireworks Permit by the Town Clerk to Santore's Fireworks on behalf of the North Fork Country Club, for a fireworks display on Saturday, July 3, 2021 at 9:15 PM (Rain Date: Sunday, September 5, at 9:OOPM) at 26342 Main Road, Cutchogue,New York upon payment of a single fee of$100.00 and subject to the applicant's compliance with any Executive Orders of the Governor and compliance with any conditions and requirements of the Town of Southold policy regarding the issuance of fireworks permits. j a Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Sarah E. Nappa, Councilwoman SECONDER:Louisa P. Evans, Justice AYES: Nappa, Dinizio Jr, Doherty, Ghosio, Evans ABSENT: Scott A. Russell Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday,June 16, 202110:22 PM To: .mail 0northforkcc.com' Cc: kelly@santorefirewgrks.com Subject: Fireworks Permit#2g21-3 Attachments: Fireworks Permit#2021-3 20210616222510.pdf Importance: High Mr. Haas, Attached, please find your Fireworks Permit#2021-3 and Town Board Resolution #2021-504 approving it. We received the insurance certificate from Santore Firework's,therefore, we do not need another insurance certificate from you. Everything is in order and your permit is enclosed. Best Wishes for a festive event! Elizabeth A.Neville 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 1 Neville, Elizabeth From: Rudder, Lynda Sent: Wednesday,June 16, 202112:58 PM To: Neville, Elizabeth Subject: RE:July 3rd fireworks Thanks. I would but don't have info From: Lynda [Irudderl@optonline.com] Sent: Wednesday, June 16, 2021 12:47 PM To: Rudder, Lynda Subject: RE: July 3rd fireworks Thanks. I would but don't have info Sent from Mail for Windows 10 From: Rudder. Lynda Sent:Wednesday,June 16, 202112:45 PM To: lrudderl@optonline.com Subject: FW:July 3rd fireworks From: Neville, Elizabeth Sent:Wednesday,June 16, 202112:45:42 PM (UTC-05:00) Eastern Time (US&Canada) To: Rudder, Lynda Subject: RE:July 3rd fireworks I will take care of responding to him when I finish the meeting resolutions! From: Rudder, Lynda Sent:Wednesday,June 16, 202112:42 PM To: Neville, Elizabeth Subject: FW:July 3rd fireworks Importance: High please respond. I don't know answer From: mail nfcc [mail@northforkcc.com] Sent:Wednesday,June 16, 20218:39 AM To: Rudder, Lynda Subject:July 3rd fireworks Lynda, Sorry,there seems to be some confusion here. Santore's World Famous Fireworks is processing the necessary paperwork with you so that they can provide us with a fireworks display on July 3. We thought that North Fork Country Club needed to provide a certificate of insurance to the Town of Southold directly. I am now being told that we do not have to provide the certificate of insurance since Santore's World Famous Fireworks has provided the certificate to you. 1 Can you please confirm that you do not need a certificate of Insurance from us and that you have everything you need to process the permit. Thanks so much, George George F Haase Jr North Fork Country Club 631-734-7139 ext 104 mail@northforkcc.com ATTENTION:This email came from an external source. Do not open attachments or click on links from unknown senders or unexpected emails. 2 MAY 2 4 2021 Southold Town Clerk ELMBETHA.NEVILLE,MMC �� _ �� Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Southold,New York 11971 REGISTRAR OF N71TAL STATISTICS 1� Fax(631)765-6145 MARRIAGE OFFICER �� ®° Telephone(631)765-1800 RECORDS OF MANAGEMENT OFFICER �� southolone( n)765 1800 FREEDOM OF INFORMATION OFFICER 110`/DD, OFFICE OF THE TOWN CLEC TOWN OF SOUTHOLD APPLICATION PERMIT 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 North Fork Country Club. PRINCIPAL OFFICE AT 26342 ivfairi Roacl,Cutclioguc,F5Y 1.1935 DATE&TIME OF,DISPLAY 7/3!21 at 9:15 Dm EXACT LOCATION-OF'DISPLAY 'North Ford:Country Club golf course _ SUFFOLK COUNTY TAX MAP NUMBER FOR SITE , 1 ---------_- RAIN(DATE &TIME 9i5r21 at 9:00 prn The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition Peteriames Mai-shall 70 24+Nears Health:Excellent (Additional names and information may be submitted on an attached sheet Number and type of fireworks-is as follows: I AG Calve.s - 13G Calces - 2.5" Shells- Manner and place of storage of fireworks prior to display: DeliveLy of-product oil 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 at the ProjgLrL Owner,nrUst be suhmitted with the Application. Santore's World Famous Fireworks, LL,C, FEE. $100 Name of Organization See policy-for additional information August N. Sap-Lore, jr. By-- P-r-Inted Name ot Applicant Signator of Applicant e-mail address:asantorejr@sailtore-firewor-l:s.eom Telephone Number 908-872-0624 Datee oof Application 1 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 05/24/21 Receipt#: 281228 Quantity Transactions Reference Subtotal 1 Fireworks 7/3/21 $100.00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#001743 $100.00 Santore's World Famous Fireworks, LLC Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: North, Fork Country Club Pob 725 Main Road Cutchoque, NY 11935 Clerk ID: SABRINA Internal ID*7/3/21 .;^ n.. «a•� ,� -..us,.Y., �-•..wads. a,, _ -5-..L,t.:ti 1• -•r-•.., ;n.- , 'y P6P,a"' ,,•3,a"n5 , .., A. i.' ,"' , '� »y �I-ta'� _' �s`^'.N�k,"i+:l'.5i,.�•tt.,.Mf,a.,'-:J ,U". , r +:.,,-,�jx--+v .�y�,� -r.•.�,.:P.. 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Goo& Maps North Fork Country Club -7/3/21 . .. �,�h: � «. �•�:_ moi.� �� f ��' F• ��- 350 Ft Measure Algi Eounlry CftiG Dr, Crnmtry CIuU Dr]�'#!•, \\�� + _�, 1. �' r- ,fi�C`;b Dr-• 4 of _ _ - - �� + ��1_ a-, ,gt� I`-��..- 'i'�i�'✓_L._'�Te.�?n.."-D ltii-.. 1.t��K'.+.__ 'LSA..... �� f„ � distance Total distance. •.63 ft • Launch Site- F • to Audience• FalloutLaunch Site - Cakes- 1.25" 0 • for 1 Radius OFallout • • 1 Radius Launch Site • 11 Display Location: North Fork Country Club, 26342 Main Road, Cutchogue,Southold, NY SANT WORLD rAMOUS- 1r North Fork-Country Club May 20,2021 Santore World Famous Fireworks 846 Stillwater Bridge Road Schaghticoke, NY 12154 Dear Kelly, As per our Fire Works Display Agreement dated May 13, 2021,we have hired you to perform a fireworks show at our property located at 26342 Main Road,Cutchogue, NY 11935 on July 3, 2021.You have our permission to apply for the necessary permits. Thank you, Raluca Pintea General Manager P.O.BOX 725 • CUTCHOGUE,NEW YORK • 11935-0725 (631)734-7139 • Fax(631)734-9004 • nfccmail@optonline.net • www.northforkcc.com ,4co CERTIFICATE' F LI DATE(MMTprYYI O ABILITY INSURANCE 5/14/202' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLIA,,TI 1S CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE`rLld'.1ES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING ISUR R(S), AU{_[HOR17�Ep REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. �Irr .