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HomeMy WebLinkAbout2022 DENIS NONCARROW ®� �.�� Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Cn Southold,New York 11971 REGISTRAR OF VITAL STATISTICS t5 Fax(631)765-6145 MARRIAGE OFFICER 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, DENIS NONCARROW, 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: GREENPORT FIRE DEPARTMENT STAR HOUSE CO. , THIRD STREET, GREENPORT A PERMIT FOR THE PUBLIC DISPLAY OF FIREWORKS by said organization in accordance w th the provisions of Section 405.00 of the Penal Law of the State of New York at 10:00 p.m. on Saturday, . a # 4� 12�tRaindate: Sunda May 29 2022 on the property of GREENPORT PUBLIC SCHOOL Athletic Field north side Front Street and east side Moores Lane, Greenport , New York. 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 feel from the nearest above ground telephone or telegraph line, trees or other overhead obstruction; that the audience at such 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 in 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 manner that the falling residue from the deflagration will fall in to such lake or body of water; that any fireworks that remain unfired after the display is conducted 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 pe fire extin ` *shers of at least two and one-half gallons capacity each shall be kept at such widely sep at po'nts as sible within the actual area of the display. Denis Noncarrow, Southold Town Clerk (Town Seal) Suffolk County,New York Date: March 29, 2022 THIS PERMIT IS NOT TRANSFERABLE Southold Town Board - Letter Board Meeting of March 29, 2022 RESOLUTION 2022-290 Item# 5.28 y3 '�°lam Yea ADOPTED DOC ID: 17925 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2022-290 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MARCH 29,2022: RESOLVED that the Town Board of the Town of Southold hereby approves the issuance of a fireworks permit by the Town Clerk to Star Hose Company of the Greenport Fire Department for a fireworks display at 10:00 PM on Saturday May 28, 2022 (Rain Date of: Sunday May 29, 2022) at Greenport High School's Athletic Field located on the north side of Front Street and the east side of Moores Lane, 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 and subject to the approval of the Town Attorney. Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Brian O. Mealy, Councilman SECONDER:Sarah E.Nappa, Councilwoman AYES: Nappa, Doroski, Mealy, Doherty, Evans Generated March 30, 2022 Page 42 RECEIVED VAR 17 2022 ELVABET111A.NEVILLE,MMC pyo l/ Zbwn XWjS lA T WA Clerk TOWN CLERK p P.O.Box 1179 cSouthold,New York 11971 REGISTRAR OF VITAL STATISTICS p Aftv Fax(631)765-6145 RECORDS OF MANAGEMENT OFFICER AGE OFFICERy�®j ,A`�4� Trlephone n.no 765-1800 e FREEDOM!OF INFORMATION OFFICER southoldtown.norEhfork.net >02140660c OFFICE OF THE TOWN CLERK FOR DEPOSIT ONLY TOWN OF SOUTHOLD DENIS NONCARROW APPLICATION SOUTHOLD TOWN CLMK PERMIT TO DISPLAY FIREWORKS 0500015466 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 tia R' s -Greenpo r De ac e t PRINCIPAL OFFICE AT P.�."F 7 ;G— e' rfe amort l .�a T, , €� �1'g'4 DATE&TIME OF DISPLAY 5/28/22 @ 10:00 pm EXACT LOCATION-OF DISPLAY Greenport High School Athletic Field SUFFOLK COUNTY TAX MAP NUMBER FOR SITE see attached map RAIN DATE&TIME 5/29/22 @ 10:00 pm The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition Richard Gomberg 59 15 yrs. Fit Edward Matuszak 67 20 yrs. Fit (Additional names and information may be submitted on an attached sheet Number and type of fireworks is as follows: 1.3G Fireworks: Opening: 5-3"Shells&64-1" Shells (1 Cake); Body: 20-2 1/2"Shells, 127-3"Shells, 5 - Multi Shot cakes 1"or less shells (243 total shots), Finale: 1 - Multi Shot Cake (64- 1" shells), 100-2 1/2" Shells, 70-3"Shells. Manner and place of storage of fireworks prior to display: Fireworks will be stored in a SWFF box truck and arrive 4 hours prior to display. Fireworks will be placed in there appropriate mortars for firing. 