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Southold Town Board-Letter Board Meeting of July 5, 2022 RESOLUTION 2022-570 Item# 5.14 oy�o�a� ADOPTED DOC ID: 18232 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2022-570 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JULY 5, 2022: RESOLVED that the Town Board of the Town of Southold hereby approves the issuance of a fireworks permit by the Town Clerk to Peconic Landing at Southold,Inc. for a fireworks display on August 13th,2022 at 8'•15PM (Rain Date: August 14th, 2022 at 7 8.15 PM), on the Peconic Landing's property at 1500 Brecknock Road, Greenport,New York,upon the payment of a single fee of$100 and subject to the applicant's compliance with the requirements of the Town's policy regarding the issuance of fireworks permits. Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Greg Doroski, Councilman SECONDER:Brian O. Mealy, Councilman AYES: Nappa,Doroski,Mealy, Doherty, Evans, Russell Generated July 6, 2022 Page 31 FO[,4-c DENIS NONCARROW �� ®G� Town Hall,53095 Main Road TOWN CLERK ® P.O.Box 1179 co 2 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS %95 Fax(631)765-6145 MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER �Q� .��® Telephone 765-1800 FREEDOM OF INFORMATION OFFICER www.southoldtldtownny.gov 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: Peconic Landing of Southold Inc. A PERMIT FOR THE PUBLIC DISPLAY OF FIREWORKS by said organization in accordance with the provisions of Section 405.00 of the Penal Law of the State of New York, on Saturday. AulZust 13th, 2022 at 8:15 P.M. (Rain Date: Sunday, Aulzust 14th, 2022 at 8:15 P.M.) on property located at 1500, Brecknock Road, Greenport, 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 th hall be at least two such operators constantly on duty during the discharge and that at least two soda-a d or other approved type fire extinguishers of at least two and one-half gallons capacity each shall be kept at uch i ly sep -ated points as possible within the actual area of the display. Denis Noncarrow ,, Town Clerk Town of Southold Date: July 5th, 2022, THIS PERMIT IS NOT TRANSFERABLE i ELIZABETH A.NEVILLE,MMC 1421 TOWN CLERK �� Town Hall,53095 Main Road P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS ® Fax(631)765-6145 MARRIAGE OFFICER Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER �� �� www.so a(631)765- 800 FREEDOM OF INFORMATION OFFICER gov CREED OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD UN 4 -t2O2 n ategig: INSTRUCTIONS FOR DISPLAY OF MEWORKS L Name ofbody sponsoring fireworks display. 2 The date and time of day at which the fireworks display is to be held. 3. The exact location planned for the fireworks display, including TAX MAP NUMBER 4 The age,experience and physical characteristics of the persons who are to do the actual discharging ofthe fireworks. 5 The number and kind of fireworks to be discharged. o. The manner and place of storage of such fireworks prior to the display. 7. A diagram of the grounds on which the display is to be held, showing the point at which the fireworks are to be discharged, the location of all buildings, highways and other lines of communication, the lines behind which the audience will be restrained and location of all nearby trees; telegraph or telephone lines or other overhead obstructions. S Such other information as the Southold Town Clerk may deem necessary to protect persons.and property. Written permission ofthe property owner is required. 9. An indemnity insurance policy with.liability coverage and indemnity protection of$.1,000,000.00 per person for bodily injury;.$1,000,000.00 per accident; $1,000,000.00 property damage. 10 The Town Clerk ofthe Town of Southold must have the insurance policy in her possession before the fireworks permit is issued. The named insured must read:,TOWN OF SOUTHOLD. Thirty (30)Town of Southold POLICY 11. Application for a fireworks permit must be made at least fwe=days in advance ofthe date ofthe fireworks display. (The above instructions are in accordance with the Penal Law, Article 405 -Licensing and.other provisions relating to fireworks.) ELIZABETHTOWN NEMS E,MMC F rdy� Town Tull,53095 Main Road o P.O.Bog 1179 Southold,NewYork 11971 REGISTRAR OF VITAL,STATISTICS Fax(63I)?65-6145 MARRIAGE OFFICER $� p� Tel hate(63I)76b-1800 RECORDS OF MANAGEMENT`OFFICER FREEMM OP INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD APPLICATION PERMIT TO DISPLAY FIREWORKS APPLICATION IS HEREBY MADE, pursuant to the provisions of Section 405.00 of the Penal Law of the State of New York,for a permit to display fireworks as hereinafter specified: DISPLAY IS TO BE SPONSORED BY Reconic T anrjin or PRINCIPAI.OFFICE AT 1500 Brecknock Rd.,Greenport,NY 11944 DATE&TIME OF DISPLAY 8/13/22 at 9:15 pm EXACT LOCATION-OF DISPLAY Greenport NY.41°0708.