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HomeMy WebLinkAbout2023 9:15 pm DENIS NONCARROW ��° � ; . Town Hall,53095 Main Road TOWNCLERK P.O.Box 1179 Southold;New York 11971 REGISTRAR OF VITAL STATISTICS ��' d �, Fax(631)765-6145 MARRIAGE.OFFICER Telephone(631)765-1800 RECORDS MANAOEMENT OFFICER ��" www.southoldtownny.gov FREEDOM OF.INFORMATION OFFICER RECEIvED OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD .JUN - I 20M APPLICATION PERMIT TO DISPLAY FIREWORKS Southold Town Cleri� APPLICATION IS HEREBY MADE, pursuant to the provisions of Section 405.00 of the.Penal Law o the State of New York, for a permit to display fireworks as hereinafter specified: DISPLAY IS TO BE SPONSORED BY: Peconic Bay Vineyards (Crossroads'Wine LLC),,,,,,,,,,,,,,,,,, PRINCIPAL OFFICE AT 31320 Main Rd Cutchogue NY 11935...............................;,;............................... DATE &TIME OF DISPLAY 7/1/2023 9:15pm - EXACT LOCATION OF DISPLAY 31320 Main Rd.Cutchogue NY'11935 _ SUFFOLK COUNTY TAX MAP NUMBER FOR SITE RAIN DATE & TIME 7/08/2.023 9:15pm................................................................................................ The following persons are to be'in.charge of:the actual shooting.of the fireworks: Name Age' Experience Physical Condition Rich Davin 56yrs. 20+ good (Additional names and information may he submitted on-an.attached sheet Number and type,of fireworks-isas.follows:' 150-2.5".=shells,192=3"shell8 ,102-.4"shells=8=1.3G.Cakes Manner and ;place of storage of fireworks" .prior to display:D.elivery_of:product in secured SWFF Truck on day of.display Attached hereto and-made a part of hereof-i&a-diagram.of the:-grounds on which the,display is.to he held. Also attached is a certificate,or,policyof insurance coverage.; NOTICE: Written permission-`With signature;of the:progetW-% wner.:must be`submitted with the Application. J' Santore's World Famous.Fkeworks LLC FEE: $100: "0'0 Naive of Organization By " C, — Signature of Applicant — 22 z-;j9 DntP of A nnlir.atinn •• . r oil dL a ' s + x R, V61, f" f SAN"I't �4�• � - ,� - HK)ttt. 1 tou - �. fIRE:WORKS Peconlc Bay Vineyards Red circle=Fallout lone 3W Leet(max.Yshell) Blue square=Launch location Yellow rectangle=Spectators All mm,;eircmryitx meel or o-A-rerd XTPA 9:15 pm FFdL/(�,� DENIS NONCARROW , � Town Hall,53095 Main Road TOWNCLERK P.O.Box 1179 res Southold,New York 11971 REGISTRAR OF VITAL STATISTICS 1810 �. Fax(631)765-6145 MARRIAGE OFFICER �p �y� Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER `+�: www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD AULICATION 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, f6r a permit to display fireworks as hereinafter specified: DISPLAY IS TO BE SPONSORED BY: Peconic Bay Vineyards (Crossroads Wine LLC .................. PRINCIPAL OFFICE AT 31320 Main Rd Cutchogue NY 11935................................................................. DATE &TIME OF DISPLAY 7/1/2023 9:15pm EXACT LOCATION OF DISPLAY 31320 Main Rd. Cutchogue NY 11935 SUFFOLK COUNTY TAX MAP NUMBER FOR SITE RAIN DATE & TIME 7/08/2023 9:15pm............................................................................................... The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition Rich Davin 56yrs. 20+ good (Additional names and information may he submitted on an attached sheet Number and type of fireworks is as follows: 150-2.5" shells,192-3"shells ,102-4"shells 8-1.3G Cakes Manner and place of storage of fireworks prior to display:Delivery of product in secured SWFF Truck on day of display Attached hereto and made a part of hereof is a diagram of the grounds on which the display is to he held. Also attached is a certificate or policy of insurance coverage. N Written permission, 'With signature of the Property Owner, must be submitted with the Application. J Santore Is World Famous Fireworks LLC FEE: $100. 0'0 Name of Organization — Signature of Applicant -22;2-;,? l)atP of A nnliontinn U.S.Department of Justice Federal Explosives License/Permit Bureau ofAleohol,Tobacco,Firearms and Explosives (18 U.S-C. Chapter 40) „a, a,�l�,uu>I�a�Rmin 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 ofChapter40,Title 18,United States Code and the regulations issued thereunder,until the expiration date shown. TIFFS LICENSE IS NOT TRANS17ERARLYT3NDFR 27 CFR-5-9-;.%- See"WARNINGS”and"NOTICES"on reverse. Direct ATF ATF-Chief,FELC Lieense+Permit Correspondence To 244 Needy Road Number" ; Martinsburg,WV 25405-9431 Chief.Federal Explosives Licensing Cente (FELC) Expiration. 