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. Santore's World Famous Fireworks LLC FES: $100 Name of Organization See policyvfor additional information Jeffrey Ward - Manager B,y Printed Name of Applicantignatur of Applicant e-mail address: Jward@santorefireworks.com 518 3/15/2022 Telephone Number ( ) 664-9994 Date of Application oFOL��o ELIZABETH A.NEVILLE,MMC may. �y Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 t� Southold,New York 11971 REGISTRAR OF VITAL STATISTICS • . Fax(631)765-6145 MARRIAGE OFFICER yaQ� Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.southoldtownny.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, ep rsons 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 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:- (a) ollowing:(a) a copy of a valid certificate of competency as a pyrotechnician for the individual supervising 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 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. 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 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.) ,�- rC io GREENPORT FIRE DEPARTMENT GREENPORT, NEW YORK 300 ft radius , 3 inch max .: ` `AT "# ® amid vt ow LL (72 Aw �r s a r t STATE OF NEW YORK - DEPARTMENT OF LABOR PYROTECNNICIAN CERTINCATE CSE COMPETENCE RICHARD W GOMBERG CLASS: P NON PROXIMATE AUDIENCE ONLY THIS CARO MUST RE CARRIED WHEN USING PYRGT F*695 NYC & NYS CERTIFICATIONS REQUIRED IN NYC , STATE OF NEW YORK DEPARTMENT OF LABOR PYROTECHNICIAN CERTIFICATE OF COMPETENCE EDWARD MATUSZAK 3: CLASS: B NON PROXIMATE AUDIENCE ONLY THIS CARD MUST BE CARRIED WHEN USING PYROT CERT# P425 NYC & NYS CERTIFICATIONS REQUIRED IN NYC I�nitlt���tll �Itl�t/lilt i� UNITED STATES OF AfAERIicr xi DEPARTMENT OF TRANSPORTATION . FEDERAL AVIATION ADMINISTRATION IV NAME EDWARD MATUSZAK V ADDRESS 675 BOELSEN DR WESTBURY NY 11""90-5904 VI NATIONALITY USA SEX HEIGHT WEIGHT HAIR EYE IVa D.O.B. 5 DEC 1954 M 71 260 BROWN BLU IX HAS BEEN FOUND TO BE PROPERLY QUALIFIED TO EXERCISE THE PRIVILEGES OF II REMOTE PILOT 01 CERTIFICATE NUMBER 4081457 Y DATE OF ISSUE 26 DEC 2017 XN VM ACTING ADMINISTRATUR pF NEI{ STATE OF NEW YORK �;��„ AT DIVISION OF DEPARTMENT OF LABOR '' SAFETY AND HEALTH LICENSE TO DEAL IN OR MANUFACTURE EXPLOSIVES Expires: 12/31/2022 Santore's World Famous Fireworks, LLC 846 Stillwater Bridge Rd THIS LICENSE MUST BE Schaghticoke, NY 12154 POSTED IN YOUR PLACE OF BUSINESS August N. Santore, Jr. License No D-5796 is hereby licensed to deal in or manufacture explosives in compliance with the requirements of the Labor Law and Industrial Code Rules. Any change in the conditions under 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 transaction, including: 1) the NAME or TYPE and QUANTITY of explosives SOLD, DELIVERED or GIVEN. Note: No license is needed to purchase smokeless powder,or black powder in quantities not exceeding five pounds for use in firing antique firearms or artifacts or replicas thereof. However,dealers MUST post all such transactions on the"Dealer-Manufacturer Report 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 such person. 4) the NAME,ADDREFS, and LICENSE NUMBER of the person TAKING THE EXPLOSIVES AWAY from the seller or donor. SH-862(5-98) Federal Explosives License/Permit U.S.Department of Justice Bureau of Alcohol,Tobacco,Firearms and Explosives (I8 U.S.C. Chapter 40) us�u�rarsaamen®awl 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 permit within the limitations of Chapter 40,Title 18,United States Code and the regulations issued thereunder,until the expiration date shown. THIS LICENSE IS NOT TRANSFERABLE UNDER 27 CFR 555.53. See"WARNINGS"and'NOTICES"on reverse. Direct ATF ATF-Chief,FELC License,Permit Correspondence To 244 Needy Road Numberi Martinsburg,WV 25405-9431 C-01 080 Chief.Federal Explosives Licensing Cente (FELC) Expiration Date March 1 , 2024 Name SANTORES WORLD FAMOUS FIREWORKS LLC Premises