$"N 72"21'49.1"W SUFFOLK COUNTY TAX MAP NUMBER FOR SITE .RAIN DATE&TIME The following persons are to be in charge of the actual shooting of the fireworks: Name , Age Experience Physical Condition Richard Davin , 55 25+years Able bodied (Additional names and information may be submitted on an attached sheet Number and type of fireworks is as follows: Manner and place of storage of fireworks prior to display: Delivery Q Drod uct on 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. NOT'IC'E. Written permission,with signature of the Property Owner,must be submitted with the Application. FEE: C`,,.+., c1A7nrlrl �WPI' 1515 i d0 Name o amzatFon See policy-40f additional information August N. Santore,Jr. By Printed Name o ppscan Signat of Applicant e-mail address: asantorejr@santorefireworks.com. 6/10/22 Telephone Number 908_272_j)624 Date of Application ELIZABETH A.NEVILLE,MMC ��� Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Southold,New York 11971 REGISTRAR.OF VITAL STATISTICS ® Fax(631)765-6145 MARRIAGE OFFICER Telephone{631)765-1800 RECORDS MANAGEMENT OFFICER �.( �� w Telephone (631)765-1800 FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD POLICY for the Issuance of Fireworks Permits. L The Town may grant a permit for the display of fireworks by municipalities,fair associations, amusement parks,persons or organizations ofindividuals. Penal Law Section 405.00(2). 2 An "organization ofindividuals" is areligious, civic, or comparable organization. Op. Atty. Gen No. 2007-3. �. 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) 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 ofPenal Law Section 405(2); (d) A copy ofthe 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 Towel Board. 5. Allapplications for a fireworks pennit shall be subject to an application fee in an amount of$100.00, together with aprocessing fee in an amount to be detennined by the Town Board to cover the Town's costs for monitoring and enforcing compliance with the Penal Law. (The above instructions are in accordance with the Penal Law,Article 405 -Licensing and other provisions relating to fireworks.) ACC? CERTIFICATE OF LIABILITY INSURANCE DATE(MNMD YYY) 6/10/2022 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(les)must he endorsed. If SUBROGATION 1S 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. Pt MN!EN One Cleveland Center,Floor 30 (MO •216-658-7100 �a c N,:216 58-7101 1375 East 9th Street ADDRESS: Cleveland OH 44114 INS S AFFORDING COVERAGE NAIL# INSURERA:Everest National Insurance Company 10120 INSURED 18341 World Famous Fireworks LLC 98 ' INSURERS:AXIS Surplus Ins Company 26620. 846 Stillwater Bridge Road INSURERC: Schaghticoke NY 12154 INSURER D: INSURER E: INSURER F: COVERAGES GER71FICATE NUMBER.,2088837815 REVISION NUMBER: THIS 1S 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. ADDL SUBR POLICY EFF POLICY EXP LTR TYPEOFINSURANCE POLICY NUMBER M D POLICY LIMITS A I GENERAL LIABILITY S18ML00236--221 219!2022 2/9/2123 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY ToD FRIPREMISES RENTErrence $500,000 CLAIMS MADE OCCUR MED EXP one person) $ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOPAGG $2,000 000 POUCY' X 1 PRO- LOC $ A AUTOMOBILE LIABILITY SIBCA00102-221 219/2022 21912023 COMBINED SINGLE-00 a accident) 1 00 ALLLL OWNED SCHEDULED X AWNO BODILY INJURY(Per person) $ AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X ANN-OWN0 � PRr MROPERTY'ZDAMAGE et $ $ B UMBRELLA LIAB X IOCCUR P-001-000074909-04 2192022 2192023 EACH OCCURRENCE $4,000,000 X EXCESS LJAB CLAIMS-MADE AGGREGATE $4,000,000 DED I I RETENTION$ S WORKERS COMPENSATION WC STATU-_LIMITS OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNERIEXECUTNE E.L.EACH OFFICER/MEMBEREXCLUDED? NIA $ (Mandatory in un) E.L.DISEASE-EA EMPLOYE ]ryes,describe under $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks schedule,If more space is raqulred). Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement Display date:6/13122; Rain date:8/14/22. Location:Peconic Landing,1500 Brecknock Rd.,Greenport,NY Additional insureds•are Peconic Landing Housing Association Cooperative,Inc.;Breclmock Hall Foundation;Peconic Landing Home Health Services;Inc.;The Shores at Peconic Landing Assisted Living Residence,Inc.,County of Suffolk and Town of Southold,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 DELIVERM IN Peconic Landing at Southold, Inc. ACCORDANCE WITH THE POLICY PROVISIONS, 1500 Brecknock Road Greenport NY AUTHORIZED REPRESENTATIVE ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD DATE(MM/DDIYYYY) ACC?REP® CERTIFICATE OF LIABILITY INSURANCE 4/1/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jennifer Corry The Graham Company PHONE FAX The Graham Building No Ex • 215-567-6300 A/c No:215-405-2694 1 Penn Square West ADDRESS: CORRY UNIT@qrahamco.com Philadelphia PA 19102- _ INSURERS AFFORDING COVERAGE NAIC# INSURER A:Columbia Casualty Company 31127 INSURED PECOLAN-01 INSURER 13:American Casualty Company of Reading,PA 20427 Peconic Landing at Southold, Inc. 1500 Brecknock Road INSURER C:The Phoenix Insurance Company 25623 Suite A INSURER D: Greenport NY 11944 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:850579971 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 EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 6080464236 4/2/2022 4/2/2023 EACH OCCURRENCE $1,000,000 CLAIMS-MADE FX_1 OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY❑PRO � JECT LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y Y 6080464222 4/2/2022 4/2/2023 COMBINED SINGLE LIMIT $1,000,000 _ Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A X UMBRELLA LIAB OCCUR Y N 6080464219 4/2/2022 4/2/2023 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED RETENTION$ $ C WORKERS COMPENSATION Y UB3N4683962243G 4/2/2022 4/2/2023 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANYPROPRIETOR/PARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Professional Liability 6080464236 4/2/2022 4/2/2023 Limit: 1,000,000 Aggregate 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Project#/Reference:Re:Fireworks Display 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 // � -f ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 41-07-08.3"N . • +!`�y-1;>� �•, meq' ^; ���y,��i y.4:- �a..r sp�-• Peconic Landing Show Date:8/13/22 Rain Date:8/14/22 � is'�. tech/ � :1;4 �{` }�� � b�9' f--�'-a,Z•' - ,j � •8cF}'vk'k p `, }S-h.�.,,� + Q� .sem° `�i; i ����� � titer' �,`� .�,#,.• .. %1- - `. June 9,2022 Office of the Town Cleric Southold Town To Whom it May Concern, Enclosed please find an application for a fireworks permit to Peconic Landing for a fireworks display to be held on Saturday, August 13, 2022(rain date Sunday,August 14)as part of our 20th Anniversary Celebration. The event Is open to the public. We anticipate Greenport Fire . Department will be on the scene during the event. Please advise If you need any additional information for the application process. Many thanks, Diane Radigan Vice President Member Services r U.&]leparhneut of Justice Federal Explosives License/Permit Bureau ofAlcohol,Tobacco,Firearms and Explosives (18 U.S.0 Ch ifBl'4Q ar�w�m®Immaare�ar�a 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 1_0,,•TigeLd§,United Stats Code and the regulations issued thereunder,until the expiration,date shown. THIS LICENSE IS NOT TRANSFERABLE-DNDER27.CFV`SS5:93_See"WARN1NOS"and'NOTICES"on reverse. Direct ATF ATF-Chief;FELL :;': iccnse/1?etmif Correspondence To 244 Needy Road - .'Nttrriliers'. _ 6-NY-083-20-4C-01 0; Martinsburg,WV 25405-9431. Chief;FederalExplosivesLicensmgCerd (FELC) Expiratiotrt.:' Date March 1, 2024 - - 1 F. Name SANTORES WORLD FAMOUS FIREWORKS--kLC t Premises Address(Changes?Notify tBe.FELC at lea410 days before the 846 STILLWATER BRIDGE ROAD• , 4 SCHAGHTICOKE, NY 12154- '- Type ofLicense or Perrrvt 20=MANUFACTURER OF EXPLOSIVES Purchasing CertifcationStafemeht Mailing Addiess;(Changes?% otify�reFELCofanychanges) The licensee or permitteenamed above shall use a copy ofthis license 0ebefmitto•a-M;Lr= transfercrofexplosivestovet ythe idetityandtheleeosedstxnuofthe'icenseeere` permittee aAfaxeprovided ,cane CFR Part iledco� elici}nbe-or ac ctmvmdstiieanorieatal; �.;_-$i4NTORES WORLD-FAMOUS FIREWORKS LLC sienamre• Afar scanned or emailed copy ofthe iicezt�vt permitr�oifh a siglature :`: :,.'. ,••:...:N.�;^.' intended to be an original signature is acceptable. The siesta t;,muist lie that of the Federal 143 S VMMIT AVe.- ' ExpiosivesLicensee(FFL)orarespoasibkpersonoftke>~ET .IcatifyAattlusisa- SERICE-t.'rkIEIGHT. NJ 07922- copy ofa license a perrniI issued to theliceusee orpetxnitteEpa ell abbn4e t`o argage�tt*a-, y 5'' r business or operations speed above under"Type of Licease••or PeimiG.� �wr' ,.i.>+;�. .3 Licensee/Permittee Responsible Person Signature P6sit1,brV!'itlg Printed Name Date AIF Fran 5a00.13/Sa04.75P�c I PreviousEditionisObsolete IMWMRt$WCOLaFAMOUS TWHoanunusmcwnexRevised September 2011 Federal Explosives license(FEL)Castomer Service Information Federal Explosives Licensing Center(FPLC) Toll-free Telephone Number. (877)283-3352 ATF Homepage:wwav_atf gov 244 Needy Road Fax Number. .(304)616.4401 Martinsburg,WV 25405.9431 E-mail: FEL C@atCgov Change of AQdress (27 CSR J55.54(a)0))_ 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 permiMm is required to give notification ofthe new locariaa ofthe business or operations not less than 10 days prior to such removal with the Chief,Pederal Explosives Licensing Center. The license or permit will be valid for the remainder of the term of the original license orpermit. Me Chief,FELL,shall,if the licensee or pernuttee is not quabfied,refer the request for ametttied license or pet mit to the Director of Industry Operations for denial in accordance with§$55.54.) Rlght 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 ofthe term of,a c=nt license or permit. Such persons awe: (1)The surviving spouse or child,or executor,administrator,or other legal representative of a deceased licensee or permittee;and(2)A receiver ortrustee in bankruptcy,or an assignee for benefit ofcreditors. (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 Chie4 FELC,within 30 days from the date'on which the successor begins to carry on the business or operations. (Confamoed on reverse side) Cat Here X- --------------------------------- Federal ------------ ---------------------Federal Explosives License/Peratit(FEL)Information Card i I LicenseJPerinitName:SANTORES.Wq%l)FAMOUS FIREWORKS LLO j I 7 I Business Name: t j I•ieenseipet nit Number.6-NY-083-20-41-01080 ' LiccnstiPennit Type:20-MANUFACTURER OF EXPLOSIVES 1 'Expiration: March 1,2024 1 1 I PIease Note:Not Valid ft the Sale or Other Disposition of Explosives 1 I 1 .. .,_....., �. ._,s-.:—..... ,n,,.f•oes„v-rs,..