4 Date March 1 . 24 Flame --- SANTORES WORLD FAMOUS FIREWORKS LLC Prcmises Address(Changes?Notify the FELC at least 10 days bdfore the move.) 846 STILLWATER BRIDGE'ROAD SCHAGHTICOKE, NY 72754- Type of License or Permit 20-MANUFACTURER OF EXPLOSIVES Purchasing Certification Statement Mailing Address(Changes? Notify the FnC of any changes.) The licensee or permittee named above shall use a copy of this license or pennitto assist a ransferor of explosives to verify the identity andthe licensed status ofthe licensee or iermittee as provided by 27 CFR Part 555. The sieiature on each copy must be an original SA�1(ORES WORLD FAMOUS FIREWORKS LLC dynature. Afatied,scanned or e-mailed copy ofthi license oipermit with a signature ntendedtobean original signature isacceptable. The signaturemustbethatoftheFederal 143 SUMMIT AVE isplosivesLicensee(FEL)or a responsible person of the FEL. Iea fythatthisisatnre BERKELEY HEIGHTS, NJ 07922- :opy of a license or permit issued to the licensee or permittee named-aboveto engage in the - rosiness or operations speed above under"Type of Licenseor Permit." Licens='Permittee Responsible Person Signature Position/Title Printed Name Date ATF Form 540uJ-t154t0.15 Part I reviousEdition isObsolete SARWESWORLD FRAOUSFREWCAULICAUSTNIVIATM mGCROAU 7151LR tM4DaC-0iWOIbrt91.M42 YAIBIFKiUMOFM051Yt2 RmisedSeptember2011 Federal Explosives license(FEL)Customer Service Information 'ederal Explosives Licensing Center(FELC) Toll-free Telephone Number: (877)2833352 ATF Homepage:%vww.atf gov 44 Needy Road Fax Number. (304)616-4401 nartinsbura WV 25405-9431 E-mail: FELCuatf-gm, 'range of Address (27 CFR 555.54(a)(I)). Licensees or permittees may during the terns of their current license or permit remove their business or operations to a ew 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 'usiness or operations not less than 10 days prior to such removal with the Chiu Federal EVosives Licensing Center. The license or permit will be valid for the emainder of the term of the original license or permit. (Ihe Chief,FELL,shall,if the licensee or perttdttee is not qualified,refer the request for amended license ,r permit to the Director of Industry Operations for dental in accordance with§555.54.) tight 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 ousiness or operations at the same address shown on,and for the remainder of the term o�a current license or permit. Such persons are: (1)The surviving spouse T 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 arty oil the business or operations. /L',ontrnued ox reverse.ride) tut Here 5 Federal Explosives License/Permit(FEL)Information Card t I License'PermitName:SANTORES WORLD FAMOUS FIREWORKS LLC I I 1 Business Name: 1 I License)Permit Number:6-NY-083-20-4C-01080 1 I 1 LicanaewP¢rm it Typ -20-MANUFACTURER OF EXPLOSIVES t x 1 _ Expiration: March 1,2024 t f 1 Please Note: Not Valid for the Sale or Other Disposition ofF-Vlosives. I ---------------------------------- i 9K862�3W) to x. ENSE RT ry _Iq , Cifit`f 1222s } ii/► C3 p� TSL Int C3oa 6- Alft y�r �{.'31l'±.0 Sire`s 1flf.orld Famous 1=IreV�arks, LLC h - -84 StiiCwater BaRd t Schaghticoke,_NY -�2154 1 _ i�erefI . des ' ' �:Jy _ '�; ���+�1 -f ��..��C� Fd`.'tel T•� 1� '�tl`"�'..1 ...r :_. ��� b j e r a-Plow' n`4., :. pt Fit klli •fhb ,. ,� z - ,.:s� r � _ � the - T • TlYFJ T`VQ I•� Tfl'AT�-_[��,,,A,}��bF1C_. _ ��._• .— "t - Ma I l Ken Cereola <ken@pbvineyards.com> July 1st Event Letter Ken Cereola <ken@pbvineyards.com> Tue, 30 May at 1:25 AM To: Ken Cereola <ken@pbvineyards.com> On Saturday July 1st , 2023 Peconic Bay Vineyards also known as Crossroads Wine LLC is requesting permission and support from the Town of Southold to host its 2nd Annual Fireworks Celebration. Last years event was a great success and we are looking forward to providing our guests, neighbors, wine club members and many other visitors to join us again this year. Once again this event will be held at the tasting room patio of Peconic Bay Vineyards offering up to 130 guests to enjoy our regular wine service , cheese and charcuterie platters and food catered by The Catered Fork - Steven Amaratti. We will also be offering our East Lawn for additional viewers. This area is able to accommodate 95 vehicles. Please see packet of information including the Fireworks company information, license, insurance , etc. We've also provided a site map of the area to show the event layout. Thank you for considering this opportunity for us to put on another event that our community can enjoy and celebrate the 4th of July. The Red Circle shows the area of the fireworks The Yellow Squares show the area of guests w f i • ✓,fir_ �.,1►r�'��� - � � � +ww���l■�rri rt+r_! rr r rrr� �■fir■+ iii���.. f � � r.