�,, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,'su'i'gllrtof,,, the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights?tg tine certificate holder in lieu of such endorsement(s). PRODUCER CONTACT , Britton-Gallagher and Associates, Inc. PN oE: FAX One Cleveland Center, Floor 30 ac No Ext:216-658-7100 A/c No:216-658-7101 1375 East 9th Street ADDRESS: Cleveland OH 44114 INSURERS AFFORDING COVERAGE` NAIC 0 INSURERA:Everest National Insurance Company 10120 ISan Ofe's World Famous Fireworks LLC 18341 INSURER B:Axis Surplus Ins Company 26620 846 Stillwater Bridge Road INSURER C: Schaghticoke NY 12154 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:128377900 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS , CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY ERP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD MM/DD LIMITS A GENERAL LIABILITY Y Y S18ML00235-211 2/9/2021 2/9/2022 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $500,000 CLAIMS-MADE FKOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 17 POLICY X PR0.CT LOC $ A AUTOMOBILE LIABILITY Y Y S18CA00102-211 219/2021 2/9/2022 COMBINED SINGLE LIMIT Ea accident $1,000.000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ( ) AUTOS AUTOS accident)Per BODILY INJURY $ X X NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ B UMBRELLA LIAB X OCCUR Y Y P-001-000074909-03 21911021 2/9/2022 EACH OCCURRENCE $4,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- On,- AND EMPLOYERS'LIABILITY YIN IIQR I E ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? F NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement Display Date:7/3/21.Rain Date:9/5/21.Location:North Fork Country Club North Fork Country Club,Hamlet of Cutchogue,Town of Southold,Suffolk County are named as additional insureds,but only in respect of liability caused-by the negligent acts or omissions of the named Insured.Subrogation waived to the extent required by written Contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF SOUTHOLD ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Main Road P.O. Box 1179 '-`14, duTHOK'MD REFRESENTA�TIVjE Southold NY 11971 ©1988-2010 ACORD CORPORATION. All rights-reserved. ACORD 25(2010/05) The ACORU.name and logo are registered marks of ACORD CERTIFICATE F LIABILITY INSURANCE DATE{f.1MIDOIYYYr 511412021 , THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE,HOLDER. TRIS 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), AUTH(31212ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies)must 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 ts� Britton-Gallagher and Associates, Inc. PHONE 2I6 658-7100 c No.216 658 7101 One Cleveland Center Floor 30 1375 East 9th Street E P4AILADDRESS. Cleveland OH 44114 INSURER(S)AFFORDING COVERAGE j NAIL# INSURER A. Everest National Insurance Company 10120 INSUREDf 18341 INSURER B.Axis Surplus Ins Company - _ 26620 Santore s World Famous Fireworks LLC 846 Stillwater Bridge Road INSURER C: Schaghticoke NY 12154 INSURER D. INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER:1309648716 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 CONDI T IONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDNYYY) MMfDDiYYYY _061TS A !GENERAL LIABILITY Y Y SI8MLG02-35-211 219,2021 2f9/2022 EACH OCCURRENCE S 1,0G0,000 X COMMERCIAL GENERAL LIABILITY D M O ftE PREMISES Ea occurrence $500,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) _ S PERSONAL&ADV INJURY S1,000000 I GENERAL AGGREGATE $2,000,000 f GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COM PIOPAGG $2009000 POLICY I PRO-'ECT LOC I 5 A AUTOMOBILE LIABILITY Y Y SIBCA10102-211 i 2192021 2!92022 CObiBIN£D SfLt NGLE M:T X Ea acc,,T,) 51 D00000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per acc dent 5 AUTOS 4UTQS ( 1 NON-&NED PROPERTY DAMAGE -LLIX HIREDAUTOS X AUTOS Per accede;t) 5 5 B UMBRELLALIAB X OCLUR Y Y P-001-000074909-03 2192021 219/2022 EACH OCCURRENCE $4,000400 X EXCESSLtAB CLAIMS-c3ADEi AGGREGATE S400,000 i DFS RETENTIONS S WORKERS COMPENSATION � wCSTATU- 0TH- i AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORiPARTNERrEXECUTIVE EL EACH ACCIDENTOFFICERIM5 (Mandatory In NH)EXCLUDED? ❑ NIA � E L DISEASE-EA EMPLOYEE S {Mandatory to NH) If yes,describe under DESCRIPTION OF OPERATIONS below £L DISEASE-POLICY LIMIT 5 t DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Additional Insured extension of coverage is provided by above referenced General Llability policy where required by written agreement. "North Fork Country Club are interested in the maintenance of this Insurance and it Is agreed that the insurance will not be canceled,materially changed or not renewed without at least a thirty(30)day advance written notice to North Fork Country Club by certified mail-return receipt requested” Display Date:7i-3121. Rain Date:915121,Location.North Fork Country Club North Fork Country Club,Hamlet of Cutchogue,Tawn of Southhold,Suffolk County are named as additional insureds,but only in respect of liability caused by the negligent acts or omissions of the named insured.Subrogation waived to the extent required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELt'VERED IN ACCORDANCE VATH THE POLICY PROVISIONS. North Fork Country Club 26342 Main Load Cutchogue NY 11935 AUTHORIZED REPRESENTATIVE O 1958-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD NYSIF Now York State Insurance Fund 1 WATERVLIET AVENUE ALBANY,NEW YORIS;12206-16g� ;ry CERTIFICATE OF WORKERS' COMPENSATION INSURANO� A A A A A A 472010297 SANTORE'S WORLD FAMOUS FIREWORKS LLC Olk 143 SUMMIT AVE BERKELEY HEIGHTS NJ 07922 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER ° CERTIFICATE HOLDER SANTORE'S WORLD FAMOUS NORTH FORK COUNTRY CLUB - FIREWORKS LLC 26342 MAIN ROAD 143 SUMMIT AVE COTCHOGUE NY 11935 BERKELEY HEIGHTS NJ 07922 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE A2353 260-9 621284 02/07/2021 TO 02/07/2022 5/14/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2353 260-9, 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;//WIII W NYSIF.COM/ICERT/CERTVAL.ASP,THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS, THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY. 