+.fi,.,�«.na{r•an..«,rer w,cmv`yaC"�.-""q:;`°'r+.,”"�:,. .: w+�.,,..'�i'"�'v`r.. .a,....... ._�.•,ys..�... :.,,., .. STATE OF NEW YORK DIVISION OF DEPARTMENT OF LABOR °A,: .`� I�;�; ' SAFETY AND HEALTH ENT- LICENSE TO'.DEAL•IN OR*ANUFACTURE�EXPLOSI'V'ES ' EX01res. 12/31/2}22, 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 inanufacture,expjosives'in compliance;;witfi'vi requirements of•.the Labor Law and ndustrlat Code-Rules:;.A iypha4ge in the condi{ions unde'rwhich"this license:is granted may cause'itto 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 transactlon,•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•,'.1f any;represented 6y such person. 4) the NAME,'ADDREFS,,and LICENSE.NUMBER of the.perscid:FAKING"THE EXPLOSIVES AWAY from the seller .or'donor. SH-862(5-98) ` 9Q580 FIREWORKS DiSPLAYACREEMENT Display Date:8113/2022 ` AGREEMENT by and between Santore's World Famous Fireworks,LLC whose address Is 846 Stillwater Bridge Road,Schaghficoke, NY 12154(hereinafter"Santore");and Peconic Landing,1500 Brecknock Road,Greenport,NY (hereinafter"SPONSOR"). WHEREAS, SANTORE designs,produces,and conducts fireworks displays;and WHEREAS,SPONSOR wishes to engage Santore to design,produce and perform a fireworks display on the terms and conditions hereinaftersetforth; NOW,THEREFORE, Inconsideration of the terms,conditions and covenants hereinafter set forth,the parties hereto do mutually agree as follows: 1. FIREWORKS DISPLAY: On, 8113122(hereinafter"the Display Date"),Santore shall provide the fireworks and equipment for the display at the Fireworks Display location.The displaywill be underthe supervision of a Santore tralned technician.It is agreed that Santore shall be the sole fireworks supplier and prod ucerfor the event contracted for herein. (Note: The actual start and stop time of the display will be determined by the governmental authorities having Jurisdiction over the display). 2. start Time of Display: Approx. Z 'J't) ,,AwAfPiease insert.)or as directed by client(not later than ordinance Permits). Z,I`7 #)i`A ALTERNATE DATE: 8/94/22 (Rain or shine or otherwise notitled) 2, COST AND PAYMENTS: FIREWORKS DISPLAY PRICE: $8,000.00 The total(Fireworks Display Price plus all other applicable charges)sum of $8.000.00 shall be due and payable as follows: a.The sumof., $4.000.00 on the execution of contract. There will bean additional fee for perm itdosts(administration included)to be reimbursed. b.Balance evening of the display$4000.00). Please Note: SPONSOR is responsible for the payment of all governmental fees and taxes,including,but not limited to,sales, use,excise,license,permit,entertainment,orother fees,taxes or surcharges Imposed orotherwise applied to this exhlbiti on. Also, please see Section 16(c)below. 3. POSTPONEMENT/RESCNEDULING: , If show Is postponed as per below Description I %of Fireworks Display Price Additional Costs If notified by 6:01 AM on 8/18/2022 30% Any 3r"Party Vendor Expenses j When fireworks tech leaves facility50% An 3r Pa Vendor Expenses Any request made by SPONSOR for rescheduling/canceling shall be directed tb info@santorefire'wor•ks,com or by phone(518)664- 9994. It Is understood and agreed that SANTORE shall have no obligation to reschedule a display except as required by inclement weatheror reasons beyond the control of SANTORE. 4.SPONSOR'S AGENT: CELL PHONE: Diane Radigan Cel l# 61%(� t) J4 - i a,1 z- shall be designated as SPONSOR'S agent to whom ail questions and inquiries shall be relayed. Sponsor's agent shall be the only agentof SPONSOR authorized to make decisions on behalf of SPONSOR orto request rescheduling of the fireworks displayon the part of SPONSOR. Please initial each page. Initial here: WSJ SP. or SANTOR S. EXHIBITION PLANNER CHECKLIST: It is understood and agreed by the parties hereto that the Fireworks Displayshall be contingentupon the strict compliance by SPONSOR with all items specified on the Exhibition Planner Checklist(EPC)which is annexed hereto and made a part hereof. Failure on the part of SPONSOR to comply with all requirements setforth in the EPG to the satisfaction of Santoro within the time limits therein set forth shall be deem ed to be an event of defaultof SPONSOR'S obligations hereunder. 6. SECURITY/SAFETY.