Address(Changes? Notify the FELC at least 10 days before the move.) 846 STILLWATER BRIDGE ROAD SCHAGHTICOKE NY 12154- Type of License 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 permit to assist a transferor of explosives to verify the identity and the licensed status of the licensee or permittee as provided by 27 CFR Part 555. The signature on each copy must be an original signature. Afaxed,scanned or e-mailed copy of the license or permit with a signature SANTORES WORLD FAMOUS FIREWORKS LLC intended to bean original signature is acceptable. The signature must be that of the Federal 143 SUMMIT AVE Explosives Licensee(FEL)or a responsible person of the FEL. I certify,that this is a true BERKELEY HEIGHTS, NJ 07922- cop),of a license or permit issued to the licensee or permittee named above to engage in the business or operations specified above under"Type of License or Permit." 0,y/j Liciggseli PerriiittreResponsible Person Signature Position,Title ,TtLfrcy 7// I /2 L Printed Name Date An Form MW W-14 u 15 Part I Previous Edition is Obsolete SANW SWOWFAMU5FIREWO ULA"STILLWTERSROGERM0.Rlbli-IY•AJ49Niloa:snn1.M4A4WWXTUsEewexnoava Revised5epternber2011 Federal Explosives license(FEL)Customer Service Information Federal Explosives Licensing Center(FELC) Toll-free Telephone Number: (877)283-3352 ATF Homepage:www.atf.gov 244 Needy Road Fax Number: (304)6163401 Martinsburg,WV 25405-9431 E-mail: FELC(datf.gov Change of Address (27 CFR 555.54(a)(1)). Licensees or permittees may during the term 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 F,xplosives Licensing Center. The license or permit will be valid for the remainder of the term of the original license or permit. (The Chief,FELL,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 555.59). (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 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 X Federal Explosives License/Permit(FEL)Information Card I LicenseiPermit Name:SANTORES WORLD FAMOUS FIREWORKS LLC I I I I I Business Name: I I I LicensePermit Number:6-NY-083-20-4C-01080 I I LicensevPermit Type:20-MANUFACTURER OF EXPLOSIVES Expiration: March 1,2024 II I Please Note: \of Valid for the Sale or Other Disposition of Explosives. I I I —----------——————————————————————— — A� CERTIFICATE ®F LIABILITY INSURANCE DA E(MMI022�n 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. 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: Britton-Gallagher and Associates, Inc. PHONE FAx One Cleveland Center, Floor 30 A/c No ExtI:216-658-7100 AIC Nol:216-658-7101 1375 East 9th Street E-MAIL Cleveland OH 44114 INSURERS AFFORDING COVERAGE NAIC# INSURERA:Everest National Insurance Company 10120 INSURED 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:217186740 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. ILTR TYPE OF INSURANCE AINSR JM DDL SUBR POLICY NUMBER MMIDDY EFF MMIDD EXP LIMITS A GENERAL LIABILITY Y Y S18ML00235-221 2/9/2022 2/9/2023 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGEPREMISESPREMISESSEa occurrence $500,000 CLAIMS-MADE �OCCUR 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 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY Y Y SIBCA00102-221 2/9/2022 2/9/2023 COMBINED SINGLE LIMIT Ea accident) cc dent $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident B UMBRELLA LIAB X OCCUR Y Y P-001-000074909.04 2/92022 2/9/2023 EACH OCCURRENCE $4,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $4,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN —IIQRY LIMITS FIR ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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. Town of Southold,Suffolk County,and The Greenport Fire Department Star Hose Company No.3 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 53095 Main Rd. AUTHORIZED REPRESENTATIVE Southold NY 11971 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i� NYSIF New York state Insurance Fund PO Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ^AAA^A 472010297 SANTORE'S WORLD FAMOUS FIREWORKS LLC 143 SUMMIT AVE ❑AD BERKELEY HEIGHTS NJ 07922 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SANTORE'S WORLD FAMOUS TOWN OF SOUTHOLD FIREWORKS LLC 53095 MAIN RD. 143 SUMMIT AVE SOUTHOLD NY 11971 BERKELEY HEIGHTS NJ 07922 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE A2353 260-9 581792 02/07/2022 TO 02/07/2023 3/15/2022 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:IIWWW.