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. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:1036397931 U-26.3 t w rymrRibm ` •_ _ _ egsns{fr items+wrnovalt t . wStiMnl�ls�q � - Y - •n'.�n"na•.af^w+w.anam+rmrr.=+es+.s,.ss4.rrwlraw'e.�rri+rn�fsex..rns..!se. e .anww BY+wh+nl +✓+ulersts*!3*rsass4,Cwc�Sfws�+•tw,M1Mfll�e..�nMe/rpfRtd4Mee3aWww+MYerfrabaxe+o��/gN�M+I1�eay��aM�.Se�tere�w.� Q�� ^MI��NaMnrn+rNW/�aOJt'Pllr$�N+H%ls�1lMLQaAM_PSit@ D246i SF8�rAt'Y�NLWrv�� ' WaotanlWra•n� _ .WyprrPeo)A+aCvetYastte»rta�w Mwl.Owt�•LblMrsornpKlAtl%�aT�sWw�rxO2yt w' t 9tis✓iRar7h+neaarc.+e E,rtrtir;,�(,�y7 ,trurtmz �e�r_!i;;.•+e:m/�+wvxr.tTsM - � - -' �J 1t tM'Ksw9KmrUtarfxrbfrp rr�f+laif°f.a»r.91n2t.NmlaWBjriachP_�xrta+f+allrdysrW+mlne+sYnom,6•.y+.:eE+.s*:l,a+m�anaacaelypim � . qr..r.�axwamcm�nurslDs,�x�rm,t9�dE?�A�E7xteEfnmlatrpa�m�w>:.asst,f,r�wao�ja+,:tai.,xnr.amn�ys,.a�9f^anla�l�Fi��afs. . Iia o.r...q,ata.+l�.s+e�rs�iaawlRY»eeNe.¢sk+ !T*ra�i�a+..J+:ro Qf•teaf+raGtg,- -- .wrt,o,.�a Llt�rarai�tno.�v+ram,nrt�l?l!.R3irSRfvrma f��+ri9Erx+»•>i LTanwpr,s4sreframt�:..,c.6e+rfcitvtttnu�an Ilorz.MuNmtrr�msraafnnr�,rr 7 ' " •C�Gur'.xk+n4fens:ucfrt'anrrna+:f7tM ' nnnPo.nemol9prPud�4+e4r�5k rt�l�`sOsw4w/a2D¢vWsemmnrfsvgF+>•fbWALm`vsmMD'+lemt f�E� kcmt+Dbi�aoDn. - nKfk:stl.ttl�v�+tnOmermsn+,sCrr�L�f9msm+PK`�fn9s%'*R1,iweM/•Snm�fe fRrWdi N'rmttlFarnbNidayiwaabv.�r An�ttt lr��{e� �''', - 63YE'J17C4D �-�11M7�1!('^1t77/] D'aA4ef¢tr , dnD Q!'mbrafnarm Ofs+«xaDvturalft«l! Edi'j��e.��.�giy-�sn��ist�Mr{edir.�agL.R�e�xi�wSp Q� ol�.faR� oocr�,.l _ afaw3iVISRd#17:Y.R1.lT7C�ElN1f+�P rY.'31757 !r.>iaystu, gtsaa,ttcyyyl+�v 4narr�Agnaur.- �'Y _ Dnwrlltb pw^MI 6w4r/fNM1Rrayo� H enfPd qs /2 %? f/0� aasWlyaWran naa 61r. /'Y' Nnn➢m.+•yE H/-Lacevs�� S Oils �,w✓o.+.ctiwt-c�ris-.�-- TP Ei �F ROR;`;'a P`�i�tC3`�'K_HO!1QWCEPTiF1CATE COMPE7Et10E' T "` —PETER CSMA►� ;. ' __ � -.•:+ /d�;T�"jft�l/J�r"y'^t*e�=s/'�•-•U['Wp }-:�-rt',�i (�, y - 4'1Ni.L{�1NGPYRQ3.= � `Pw NE 7-AT F:N W'�(�RI�'' 'c A!VISIO PF f f� E'I�RTMEPIT:O LABOR ; ^ - SAF�`t'Y�fy[�;'r-l�: l 71-1 3 / "' - "` _ - _' ' u ,• �w��' _ -_"y,^'fyffi ' . .M 1 t r �- L ''7'y``{,_' ., „ MANUF/ACTUREXPhOSNES j Expire;: 1"2/3172021'_ i 8antore's Wo rid'•Fe6ousfireworks�LLC . ° _ , •-I ! 8�6 Stillwater fridge Rd 'THIS LICENSE MILIST BE _ �chaghticoK�,`NY-12154' P(9_ T-ED'IfV�YO`l]F�-,PL:A��. AF,PPSINESS I Augutt'N. antore,,ar� _ • talo i� .e;��c� [ �57�6. w 4 , 4s hereby,licensed-to-deal,in or,manufacture explosives in,compliance with the requirements of the Labor Law;a_nd -,industrial-C6de_;Rules.-Ariy ohange`ink''the,cvnditi®ns'under•which this,license`is,granted may,oause it'to"be,- ' { revoked. e®n M.Frank®,Act ng,9irectgr THE COMMISSI0NER of LAF30R - Every person selling,tleiivering'or giving away any,explosives must keep at thq principal.piace of bu'sine'ss within. `l i' the state;a'record of each transaction,including: f (' l 1)'• the NAME or TYPE'and QUANTITY of explosives SOLD,DELIVERED or.G1VEPI:.Not®:No liconse-is f nside-d to,purchase srnokeiess ,powder,or black powder in quantities not exceeding five,pounds-for•use in ; °firing antique fire a mis gE'artifacts oP'replicas,th®reof. However,dealers,MUST post all such transactions,on.;'; the ealer•Manufaeturer Report,of Ei 1' ives Transactions". ' , I i 2) , the DATE OF-EACH SALE,OE LIVERY or GIFT. 3) ,thp,NAME,;C{CEtdrr NUMEER;and RUSINFSADlJRES$.of the,purohaser,.dnee,oGp�rson to wham the eiiploatves,were,delivered;and,th 'firm„ff any,•repres®nted'6ysuch person.- 4) the NAME,ADDRESS,and. ICENSE NUMBER of the person TAKINaTHE•EXPLOSIVES-AWAY from the � seller'or'd®nor. ,_ -, ' ,SH-862,{5=96)' , _ - - _ .. . - `- - • 'i ' PA . _ - j- •~ f..:R.S�n a Ci F.- . `.1i'• ' . t, _ f'� �', s _ - �a - -s,' s - `,rye - , - - - ;, - •z, � U.S.Department of Justice Federal Explosives License/Permit Bureau ofAlcohol,Tobacco,Firearms and Explosives (18 U.S.C Chapter 40) In accordance with the provisions of Title XI,Organized Crime Control Act of 1970,and the regulations issued thereunder(27 CFR Part 555),you may engage in the activity specified in this license or pemrit within the limitations of Chapter 40,Thiel%United States Code and the regulations issued thereunder,untiltthe expiration date shown. TILS LICENSE IS NOT TRANSFERABLEUNDER 27 CFIi 565:53.,.See"WARNINGS"and NOTICES"on reverse. Direct ATF ATF-Chiefs FELC I,jlcense/13_ermit - Correspondence To 244 Needy Road ", ; N�itriber •=<• 1 1 / 080 Martinsburg,WV 25405-9431 Chic Federal Explusiyes L"co-,using Csrite (FELC) - Expizafion;:' � -- Date March 1 2024 Name - SANTORES WORLD FAMOUS FIREWORKS,LLC •_ - Premises Address(Changes?Notify the,FF W at leiidl0 days be6re the move-). 846 STILLWATER BRIDGE ROAD.. SCHAGHTICOKE, NY 12154 Type ofLicense or Permit _ 20-MANUFACTURER OF EXPLOSIVES Purchasing Certification Statement Mailing Address:(Changes?-Notify the FELC of any changes.) The licensee or permittee named above shall use a copy of this license or peirnit to assist a_, transferor of explosivesto verifythe identity andthe•licensed status cfthe liaensee'or' • . " ' :::::: t'. permitteeasprovidedby27CFRPart555. 1lresip�rahrreoneacticwvmustliaanoriemaI• r $ANTORES:WORLD FAMOUS FIREWORKS LLC signamre. Afawd,scanned or e-mailed copy ofthe license or penurt whh a signature intended to be an original signature is acceptable. The sigpative,musi be that cfthe Federal 143 SUIMI Ail AVE;- ' ExplosivesLicxnsee(FEL)orarespeasiblepersonoftlreFEL Icaitify,thattlrisisatrue B,ERKEGEY'0E16HT-S, NJ 07922- copy ofa license of permit issued to the licensee or permittee nam -db tv wgage-rthe, business cr operations specified above under"°rype of License or Licensee/Perrnittee Responsible Person Signature PosIIian/Title" m Printed Name Date A7 FFaan 5400.14/54M 15 ram 1 PreyiousEdbonisObsolete RevisedSepta"ber2011 Federal Explosives License(FEL)Customer Service Information Federal Explosives Licensing Center(FELL) Toll-free TelephoneNumber. (877)28j-3352 ATF Homepage:www.atf.gov 244 Needy Road Fax Number (304)61611401 Martinsburg,WV 25405-9431 E-mail: FELC@atf.gov Change of Address (27 CFR 555.54(a)(1))_ Licensees or permittees may during the tern of their current license or permit remove their business or operations to a new location at which they intend regularly to carry on such business or operations. The licensee or