• SPONSOR shall provide and maintain sufficient Security before,during and after the Fireworks Display until the pyrotechnic€an in charge declares the area clear. Security shall be deemed to include,but not limited to,be all security lines,police protection,snow fencing,rope lines,barricades or any other item deemed necessary by the local government or by Santoro. SPONSOR shall also provide and maintain an area clearof any buildings cars and spectators with a minimum radius as specified by current edition of NFPA Code 1123, as a Fire Safety Zone(FSZ)during the entire period cam mencing from the time the fireworks are delivered to the site until the area Is declared clearby the pyrotechnician. It is understoodand agreed that Santore will cease all fireworks discharge due to any security breach of the FSZ Santore shall not be responsible for personal injury,vehicle or property damage occurring within the FSZ as a resultof the SPONSOR's failure to maintain the FSZ in accordance with the standards of current edition of NFPA 1123 which,incidentally,are onlyminimum standards of distances. SPONSOR acknowledges and agrees that Santore responsibilities are limited to the Fireworks Displayand that Santore is relying on SPONSOR to maintain the aforementioned FSZ and to compiywith all Federal,State,municipal and local laws,orders,regulations and ordinances pertaining to the implementation of anyand all security measures at the site of the Fireworks Display.Any site visits made during the dfsplaysetup by or on behalf of SPONSOR shall be in accordance with the current edition of NFPA 1123-and under the direct supervision of the Santore technician in charge.Any such inspection shall not in anyway interfere with the safety,setup or schedule of the preparation for and 1 disassembly after the Fireworks Display.The Santore technician in charge may,at his discretion,cancel any inspection that in his sole ti opinion may compromise the safetyof the setup or the Fireworks Display or the setup schedule. The SANTORE technician may atany time temp orarilydiscontinue the discharge of fireworks for any reason. 7. CREDITS: As a material inducementto Santore agreeing to enter into this Agreement,SPONSOR shall give Santore program credit as sole fireworks supplier and producerin all press releases,advertising,and any other program announcements,printed or otherwise. 8, INABILITY to DELIVER or CONDUCT FIREWORKS D/SPLAWFORCE 1NAJEURF Santore shall not Incur any liability for any loss or forany failure to perform anyobligaHon hereunder due to causes beyond its reasonable'control including withoutlim itation legal or regulatory restrictions,labor disputes of whatever nature,power loss,telecommunications failure,acts of God,orany othercause beyond its reasonable control, in the event SANTORE is unable to dellverthe Fireworks D€splayon the Delivery Date this contract wil I remain in full force and effectand the Fireworks Displaywill be performed on theAlternate Date or if no Alternate Date is stated then on such other date as may be agreed upon by the parties, 9.CONTRA CTSUBJECTTOGOVERNMENT REGULATION: This Agreement and Santore obligations hereunder are subjecttoall j applicable Federal,State,Municipal and local laws,rules,ordinances,regulations and codes,now or hereinafter in effect,and to the conditions and limitations contained in the permits required to be obtained by SPONSOR prior to the Fireworks Display. In the event any Federal,State,municipal ori ocal law,rule,regulation orordinance shall be enacted which in any way prohibits,limits or restricts the sale,performance or operation of the exhibition of the Fireworks Displayor in the event SPONSOR'S permitfn anyway limits or restricts the sale,performance oroperation of said exhibition,Santore shall limit orrestd6tIts;performance or the Fireworks Display so i as to comply with such law,rule,regulation or ordinance orlimitation or restriction of SPONSOR'S permit.SPONSOR acknowledges that any such limit or restriction placed on the performance or operation of the Fireworks Display shall in noway result in or entitle SPONSOR to a reduction orebatementin the full contract price. i 10. GENERAL PROVISIONS: i a) This ag reemen t constitutes the entire agreement between the parties relating to the subject matter hereof,and may not be changed,modified,renewed orextended except by a written agreement,signed by both parties, SPONSOR acknowledges and agrees that Santore has not made any representations orwarranties except those specifically set forth in this contract. Should any clause,section,or part of this agreementbe held or declared to be void or illegal for any reason,all other clauses,sections, or parts of this agreementwhich can be effected withoutsuch illegal clause,section,or part shall nevertheless continue in full force and effect. b) SPONSOR is responsible for removal of paperdebris associated with the Fireworks Display. c) Santore is not responsible for procuring any marine services associated with the production of SPONSOR'S event. Should SPONSOR require these services,Santore may,upon written request,assist SPONSOR in the location and contracting of such services. All additional costs and fees associated with marine services are the responsibility of the SPONSOR. It is specifically understood and agreed that Santore shall not be responsible in anyway If any third-party service with which SPONSOR has contracted for service falls to perform and the display cannot proceed as planned. d) SPONSOR is responsible for any additional marine costs andfees,cityPerm lt/escortfees,County/State/PD/FD/FMfees, local town permitfees,etc. e) in the event SPONSOR cancelsthe Fireworks Displaythe full contractprice as set forth