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. 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 AND/OR 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. NEW YORK STATrSU/RffE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:396422630 U-26.3 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 03/17/22 Receipt#: 295270 Quantity Transactions Reference Subtotal 1 Fireworks 1 $100.00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#000247 $100.00 Santore's, World Famous Fireworks Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Santore's, World Famous Fireworks Po Box 687 Stillwater, NY 12170 Clerk ID: DENISN Internal ID: 1 Santgre's World Famous.Fireworks, LLC TD Bank :000247 Expense Account' Avenue P.O. Box 687:. ; Park.II 4 5Y 1211$ :5P Mech51 acv Stillwater,NY 12170 ( 8)66 129 DATE � �f S-�Z :Z •;f PAY.TO THE (' ORDER OF f� It s LLAR' : .l DO S} �l 9F• . 3. .. ... AUTHORIZE SIGNAT RE .. $ 11'00,0 2.4 711':. 6.:2 5x:0.2 I1 O 2 5 ■ L6 X9,46,711 o o" AC® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/15/2020 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 Donna Ackroyd —NAMEMcMann Price Agency,Inc. PHONE (631)477-1680FAX 631 477-8930 828 Front Street E MAILo Ext): AIC No: ( ) —ADDRESS: donna@mcmannprice.com PO Box 2065 INSURERS)AFFORDING COVERAGE NAIC# Greenport NY 11944-0876 INSURERA: Arch Insurance Company INSURED INSURER B: Village of Greenport Fire Department INSURER C: PO Box 58 INSURER D: INSURER E: Greenport NY 11944-0058 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2011502713 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 MAYBE 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 SLIBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/ (MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR DAMAGE TO RENTETT_PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A Y MEPK06726914 06/01/2019 06/01/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 POLICY EPRO- JECT F7LOC PRODUCTS-COMP/OP AGG $ 10,000,000 OTHER: I Liquor Liab.Cov.Part $ 3,000,000 AUTOMOBILE LIABILITY &GI%rBFNE&,SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per. er accident $ �/ $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE g 5,000,000 A EXCESS LIAB CLAIMS MADE MEUM06473414 06/01/2019 06/01/2020 AGGREGATE $ 5,000,000 DED I I RETENTION$ $ WORKERS COMPENSATIONPER 0TH- AND EMPLOYERS'LIABILITY Y/N STATUTE 1 1 ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACHACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) _ With respect to Star Hose Carnival from May 21 to May 24,2020 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. PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 1988-2015 AC PORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACC? te C? ® 72/14/2022 (MMIDD/YYYY) ``�V�� CERTIFICATE OF LIABILITY INSURANCE 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. 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: Britton-Gallagher and Associates, Inc. N P 1C e -658-7100 MC No:216-658-7101 One Cleveland Center, Floor 30 E t: 216 1375 East 9th Street A DRIESS, Cleveland OH 44114 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Everest National Insurance Company 10120 INSURED 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:860258582 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. IN5R TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM DDIIYYYY OLICY EFF MMIDDIYYYY OLICY EXP LIMITS LTR A GENERAL LIABILITY Y Y S18ML00235-221 2/9/2022 2/9/2023 EACH OCCURRENCE $1,000,000 X