permittee is required to give notification of the new location of the business or operations not less than 10 days prior to such removal with the Chief;Federal Explosives Licensing Center. The license or permit will be valid for the remainder of the term of the original license or permit. (•Ate Chief,FELC,shall,if the licensee or permittee is not qualified,refer the request for amended license or permit to the Director of Industry Operations for denial in accordance with§555.54.) Right of Succession (27 CFR 5.55,59). (a)Certain persons other than the licensee or permittee may secure the right to carry on the same explosive materials business or operations at the same address shown on,and for the remainder of the term of,a current license or permit. Such persons are: (1)The surviving spouse or child,or executor,administrator,or other legal representative of a deceased licensee or permittee;and(2)A receiver or trustee in bankruptcy,or an assignee for benefit of creditors. (b)In order to secure the right provided by this section,the person or persons continuing the business or operalions shall furnish the license or permit for for that business or operations for endorsement of such succession to the Chief;FELC,within 30 days from the date on which the successor begins to arty on the business or operations. (Con[imted on reverse side) Cut Here X Federal Explosives License(Permit(FEL)Information Card i LicensoPermitName:SANTORESMORLD FAMOUS FIREWORKS LLC I I I I Business Name: 1 j License/Permit Number 6-NY-083-20-4"1080 I I 1 1 LicensdPermit Type:20-MANUFACTURER OF EXPLOSIVES 1 I •• e I Expiration: March 1,2024 t I` I Please Note:Not Valid for the Sale or Other Disposition cifExplosives. I I 1 GHREDEPTF CUTCHOGUE FIRE DEPARTMENT Office of the Chief 260 NEW SUFFOLK ROAD, CUTCHOGUE, L.I., N.Y. 11935 siu+o (631)734-6907 • FAX(631)734-2818 • cutchoguechiefs@yahoo.com • www.cutchoguefiredept.org • EST. 1928 Amos Meringer William Brewer Christian Voegel Thomas Shalvey,Jr. ``'"� Thomas Roslak Chaef 1st Assistant Chief 2nd Assistant Chief Department Secretary Chaplain Cutchogue Fire Department M VIE 260 New Suffolk Rd. Cutchogue,NY,11935 JUN 8 20211 RE: Fireworks display Southold Town C?erk ' To Whom it may concern, The Cutchogue Fire Department has no objections to the requested fireworks display by the North Fork Country Club scheduled for July 3,2021 at 26342 Main Rd Cutchogue. Please advise us if a stand-by crew is needed for this event. Firematically yours, �� ec( Amos Meringer Chief Cutchogue Fire Dept Neville, Elizabeth _3_4 From: Neville, Elizabeth Sent: Wednesday, May 26, 20212:40 PM `3 To: 'Cutchogue Fire District' Subject: RE: Fireworks Permit Application Matt Environ Thank you very much Matt! Elizabeth A.Neville 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: Cutchogue Fire District [ma ilto:cutfd(aboptonline.net] Sent: Wednesday, May 26, 20212:27 PM To: Neville, Elizabeth Subject: Re: Fireworks Permit Application Matt Environ Hi Betty, Thank you for your permit applications (2). North Fork Country Club &Mattituck Environmental. I have passed it on to Chief Amos Meringer for his approval. We expect-his prompt reply and will return the letter thereafter. Yours truly, Matthew Martin, District Secretary Matt Martin Cutchogue Fire District Secretary 631-766-2666 cell; 631-734-5444 office Ext 202 260 New Suffolk Rd, Cutchogue, NY 11935 1 Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday,June 16, 202110:01 PM To: 'kelly@santorefireworks.com' Subject: Emailing: Fireworks Permit#2021-3_20210626215852 Attachments: Fireworks Permit#2021-3_20210616215852.pdf Kelly, Attached, please find Fireworks Permit 2021-3 for the North Fork Country Club. Elizabeth A. Neville 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#2021-320210616215852 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 RECEIVED MAY 2 4 2021 Southold Town Cterit SANT WORLD FAMOUS- FIREWORKS Date: 5/20/21 Town of Southold Office of Town Clerk Ms. Elizabeth Neville, MMC 53095 Main Road Southold,NY 11971 Dear Ms. Neville, Enclosed please find two applications for permits to display fireworks on July 3, 2021 at the North Fork Country Club and on July 4, 2021 at the Lomangino property at 9205 Skunk Lane. All the required paperwork is attached for your review for each application. If you have any questions or concerns, please do not hesitate to contact me at (908) 418-0989 or my email, kellygsantorefireworks.com. Thank you and stay safe, Kelly Santore Santore's World Famous Fireworks Main Office: PO Box 687,Stillwater, NY 12170 (P) 518-664-9994 Email: lnfo santoreworidfamousfireworks.com Visit Our Website at: www.santoreworldfamousfireworks.com Neville, Elizabeth From: Duffy, Bill Sent: Monday, May 24, 20213:31 PM To: Neville, Elizabeth Subject: RE: Emailing: Fireworks Permit Referra_20210524113932 No objection to north fork country club event William M. Duffy, Esq. Town Attorney Town of Southold Southold Town Annex 54375 Route 25 (Main Road) P.O. Box 1179 Southold, New York 11971-0959 Office: 631.765-1939 Fax: 631.765.6639 - Email:billd@southoldtownny.gov -----Original Message----- From: Neville, Elizabeth<E.Neville@town.southold.ny.us> Sent: Monday, May 24, 20212:23 PM To: Burke,John<iohnbu@southoldtownny.gov>; Duffy, Bill<billd@southoldtownny.eov>; Easton,James <iamese@southoldtownny.gov>; Fisher, Robert<Robert.Fisher@town.southold.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>; Hagan, Damon<damonh@southoldtownny.eov>; Norklun, Stacey <Stacey.Norklun@town.southold.nv.us>;Spiro, Melissa <Melissa.Spiro@town.southold.nv.us>; Dinizio,James <iames.dinizio@town.southold.nv.us>; Doherty,Jill <iill.doherty@town.southold.nv.us>; Evans, Louisa <louisae@southoldtownny.gov>; Ghosio, Bob<bob.ghosio@town.southold.nv.us>; Nappa,Sarah <sarahn@southoldtownny.gov>; Russell,Scott<scottr@southoldtownny.gov>;Verity, Mike <Mike.Verity@town.southold.ny.us> Subject: Emailing: Fireworks Permit Referra_20210524113932 Attached, please find an application submitted by Santore's World Famous Fireworks on behalf of North Fork Country Club. Please review it and send me your comments and recommendations for approval and issuance. Elizabeth A. Neville 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 Referra 20210524113932 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: Easton,James Sent: Wednesday, May 26, 20217:51 AM To: Neville, Elizabeth Subject: RE: Emailing: Fireworks Permit Referra_20210524113932 I have no objections to this event taking place. James Easton Fire Marshal,Town of Southold JamesE@southoldtownny.eov (W) 631-765-1802 PRIVELEGED AND CONFIDENTIAL COMMUNICATION CONFIDENTIALITY NOTICE: This electronic mail transmission is intended only for the use of the individual or entity to which it is addressed and may contain confidential information belonging to the sender which is protected by privilege. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this transmission in error, please notify the sender immediately by e-mail and delete the original message. -----Original Message----- From: Neville, Elizabeth <E.Neville@town.southold.nv.us> Sent: Monday, May 24, 20212:23 PM To: Burke,John<iohnbu@southoldtownny.gov>; Duffy, Bill<billd@southoldtownny.gov>; Easton,James <iamese@southoldtownny.Rov>; Fisher, Robert<Robert.Fisher@town.southold.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownnv.Rov>; Norklun,Stacey <Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us>; Dinizio,James <iames.dinizio@town.southold.nv.us>; Doherty,Jill <fill.doherty@town.southold.nv.us>; Evans, Louisa <louisae@southoldtownny.gov>; Ghosio, Bob<bob.ehosio@town.southold.nv.us>; Nappa, Sarah <sarahn@southoldtownnv.eov>; Russell, Scott<scottr@southoldtownnv.pov>;Verity, Mike <Mike.Verity@town.southold.ny.us> Subject: Emailing: Fireworks Permit Referra_20210524113932 Attached, please find an application submitted by Santore's World Famous Fireworks on behalf of North Fork Country Club. Please review it and send me your comments and recommendations for approval and issuance. Elizabeth A. Neville 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 Referra 20210524113932 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: Spiro, Melissa Sent: Monday, May 24, 20212:56 PM To: Neville, Elizabeth; Burke,John; Duffy, Bill; Easton,James; Fisher, Robert; Flatley, Martin; Hagan, Damon; Norklun, Stacey; Dinizio,James; Doherty,Jill; Evans, Louisa; Ghosio, Bob; Nappa, Sarah; Russell, Scott;Verity, Mike Subject: RE: Emailing: Fireworks Permit Referra_20210524113932 This is not Town preserved land. Melissa S. -----Original Message----- From: Neville, Elizabeth Sent: Monday, May 24, 20212:23 PM To: Burke,John<iohnbu@southoldtownnv.gov>; Duffy, Bill<billd@southoldtownny.gov>; Easton,James <jamese@southoldtownny.gov>; Fisher, Robert<Robert.Fisher@town.southold.nv.us>; Flatley, Martin <mflatley@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun @town.southoId.nv.us>;Spiro, Melissa <Melissa.Spiro@town.southold.nv.us>; Dinizio,James <iames.dinizio@town.southold.nv.us>; Doherty,Jill <iill.doherty@town.southold.ny.us>; Evans, Louisa <louisae@southoldtownny.gov>; Ghosio, Bob<bob.ghosio@town.southold.nv.us>; Nappa, Sarah <sarahn@southoldtownny.gov>; Russell,Scott<scottr@southoldtownny.gov>;Verity, Mike <Mike.Verity@town.southold.nv.us> Subject: Emailing: Fireworks Permit Referra_20210524113932 Attached, please find an application submitted by Santore's World Famous Fireworks on behalf of North Fork Country Club. Please review it and send me your comments and recommendations for approval and issuance. Elizabeth A. Neville 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 Referra 20210524113932 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 Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday, May 26, 202110:53 AM To: cutfd@optonline.net Subject: NF Country Club-Fireworks Permit Application Attachments: Fireworks Permit Referra_20210524113932.pdf Importance: High Good Morning, We have a second (2"d) Fireworks Permit Application filed by Santore's Famous Fireworks on behalf of North Fork Country Club. The process is the same. The attached application must be reviewed by the Chief of the Cutchogue Fire Department who must send a letter to the Town Clerk's Office stating his approval and any comments/recommendations before the Town Board can adopt a resolution to issue the permit. Please respond at your earliest convenience. Thank you. Elizabeth A.Neville 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 Cutchogue Fire Department - Suffolk County, New York Page 1 of 2 PR6,UDLY SERVING THE COMMUNITY SINCE�19'28, FIRE G�• Home Fire District [ History Department Offi=cers Inside CFD I Apparatus I Events I-; Amos Meringer - Chief Photo Galleries I Recruitment William Brewer - 1st Assistant Chief Prevention Store Christian Voegel - 2nd Assistanct Chief Guestbook News Archives Members Area Local Weather Links Department Secretary - Tom Shalvey Jr. Contact Us Chaplain-Thomas Roslak 2021 Incidents Jan 40 United Fire Company No. I officers Feb 34 Mar 38 Christopher Dinizio - Captain Apr 30 May 32 Jun D Thomas Cybulski - Recording Secretary Michael C. Boken - Jui D Financial Secretary Aug 0 Sep 0 Oct 0 Timothy Horton - Treasurer Nov 0 Dec 0 Total 174 Lieutenants Past Incidents Michael C. Boken, Richard Horton, Garrett Lake, Thomas Behr, Joe 2020 476 Hinton, Kate Michalak, 2019 435 2018 413 2017 387 Will Voegel, Ken Pearsall, Arthur Brewer, Christian Figurniak 2016 433 2015 438 Chief Drivers 2014 439 2013 2012 521 Allan Glover, Robert Scott, Charles Witczak, John Hinton Sr., John 2011 484 Hinton Jr., 2010 507 2008 375 Jim Rocco, Rex Spielmann, Will Voegel, Everrett Glover Rescue Sid Richard Hartmann - Captain Kate Michalak- Lieutenant https://www.cutchoguefiredept.org/content/officers/ 5/26/2021 i ELIZABETH A. NEVILLE, C �� Town Hall, 53Q95 Main Road TOWN CLEC P.O. Box 1179 Southold..\Tew York 1IWI REGISTRAR OF VITAL STATISTICS Fax (63 1) 765-6145 MARRIAGE OFFICER Telephone(631)765-1800 RECORDS NIANAGEINIENT OFFICER �� ® www.southoldtownny.gov FREEDOM OF INF OWATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD INSTRUCTIONS FOR DISPLAY OF FIREWORKS t Name of body sponsoring fireworks display. The date and time of da at which the fueworks display is ra be held . 3. The exact location planned for the fireworks display, including TAX NW1 NUMBED, 4. The age, experience and physical characteristics of the persons who are to do the actual discharging ofthe fireworks. 5 The numnber and kind of fireworks to be discharged. 6 The planner and place of storage o f such fireworks prior to the display. '. A diagram of the -rounds on which the display is tri be held, showing the point at which the firev�,orks 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. Such other information as the Southold To-NNn Clerk may deem.necessary to protect persons and property. Written permission ofthe property owner is required. 