hereinshall'become immediatelydue and payable. SPONSOR will have up to 30 days from the date of cancellation to request Santore to reschedule the Fireworks Please initial each page*P 'sor lrnllial here: SANTORE U i I i U.S. Eastern Service Center 1701 Columbia Ave. Department of Operations Support College Park,GA Transportation Group AJV-E2 30337 FIREWORKS.DISPLAY NOTIFICATION Company Name: Santore's Mtorld Famous Fireworks Email Address of Person Submitting Request: aeon, toreir(@santorefireworks coLn Cell Phone Number for On-Site Technician:Richard Davin, (631)889-9938 . Event Name: Peconic Landing Display Date:8/13/2 2 Rain Date:8/14/22 Display Start Time pm 0 I Duration of Fireworks Display:10-12 min. Max Height of Fireworks:250 feet Address,City and State: 1500 Brecknock Rd. Greenport,NY 11944 Latitude:41' 0 7' 08.3" (North)Longitude:72' 21' 4 9. 1" ' (West) List the Closest Public Use Airport Within 5 Nautical Miles of the Display if the Fireworks Will Reach or Exceed 500 R. Special Notes Please email your request to: 9-ATO-ESA-OSG-Fireworks faa. ov Display. Fireworks Displayshall take place no later than six months from originally scheduled Firewoft Display and n12y not be rescheduled to 711 —714 of any year without express consent of Santoro. f) Santora agrees to procure liability insurance on behalf of SPONSOR,and to indemnify SPONSOR,to the extent thereof,for all claims arising out of Santoro negligence. Any additional insurance thatisrequired that incurs acost,will bethe SPONSOR'S responsibility. 11.SPONSOR'S DEFAULT: In the event SPONSOR shall fail to pay any sum when due under the terms of this contract,SPONSOR shall pay,in addition to such amount,Interest at the rate of 1.5%per month on the unpaid amount from the original due date. SPONSOR does furtheragree that it shall pay Santore reasonable attorneyfees and other costs in the event Santore shall commence any proceeding(Arbitration or any other proceeding)or incu rfees to compel SPONSOR to pay any sums due hereunder or otherwise as a result of SPONSOR'S defaultof any of the terms and provisions herein containbd. 12.LIQUIDATED DAMAGES: it is agreed by and between the parties hereto that in the event of SPONSOR'S default hereunder Santore shall be entitled to receivethe entire contract price and same shall beconsidered'Ilquidated damages"based uponan understand Ing betweenthe parties hereto thatSantore will havesuffered damages due to Sponsor's default.The damages suffered by Santore as a result of Sponsors defaUtwill be substantial,but incapable of determinationwlth m athematical precision,Itis,therefore,agreed bythe padies thatthe amount due Santore is not a penalty,but rather a m utuallybeneficial and reasonable estimate of the damages suffered by Santore. 13.SUBSTITUTIONS: Santore shall have the right,at its discretion,to substitute anyf freworks it deems necessary provided same does not detract from the aesthetic value or quality of the program.This includes,but is not limited to,shelf sizes,quantities,Types and brand names. Any substitutions shall In noway result in or entitle SPONSOR to a reduction orabatementof the full contract price. 14.ARBITRATION: Any and all disputes,differences,orany othertype of controversy arising out of or in relation to this Agreement, including as to the meaning or interpretation ofanyprovision hereof,shall be resolved by arbitration in Union County, NJ,pursuant to the commercial rules then obtaining of theAmedcan Arbitration Association.Oniyone(1)arbitrator shall be required,an d the arbitratormay award attorneys'fees.The award of the arbitratorshall be final and binding and judgmentmay be entered thereon in any court of competent jurisdiction,The arbitrator sitting in such controversy shall have no powerto alter or modifyanyexpres s provision of this Agreement,norto make any award which by Its terms effectsenysuch alteration ormodificatfon. Either party may seek from the court of corn petent jurisdiction arty provisional remedy in aid of arbitration,including,but not ilmited to,injunction,atta chm entor replevin,pending the determination of anyclaim orcontroversyin arbitration. Any and all disputes,controversies,actions,claims, causes of action,or proceedings arising under,outof,or in connection with or relating to the terms of this contract,and any amendment i thereof,commenced by,between or against any of the parties of this contract shall be deemed to have arisen from a transact!on of business in New York,and shaill be resolved by application of the substantive laws of the State of New Jersey. 15.BINDING EFFECT.This contractshallnot be bind In Santo the down payment required hereunder. g on reuntil executed bySPONSOR and Santore and Santorelsinreceipt'of i i 76. EXHIBITION PLANNER C!