DAMAGETO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500,000 CLAIMS-MADE �OCCUR 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 POLICY X PEO LOC $ A AUTOMOBILE LIABILITY Y Y S18CA00102-221 2/9/2022 2/912023 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPER PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident NON B UMBRELLA LIAB XJ OCCUR Y Y P-001-000074909-04 2/9/2022 2/9/2023 EACH OCCURRENCE $4,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $4,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N O I ITS E ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/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. Date of Display: 5/28/22;Rain date:5/29/22. Location:Greenport H.S.,Greenport,NY Greenport Fire Department;Star Hose Company;Village of Greenport,Town of Southold;Suffolk County,Greenport UFSD are hereby 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 Greenport Fire Department ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 345 Greenport NY 11944 AUTHORIZED REPRESENTATIVE USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Rudder, Lynda From: Noncarrow, Denis Sent: Friday, March 18, 2022 8:56 AM To: Rudder, Lynda Subject: FW: Fireworks application Denis Noncarrow Southold Town Clerk. Town of Southold, New York www.southoldtownny.pov denisn @south oldtownn y.go 631-765-1800 CONFIDENTIALITY NOTICE: This communication with its contents may contain confidential and/or legally privileged information. It is solely for the use of the intended recipient(s). Unauthorized interception, review, use or disclosure is prohibited and may violate applicable laws including the Electronic Communications Privacy Act. If you are not the intended recipient, please contact the sender and destroy all copies of the communication. From: Flatley, Martin Sent: Friday, March 18, 2022 8:54 AM To: Noncarrow, Denis<denisn@southoldtownny.gov> Subject: RE: Fireworks application Thanks Denis, I have no objections to this event taking place as in the past Martin Flatley, Chief of Police Town of Southold Police Department 41405 State Route 25 Peconic, N.Y. 11958 Tel: 631-765-3115 The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s)and may contain information that is privileged,confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient,you are hereby notified that any review,retransmission,conversion to hard copy,copying,reproduction,circulation,publication, dissemination or other use of,or taking of any action,or omission to take action,in reliance upon this communication by persons or entities other than the intended recipient is strictly prohibited. If you have received this communication in error,please(i)notify us immediately by telephone at 631.765.2600, (ii)return the original message and all copies to us at the address above via the U.S.Postal Service, and(iii)delete the message and any material attached thereto from any computer,disk drive,diskette,or other storage device or media. From: Noncarrow, Denis<denisn southoldtownny.gov> Sent: Friday, March 18, 2022 8:49 AM To: Blasko, Regina <rblasko town.southold.ny.us>; Doroski, Melanie<Melanie Doroski@town.southold.nv.us>; Flatley, Martin <mflatley@town.southold.nv.us>; Norklun,Stacey<Stacev Norklun@town.southold.nv.us>; Spiro, Melissa <Melissa Spiro@town.southold.ny.us>;Town Att 1 Cc: Rudder, Lynda <lynda.rudder@town.southold.nv.us> Subject: Fireworks application Please see attached. Thank you Denis Noncarrow Southold Town Clerk. Town of Southold, New York www.southold townn y.qov denisn@southoldtownny.gov 631-765-1800 CONFIDENTIALITY NOTICE: This communication with its contents may contain confidential and/or legally privileged information. It is solely for the use of the intended recipient(s). Unauthorized interception, review, use or disclosure is prohibited and may violate applicable laws including the Electronic Communications Privacy Act. If you are not the intended recipient, please contact the sender and destroy all copies of the communication. 2