9. An indemnity insurance policy with liability coverage mid 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 flamed insured must read: TOWiN OF SOUTHOLD. Thirty (30)'rown of Southold POLICY 11. Application for a firevAlorks permit must be made at least fw-e=dZs in advance ofthe date ofthe fireworks d'isplay. (Ihe above instructions are in accordance with the Penal Law, Article 405 - Licensing and other provisions relating to fireworks.) ® FoUrQ®2 ELI A.BE TH A. NEVILLE, �1 C ��, � Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1.179 r� Southold,New York 11971 REGISTRAR OF VITAL STATISTICS ® Fax (631) 765-6145 MARRIAGE OFFICER �� ®' Telephone(631)765=1800 RECORDS MANAGEMENT OFFICER w,,rw.southoldtowniy.gov FREEDOM OF TNFORMATION OFFICER OMCE OF THE TOWNT LE TOWN OF SOUTHOLD POLICY fox the Issuance of Fireworks Permits 1. The Town may grant a pennit for the display of fireworks by municipalities, fair associations, amusement parks, ep rsons or organizations olindividuals. Penal Law- Section 405.00(2). 2. An "organization of individuals" is a religious, civic, or comparable organization. Op. Atty. Oen No. 2007-3. J. Fireworks permits shall indicate that the display must be concluded by 10:00 p.m. if held Sunday-Thursday, 11 :00 p.m. ifheld Friday or Saturday. and there shall be no tune restriction if held on July 4. 4. No person shall engage in or allow the manufacture, assembly, storage or display, of any reworks or pyrotechnics display without first obtaining a pei nit issued by the Town Clerk. A completed application for display of fireworks must be received by the Town Clerk a minimum of 30 slays prior to the date of display. The permit application for any fireworks or pyrotechnics display shall be accornpanied by the following: (a) a copy of a valid certificate of competency as a pyrotechnician for the individual supervisitig the firing of the display. (b) 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. (c) 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 o fthe contract with fireworks display company, and (e) A11 applications shall require the approval ofthe Fire Chief ofthe District in which the display will tape place and the Fire Marshal before being presented for approval by the To Am Board. All applications for a fireworks pennit shall be subject to an application fee in an amount of MOM, together with a processing fee un an amount to be detennined by the ToNNm Board to cox,er the Town's costs for monitoring and enforcing compliance with the Penal Law. (Tile above instmetions are in accordance with the Penal Law. Article 405 -Licensing and other provisions relating to fireworks.) RECEIVED µ84 Southold rown Clerk ELIZABETH A. Lm MMC 1,53095 Main Road TOWN CLERK O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICSFax(631)765-6145 MARRIAGE OFFICER le hone(631)755®1800 RECORDS OF MANAGEMENT OFFICER cera oldtowmnorthfork®net FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD APPLICATION PERMIT TO DISPLAY FIREWORKS APPLICATION IS HEREBY MADE, pursuantto the provisions of Section 405. 0 of the Penal Law oft e State of New York,for a permit to display fireworks as hereinafter specified- DISPLAY IS TO HE SPONSORED BY �"J 1, C PRINCIPAL OFFICE AT EXACT 1A( .........- SUFFOLK COUNTY TAX MAP NUMBER FOR SITE RAIN DATE & W � 7 , f;, �,, :n The following persons are to he in charge of the actual shooting of the fireworks: Name Age ExperiencePhysical Condition (A.drlitional narnes and information may be submitted on an attached sheet I mmrrmller and type of fireworks is as follows: yy �a , .gg,yy -s Manner and place of storage of fireworks prior to display:_,) Attached hereto and rrm tle 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, C Q 1Written permission,with signature of the must The submitted with the Application. Il...°iwl.:W $100 , µerne of Organization. _... _ m . .. ar... See jpollcy4or additional inforunationTelle � �, 2 � .�.. We__� �.le��"Appilc�tio� ..��. ... ....�...... ..��. i ... m �w �_ � . ..._.___ m� I� RECEIVED 1 d Southold Town Cleric SAN � I'VORLD FAMOUREAVO S Date: 5/20/21 Town of Southold Office of Town Clerk Ms. Elizabeth Neville, MMC 53095 Main Road Southold, NY 11971 Dear Ms. Neville, Enclosed please find two applications for permits to display fireworks on July 3, 2021 at the North Fork Country Club and on July 4, 2021 at the Lomangino property at 9205 Skunk Lane. All the required paperwork is attached for your review for each application. If you have any questions or concerns, please do not hesitate to contact me at (908) 418-0989 or my email, Thank you and stay safe, Kelly Santore Santore's World Famous Fireworks Main Office: PO Box 687, Stillwater, NY 12170 (P) 518-664-9994 Email Info( ��nt �o ldfai nOL,s it oi[ks.,c fTi Visit Our Website at:www.santoreworldfamousfireworks.com Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 05/24/21 Receipt#: 281228 Quantity Transactions Reference Subtotal 1 Fireworks 7/3/21 $100.00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#001743 $100.00 Santore's World Famous Fireworks, LLC Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: North, Fork Country Club Pob 725 Main Road Cutchoque, NY 11935 Clerk ID: SABRINA Internal ID:7/3/21 r .., �ePr vrr»a'd'n:Wn�raVi1" mmuuw, ia .r YD/i Nia q r9/;,i wr., ,,, ,,,.„.,, „�, ,vr v�>-,INr umlln rk�Yl� r x✓ / v daw rl,/,414iNJ rrAF •wrewm ,w um+ww,w,q n!"''9rN ` v,n '�� /lr�d,1''4+,N' A4�Ai , ,.:, err r P; iid� ill Vii' i4 � r Ghal r $979M w4 XfOROMPOP / " d/�i�i 4l' ,r w, ,,,„ „" !✓,� q " i ,'„r ` k ,:4 N ;,iJ ,�!lr`�l / r 1'�vYJ� ” u �,/,r v1J (,1 0 4'u'D��ai�G, d rl „r,,,,W^wwrorrv�yb��i'"�rry '"� ,i ,:�+atil,;6� .,.�� i � ;,,., r Ji i,rt ✓w Y'��rv "rr�/�7�'�WI�PJJ'°�r��r'�r��'�rY��filil cfr ,�,Y, , "r liAUr , qk„' n 4ror �ro rtlw i(rl aatiUPu r rU N TO a �parmG�in� M r a m/ 4Y r w M,4">/1+rim r � mrw,e w'16»�hW�v�ryU 'V�'%hnr� =v,�wrvowvmr`rµJlydl a '�vIr�IN"�'� nw7r v ,w..� ,r ,�� w 1 �� i ry ""„rM r .ra„^py vPfi�J° "�tisa � y"dnw d✓ a„r��rW ;qrP 4a pw,ld I rw�^rCY"""� ',,; r ada7'` Un449am. u ° kd� 0 4a G1r r a4 ;91 U C4for& ' +C rl f !! 4»I "F " n T A?w 7 J G d9 r �Vs a dbl 4.P,8 �"hp” m "d'ia w. d1� r y `.�,” I,o.' �, ,�G Y fl, ,ud. `µ,P�'�I'n'ro✓° +"�r4 uI,WdYW'JF ry s 1 9 C9vw"a 9 P b ",�q �µ CPY PlB VPiCI r°NY� 11� OW, ,I.ww"T�P°a'� s¢ PP5129' �* ayu, �V b', SIM " ,,,twr , [ (a183} 4 51 ,w riu.4d rh V 4d° �. 