-iECKLIST{EPC): • a. FIREWORKS_DiSPLAY PERMIT: (Note: The actual start and stop time of the display will be determined by the governmental authorifles having jurisdiction over the display). SPONSOR'S RESPONSTBIUTY: it is Sponsor's responslbl fity to call your State, City,County,Town,Borough,or Village Fre Marshal or other appropriate authority to file forand obtain the Fireworks Displaypermit Santore will prepare the paperworkfor the permit application on SPONSOR'S behalf. Upon receipt of your perm Jt,you mt tet send the permit to our office for our records no later than 30 days DrIor to your display te. Failure to do so could serious) 'eo ardize our dis -lay. You mustobtain information on: 1. Fllingapplication deadline and fees. 2. Local and state requirements forfireworks license for transportation and/ordisplay. if a license is required,faxall forms immediately to us. 3. Fire Marshal's requirements forsecurity of fireworks truck upon arrival,and the securityof the fire zone before and during the display. i 4. Federal regulations require thatwe carry an accurate route plan to the display site. Fax us a copy of the route Instructions from the nearest US interstate to the display area(approved by the fire marshal or other authority,if necessary). 5. Notify FAA on day of your display,according to the instructions in the FAA Letter of Approval,which will be forwarded to you priorto yourdfsplay. b.COAST GUARD PERMITS(where required): Please initiat each page. initial here: S 5p sor SANTORE ' I. If the fireworks are to be displayed on or near the water,the following maybe required: (Requests for permits mustbe filed at least 60 days prior to the Display Date(135 days prior for4th of Julyevents). 2. Coast Guard Application and Perm itto Handle Hazardous Materials. 3. Coast Guard Marine Event Permit. c,SPONSOR RESPONSIBILITIES AND EXPENSES(The following services need to be provided and pall for by the SPONSOR in additipri to the Fireworks DIsnIav Price. �} SECURITY: MUST BE PROVIDED FOR FIREWORKS TRUCK(S) AND TO MAINTAIN THE FIRE SAFETY ZONE AT STAGING AREA FROM FIREWORKS TRUCK(S) ARRIVAL, UNTIL TRUCK DEPARTURE WHICH MAY BE FOLLOWING THE REQUIRED FIRST LIGHT DUDSEARCH ON THE MORNING AFTER THE DISPLAY. cFGW awes ' d.RADIO SIMULCAST EXPENSES(if a»pRcabie): 3) SP49 e_INSURAN6E—P�ase Ilst below the additiona ns d as they should appear on the insurance certificate: . L ..� u 2. c ir'r Sd d { (.c r 1 ,1 I�' 9�c ied Q V(Vv�, (Sa Name of S'onsew n arse digan Date ASentaSM �' S �2- Date Y rSigne by o beh If of ponsor Si nature rint � �-(- „-{v�F' Title f uthor d re resentative of S onsor Title ®aga��rrm���e��rra�a�me��ar����sua�a�ta®■�e�r�r�oaa�■a��a�rY■���rw��swr��R�, ��w�aar���Rr�wa � I I, �1t.J rt. {1.a1. �()l.t^}'�'lli ic^�. \• �1 f �1 j i Please initial each page. Initial hare: po r SANTC}RE ( 'Santare DISPLAY SITE PLAN QUESTIONNAIRE Ail items listed below are subject to all governing Federal,State,Municipal and local laws,rules,ordinances,regulations and codes,noworheteinafter in effect,and to the conditions and limitations contained i n th a permits required or to be obtalned by Sponsor. SPONSOR: Display Date August 13, 2022 Rain Date_8/14/22 Budget:$8,000 Display Location:_Near Brecknock Hall (as per site map) Time of Display; _ L` (Note: The actual start and stop time of the display will be determined by the governmental out or�ties having jurisdiction over the display). IMPORTANT: PLEASE PROVIDE A SITE PLAN FOR YOUR EVENT LOCATION, INDICATING WITH AN X THE EXACT SPOT INHERE FIREWORKS ARE TO BE SET-UP. Local Flre Marshal. Telephone No: Cell Phone No: {x" .3 -- 4 Crew ontact Person., Telephone No: ch i.fi.I l:3�t�.I,:{ Cell Phone No: 310 1 The Following information is necessary in order for us to provide your community or organization with a display that conforms with fireworks safety regulations and for the issuance of your insurance certificate � DISTANCES, IN FEET,FROM THE FIRING AREA TO THE FOLLOWING: FEET SPECTATORS, AUDIENCE OR PARKED CARS................. OCCUPIED BUILDINGS (HOMES, APARTMENTS, ETC.)..................................... PUBLIC BUILDINGS (SCHOOLS, HOSPITALS, CHURCHES, ETC.)...................... TEMPORARY EVENT SET-UPS (CONCESSIONS, TENTS, ETC.)......................... MAIN PARKING AREAS........... . .... .. ..................................................... HIGHWAYS OR ROADS................................................... OVERHEAD OBJECTS (POWER LINES,LIGHT POLES, TREES,ETC..................... FUELSTORAGE..............„......................................................:....... ........... PLEASE PROVIDE DIRECTIONS FROM NEAREST INTERSTATE TO DISPLAY SITE. A MAP WOULD ALSO BE HELPFUL. Local Motels/Hotels: Telephone Nos. Signature ____ pians-Rodin--. {b t0 ee i— • tVAJ i Title.* r Date 3//,6/z 2i i I Please initial each page. Initialhera: - ��"t / S r SANTORE NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 j nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE NA A A A A 472010297 ' SANTORE'S WORLD FAMOUS FIREWORKS LLC 143 SUMMIT AVE Q BERKELEY HEIGHTS NJ 07922 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SANTORE'S WORLD FAMOUS PECONIC AT SOUTHOLD,INC. FIREWORKS LLC 1500 BRECKNOCK RD '143 SUMMIT AVE GREENPORT NY 11944 BERKELEY HEIGHTS NJ 07922 POLICY NUMBER CERTIFICATE NUMBERT POLICY PERIOD A2353 260-9 997187 .02/07/2022 TO 02I07/Z023 ��2 s THIS 1S TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2353260-9. 