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I he pumi� C 'v Iht", a I� o t o, a I i Cir i i f ica u,:, c('"11)rh",k2 I h"'Y JS a F) I'(1 b�21 'i n I r I-t4 I ",C 10 4) dCh S WU I ny; n a i n Q0 e 1 n"n o a INdd as a d d U h w a I h m u nA "„4,A1 i 1,000 fi-w puNic HuNhy ond KjWON bw pnqxq J UAW dhqnmi shwAy In"dom of AwmqW, Tsclunp; mul iniihnium disl ices W accokswe xvAh die Lav", oJAW muruct NOT Tem"As dkphq cNiTaij ! W sh�-ffl �,ipprov�'R Clhif�loflhc Hre p"I'L'u'shal hing kfi In"y I cro,ri 1��onrd, All ,uppH,4,:,afic)jv,:i firc-,voits pewit WH be suNed U) mn apWAGAi be in mi mount M I WAR QeWwAi a 1pirtwessirig ke hi mi mnowA in be deWnn bed by A I Wri �o cov'c"t" IN"'. Town's Ar numboHng wuhwdNr&g cumpUmuc Mi le 11m] Vhc� instrwhins an? W accordance ,vith, thc, ),rfitAc, 405 "'Incl othel prw,Jsiolls �o gle Maps North Fork Country Club 7/3/21 W is 350 Ft 150 Ft Ohl '" i Measure distance Total distance:350.63 ft(106.87 m) Launch Site- up to 4" Shells =Audience Viewing Launch Site - Cakes- 1.25" . .00 Fallout Zone for Cakes—150 Radius _. Fallout Zone for 4"Shells- 350' Radius Launch Site Lat/Long: 410 00' 16" N /72 29' 25"W Display Location: North Fork Country Club, 26342 Main Road, Cutchogue, Southold, NY SANI k AVORID I° US-I� "N North Fork Country u May 20, 2021 Santore World Famous Fireworks 846 Stillwater Bridge Road Schaghticoke, NY 12154 Dear Kelly; As per our Fire Works Display Agreement dated May 13, 2021,we have hired you to perform a fireworks show at our property located at 26342 Main Road, Cutchogue, NY 11935 on July 3, 2021.You have our permission to apply for the necessary permits. Thank you, " /�4� Raluca Pintea General Manager PO.BOX 725 a CUT "HOGUE,NEW YO * 11935 07 5 (631)734-7139 - u�A (631)734-9004 a nfbcvnaiI@ ptonIin ,ne[ « ww.northforkcc,.com DATE(MMIDONYYY) CERTIFICATE LIABILITY S C 5/14/2021 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 be endorsed. H 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 Britton-Gallagher and Associates, Inc. PHONE - FAX -— One Cleveland Center, Floor 30 + Hp,.Exq 216-658-7100 _t,�N�;216-658-7701 EMAIL -- 1375 East 9th Street AHN]RI 5 Cleveland OH 44114 INSURER(s AFFORDING COVERAGE MAIC# .,,,.,, �,....., �_____rr,,,,,... INSURERA:Everest National Insurance Compan r 10120 - — - -- - ... .................... INSURED Sa ore's World Famous Fireworks LLC 183x1 INsuRER B:Axis Surplus Ins Company 26620 846 Stillwater Bridge Road INSURER C:—_—_ Schaghticoke NY 12154 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:128377900 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .................. ........TYPE OF INSURANCE INSR WVD POLICY NUMBER .MOLIC IM" .. ................... -- --................. v...wgn, LIMITS. .................................. _........ I SSR ADDU RRDBR POLICY EFF POLICY EXP A GENERAL LIABILITY Y Y S18ML00235-211 2/9/2021 2/9/2022 EACH OCCURRENCE $1,000,000 X X DAMAGE TO O II=I) COMMERCIAL GENERAL LIABILITY _-.-- _PREMIS_ES(EBu $500.000 CLAIMS-MADE ,OCCUR MED EXP(My one person) $ ........ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $...2..,0....0.....0..,000 - ... PNMT PER: PRODUCTS-COMP/OP AGG $2.000,000 AGGREGATE _ ....._..... w LIMIT APPLIES POLICY X L,(':I[': $ A AUTOMOBILE LIABILITY Y Y S18CA00102-211 2/9/2021 2/9/2022 COMBINED SINGLE'.LIMIT _(La,arr{dea.Et) ......... .1vgW . X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS _AUTOS ( ) NON-OWNED PROPERTY DAMAGE X X �SderrtO HIRED AUTOS AUTOS (Per $, m, $ B UMBRELLALIAB X OCCUR Y Y P-001-000074909-03 2/9/2021 2/9/2022 EACH OCCURRENCE $4000000 X EXCESS LIAB CLAIMS-MADE __ ___,__� AGGREGATE $4,000,000 ......... ,. ......... .. DEED RETENTION WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ,_ ,.T._rI't't tMY.Ca', hat ... ..... ... ............ ANY PROPRIETOWPARTNER/EXECUTNE E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ N yes,describe under �. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,rf more space is required) Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement. Display Date.7/3/21.Rain bate°9/5121.Location:North Fork Country Club North Fork Country Club,Hamlet of CutChogue„Town of Southold,Suffolk County are named as additional insureds,but only in respect of liability caused by the negligent arts or omissions of the named insured:,Subrogation waived to the,extent required by written contract, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF SOUTHOLD ACCORDANCE WITH THE POLICY PROVISIONS. 53095 Main Road P.O. Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD rr� lug � i I � ..�.. � II � Lh,�wuA"��WO' X;"�tlu Au'u`A ��II E � � U I10��I� ulu EVIII SII�II� IIII LS CMJ CE'R.NNIIICA E IS ISSUEll.,,;ll' AS A MN rrIBWIR OF WFOUMV10IN IL..VNLli .AIIwMD CON'wNPERS NO RM NMIS N„MPOPM THE Clll,��N III fl::l AMUSrrEWEF. 'lin CM'RwnRC, TE Oiwwll,°°'S Will" V9uN„" hRIAXT'h'CIM °u Ofl! MAMEG,io "q'M"d"El.:'I4 AMEICNN,w, 11EEKTIEND O I .q.MVE wJO"V'q`RAG, ! AIM' OR11DE I:Pii` a I LG , �wM ' ' J � 91�� CN � LMI ��MNCMM � A�N � C" �� w�� , �ll!AJNMIN IP� l .�IIwM "Cw � � �INNNNJ �MCN : J�C " `hwNCu C R'MuFIR ESEN7A,IC`Pl I"wR NDN,'ODIIJId OZ i0,11IC C'NII' A N 111111:::::tiw ,A E CI"CLDERI NuMuw,wlV Nrr nMa,p. a rrarr swIIMMNsJCd:C•11. ICa:.CL, " .L.a CNuA,„ p u.nNlllA 'Id'P;IIA, '4 apuu,:,M: Mwrrrw:Nawuw.N. 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W MI o me CI ryNu'*14,r wN krruaG s wAll'', C CPRD, /7-096\N1111 NYSIF New York State Insurance Fund 1 WATERVLIET AVENUE ALBANY,NEW YORK 12206-1649 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A^"^^^ 472010297 SANTORE'S WORLD FAMOUS � FIREWORKS LLCI 143 SUMMIT AVE BERKELEY HEIGHTS NJ 07922 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SANTORE'S WORLD FAMOUS NORTH FORK COUNTRY CLUB FIREWORKS LLC 26342 MAIN ROAD 143 SUMMIT AVE CUTCHOGUE NY 11935 BERKELEY HEIGHTS NJ 07922 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE A2353 260-9 521284 02/07/2021 TO 02/07/2022 5/14/2021 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2353 260-9, 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://WWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF A LIMITED LIABILITY COMPANY, 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. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 1036397931 U-26.3 a�aw dl �,aa�� a a2 a �a+��ne� aka!�`didn��YCP^"drr+w«k.��.�am�aw;�u�ma+ww�wJ,a�..;p.u�awn t�ona�aawwwawv+�wwmt��m a.