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.COMfCERTfCERTVAL,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 STAT SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:941939149 YS F New York State Insurance Fund PO Box 66699,Albany,NY 12206 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE a n A A A A 472010297 . 01 SANTORE'S WORLD FAMOUS FIREWORKS LLC 143 SUMMIT AVE aj. BERKELEY HEIGHTS NJ 07922 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SANTORE'S WORLD FAMOUS TOWN OF SOUTHOLD 143 SUMMIT AVE FIREWORKS LLC 53095 MAIN RD.BERKELEY HEIGHTS NJ 07922 SOUTHOLD NY 11979 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE A2353 260-9 581792 02/07/2022 TO 02/07/2023 6/10/2022 THIS 1S 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:/IWWW.NYSIF.COMICERT/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 STAT SU NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:396422630 • Air Traffic Organization 1701 Columbia Avenue Eastern Service Center -College Park,GA 30337 U.S..Department of Transportation Federal Aviation Administration Dear Fireworks Proponent: Thank you for informing us of your proposed fireworks display. Although there are currently no federal regulations specific to fireworks displays,the Federal Aviation Administration (FAA) has been tasked with regulating the safe and efficient use of the navigable airspace (49 U.S.C.§ 40103). In recognition of this role in promoting aviation safety, many jurisdictions require.notice to the FAA as a condition of approval of a fireworks permit. We acknowledge your notification and have no objection to the fireworks display,provided it is conducted in a manner that does not create a hazard to other persons or their property. To enhance the safety of your event,we recommend the following actions: • Fireworks staff should remain vigilant to ensure that no aircraft are in the area prior to beginning the fireworks display. • If your event is within 5 miles of a public use airport, or if the display will exceed 500 feet Above Ground Level (AGL), contact Leidos Flight Service at 1-877-4-US-NTMS (1-877-487-6867) at least 24 hours (but not more than 7 days) in advance to request a Notice to Air Missions (NOTAM). You will need to provide the following information: o Name and address of the person filing the NOTAM o Date,time(s), and event location (City, State, and location in reference to the airport) o Maximum altitude of the display This letter should not be construed as superseding or invalidating any existing rules or regulations promulgated by any other federal, state, county, or municipal government which may be required for this display. If you have any questions regarding this information,please contact our office at(404) 305- 5570 or 9-ATO-ESA-OSG-Fireworksgfaa.gov_ Sincerely, Matthew N. Cathcart Manager, Operations Support Group v F 77 ('ee��bft ecac LII ng at Southold,Tn — .. 4 0\0�000t� ai� ;�fj rJ 96 1500 Brecknock Road SANDING�. N ,� x reenport, hTY sk3z t 06(13/2D22 aro 7 One hu�dretl and 001100 dollars 00"00 Pay to the order of F u ` €� 7 VoidArter 90 Days TWD SIGNATURES REQUIRED OVER$35 pp0 04 7 Town of•Soouthold +u k� 3 �, fl� •� d �' M ap Southold, NY 11`97 _ 3 i E SI6AATURE .r pa w 1110000096 1 10110 1:0 2 140666 71: 08000094 1 7115 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 06/14/22 Receipt#: 301139 Quantity Transactions Reference _ Subtotal 1 Fireworks 8/13/2022 $100.00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#96110 $100.00 Peconic, Landing Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Peconic, Landing P. O. Box 430 1500 Brecknock Rd Greenport, NY 11944 Clerk ID: DENISN internal ID:8/13/2022 Noncarrow, Denis From: Flatley, Martin Sent: Tuesday, June 14, 2022 1:21 PM To: Noncarrow, Denis Subject: RE: Fireworks app I have no objections to this permit being approved 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 recipientis 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, orotherstorage device or media. From: Noncarrow, Denis<denisn@southoldtownny.gov> Sent:Tuesday,June 14, 2022 12:45 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Doroski, Melanie<Me.lanie.Doroski@town.southold.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>; Norklun, Stacey<Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us>; Doherty,Jill <jill.doherty@town.southold.ny.us>; Doroski, Greg <greg.doroski@town.southold.ny.us>; Louisa Evans<Ipevans06390@gmail.com>; Mealy, Brian . <brian.mealy@town.southold.ny.us>; Nappa, Sarah <sarah.nappa@town.southold.ny.us>; Noncarrow,.Denis <denisn@southoldtownny.gov>; Rudder, Lynda <lynda.rudder@town.southold.ny.us>; Russell, Scott <Scott.Russel I@town.southoId.ny.us>; Standish, Lauren <Lauren.Standish@town.southold.ny.us>;Tomaszewski, Michelle<michellet@town.southold.ny.us>; Burke,John <johnbu@southoldtownny.gov>; Hagan, Damon <damonh@southoldtownny.gov>; Mirabelli, Melissa <melissa.mirabelli@town.southold.ny.us> Subject: Fireworks app Please see application for Peconic Landing Fireworks. Denis Noncarrow Southold Town Clerk. Town of Southold, New York www.southo/dtownny.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. 1