�a,m.rorwu�n w.�ra,��r��w avm arc�mmnxw�m mea a„y saamW �Ik' �� kPd alP`B,aar�gd091%WJP�an�'aawa,�a!re,Nm6w'a�dos�rn�ueae u�4anau�w iF�rvmMwMMmm�vp�@m,w�awr�umn�wmmima^.�,�, kn, aa✓m�CmNwdwrouo�ry mr' a�a� �a a, �A arara�uwre�w rrwmam,wmwry mma ,,�,wa� �.Fmmw �,,w.�a».w�a n pa..ww,..�sy� r+•mow pe.w+��r.r�obrrtlf�lCtilr�r '.+•w, �.am�m�.Hr "a prn.�..rA.rnw�..war.�sannar�.r Ctaura.aMar.rwOt w,..n,r� Q r...ewy aw fr.aw..eanwr W ro zz— s..inlw�A—swrrr.n rr.awwr..a �,wa.mm ws ma wmyy ur+ron.* ua+,tt u[wsm.rww.w�w�rw a e �` R;Na f'rrturo7� m0 .'tl�M,ro,.ea�; u•'��f�C�f R'.ka5+e�«m�,aw«��war aAa'f�N � Il.tl.�?'iuKMaiWR' a ,6'..1175/ ��+�aYr �a 11 �• w.vr ,,,. ...., ,,. _ 77 .,-21 .�Lrrrru' Sy"" ti PETER IF MAR,SHALt •g NOM PRGXIMATE AUDIENCE ONLY THM"CA C MUST BE CARRIED WKNOINSINROTff U��rt, I,i Ii1 i 6�`� pry IIpps� �9ee��r�'b`�'�"a��q// we R„i S I�a N� �1I�V IN Irl c Nri STATE OF NEW YORK DIVISION OF DEPARTMENT OF LABOR ' � � � � AE AND HEALTH ,µt, EXPLOSIVESLICENSE TO DEAL IN OR MANUFACTURE Expires: 12/31/2021 Santore's World Famous Fireworks, LLC 846 Stillwater Bridge Rd THIS Schaghticoke, NY 12154 IN YOUR PLACE OF BUSINESS August N. Santore, Jr, License is hereby licensed to deal in or manufacture explosives in compliance with the requirements of the Labor Law and Industr sl Code Rules. Any change in the conditions ander which this license is granted may cause it to be revoked. Eileen M.Franko,Acting Director FOR THE COMMISSIONER of LABOR Every person selling,delivering or giving away any explosives must keep at the principal place of business within the state,a record of each transection,Including; 1) the NAME or TYPE and QUANTIT &explosives SOLD,DELIVERED,or GIVEN, Now:No llcenss is needed to purchase ornotreless powder,or black powder in quantities not exceeding,five pounds for use in firing antique firearms or artifacts or fepiicas thereof, However',dealers MUST post all suchtransactions on t.he'°Eiealer-Manufacturer Deport of Explosives Transactions", 2) the DATE OF EACH SALE,DELIVERY or GIFT. 3) the NAME,LICENSE NUMBER,and BUSINESS ADDRESS of the purchaser,donee,or person to whom the explosives were delivered and the firm,if any,represented by suc"person. 4) the NAME,ADDRESS,and LICENSE NUMBER of the person TAKING THE EXPLOSIVES AWAY from the seller or donor, SH-862(5®98) U.S.Departincut of Justice Federal Explosives License/Permit Bureau ofAlcahol,Tobacco,Fireanns and Explosives (18 U.S.C Chapter 40) -------------- Inacco Tice with Uii'o`li(�,visionsof Tit 0ff, �Ciij=. a:«Wm_lKa of 197-0,and the_ieg_@ions iasued'i.fiexeiind CFTNir5!� you may engage in the activity specified in this license or permit within the limitations ofChajAoi 40,,TillcI4.,United States Code and the regulations issued thereunder,until the expiration date shown. TRIS LICENSE IS'NOT TRANSFERABLEV.NDER27UR' .53. See"WARNINGS"and vN01TCES"on reverse. Direct ATF ATF-Chief FELC Correspondence To 244 Needy Road MartinsburF,WV 25405-9431 Chief Fede m]Ex plosivcsT,'ccn,%'ngCen (FE- to 1 Expiration aDate Name SANTORFS WORLD FAMOUS FIREWORKS LLC Premises Address(Changes?Noffythe.;ELC at least 10 days before the move.) 846 STILLWATER BRIDGE ROAD Type ofLicense or Permit 20-MANUFACTURER OF EX-PLOSIVES Purchasing Certification Statement Mailing Address,(Changes?-Notify the FELC of any changes.) The licensee or permittee nstmed above shall use a copy of. lice=ci permit to assist a tvinderor of explosives to verify the identity and the.licmsW status afthelicensee or permittee asprovided by 27 CFR.Part 555. re2p mch c2a must be an original S-AN_TORES_WORLD FAMOUS FIREWORKS LLC !katum A fazed,scanned cc"roiled cater of the licaRm or permit with a signalwe irtanded to bean aiginal signature is acceptable. 'Ibe:sip.uwremusinae lbatcftbo:Federal 143 SUMMI-r AVE, Explosives Lica risee(ML)Lva msponsibleperson ofthejffl. IcemilYthathis isatrue RERKELEY HEIGHTS, NJ 07922- f!opy ofa license or permit issued to the limace or permittet,aamcd 2b6ye to engAgiria*e- business cr operations specified above ram 'Type of Doease-or Pernik!' Lir ensw)Perruittee Responsible Person Signature PtisifibriTtic,' Printed Name Date ATFF�540o14/_5A0o15ParLI Revised STtcn9)qz 2011 Federal Explosives Licam(FEL)Custmer Service Information Federal Explosives Licensing Center(FELC) Toll-free Tehpfioneblumber: (977)283-3352 ATF Homepage:www.atf.gov 244 Needy Road Fax Number_ (304)616-4401 Martinsburg,WV 25405-9431 E-mail: FELC@atf.gov Change of Address (27CFR 555.54(a)(1))_ Licensees or permittees may during the term of their current license or permit remove their business or operations to a now location at which they intend regularly to carry on such business or operations. The licensee or permittee is required to give notification of the new location ofthe business or operations not less than 10 days prior to such removal with the ChiK Federal Explosives Licensing Center. The license or permit will be valid for the remainder ofthe term of the original license or permit. (lbe Chief;FELC,shall,if the licensee or permittee is not qualified,refer the request for amended license or permit to the Director of Industry Operations for denial in accordance with§555.546) Right of Succession (27 CFR 555.59). (a)Certain persons other than the licensee or permittee may secure the right to carry on the some explosive materials business or operations at the same address shown on,and for the remainder ofthe term of,a current license or permit. Such persons are: (1)The surviving spouse or child,or executor,administrator,or other legal rqyresentsdive of a deceased licensee or pemittec,and(2)A receiver or trustee in bankruptcy,or an assignee for benefit of creditors- (b)In order to secure the right provided by this section,the person or persons continuing the business or operations shall furnish the license or permit for for that business or operations for endorsement of such succession to the Chief,FELC,within 30 days from the date on which the successor begins to carry on the business or operations. (Continued on reverse side) Cut Here ———————————————————---- .......... Federal Explosives License/Permilt(FEL)Information Card LicensuPerinitNanw:SANTORESWORLID FAMOUS FIREWORKS LLC BusinessName: Li it Number:6-NY-083-20-4C-01 080 Li it Type:20-MANUFACTURER OF EXPLOSIVES Expiration-- March 1.2D24 t Please Note: NoL Valid for the Sale or Other Disposition of Explosives. -————————— ———————————---——