■wr•r�r■�r - �.���� - - w�f��rr�rr r�r.r�■ ■ r■+rlr�■■F 1 f f qr ion f .�w��f■■f11 25 [Quoted text hidden] Y4 , I r x - MGma ` Ken Cereola<ken@pbvineyards.com> permission letter fireworks Ken Cereola <ken@pbvineyards.com> Thu, 25 May at 12:17 PM To: Ken Cereola <ken@pbvineyards.com> To whom it may concern . Crossroads wine LLC hereby authorizes Santores World Famous Fireworks LLC to perform a fireworks display at 31320 Main Rd Cutchogue NY 11935 on Saturday July 1st, 2023 at 9:15pm Sincerely. Stacey Soloviev, Owner Ken Cereola , General Manager [Quoted text hidden] CO cam. �� �, ` O CERTIFICATE OF LIABILITY INSURANCE DATE 5/25/202x3 ACORD 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 Britton-Gallagher and Associates,Inc, HONEFAX One Cleveland Center,Floor 30 :216-658-7100 AIC No:216-658-7101 1375 East 9th Street ADDRESS: Cleveland OH 44114 INSURERS AFFORDING COVERAGE NAIL 9 INSURER A:Everest National Insurance Company 10120 INSURED 18341 INSURER 8:Axis Surplus Ins.Company 26620 Santore's World Famous Fireworks LLC 846 Stillwater Bridge Road INSURER C: Schaghticoke NY 12154 INSURERD: INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER:71844512 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING•ANY REQUIREMENT,TERM.OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR ,POLICY NUMBER POLICY YYYEFF MLID EXP LIMITS LTR A GENERAL LIABILITY Y Y SISML0o236-231 2192023 2192024 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY Pne REMISES(Ea occunce $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 POLICYFX PRO- LOC $ A AUTOMOBILE LIABILITY Y Y S18CA00102-231 2192023 2/9/2024 "COMB ED.SINGLE LIMIT Ea acGdent 100 IX ANY AUTO BODILY INJURY(Per person). $ ALL OWNED SCHEDULED" BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS X NON-OWNED PROPERTY GE $ $ 'B UMBRELLA LWB x OCCUR Y 'Y P•OOi-000074909-05 2192023 2192024 EACH OCCURRENCE $4,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $4,000,000 DED I I RETENTION $ WORKERS COMPENSATIONWC STATU- OTH- . AND EMPLOYERS'LIABILITY YIN ANY PROPRIErORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) E.L:DISEASE-EA EMPLOYEi 9 If yes,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 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 Peconic Bay Vine' rds•(Crossroads Wine,LLC) are named as additional insureds,but only in respect of liability caused by ya the negligent acts or omissions of the named.insured."Subrogation waived to the extent required:by written contract: Group Code:,12154 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'POLICYPROVISION& Town of Southold 53095 Main Rd. SouthoWNY 11971 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD.CORPORATION'_ All rightu reserve& ACORD 25(2010105) The ACORD name and logo are registered-marks of ACORD' �1-N� Workers' CERTIFICATE OF INSURANCE COVERAGE sr°are Compensation Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use:street address only) 1 b.Business Telephone Number of Insured SANTORE'S WORLD FAMOUS FIREWORKS LLC (518)664-9994 846 STILLWATER BRIDGE ROAD .SCHAGHTICOKE,NY 12154 1 c.Federal Employer Identification Number of Insured or Social Security Work Location of Insured(Only required ifcoverage is specifically limited to Number certain locations in New York State;i.e.,a Wrap-Up Policy) 472010297 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance-Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund(NYSIF) Town of Southold 53095 Main St. 3b.Policy.Number of Entity Listed in Box"1 a" Southold NY'l1971 DBL 6582 92-9 3c:Policy effective period 02/06/2023 to 02/06/2024 4.Policy provides the folloWng•benerds: ® 'A.Both disability and paid'family leave benefits ; B.Disability benefits only C.Paid family leave benefits only S.Policy covers: ® .A.All of the employer's employees,eligible under the NYS Disability-and Paid Family,Leave Benefits Law B.Only the following,class or..classes of employer's employees: 'Under penalty.of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Dlsabil'dy and/or Paid Family Leave Benefits Insurance coverage as described above. Date Signed 3/09/2023 By-� wf (Signature of Insurance carrier's authorized representative or NYS Ucensed Insurance,Agent of that insurance carrier) Telephone Number(866,697-4332, ;.. Name,and Title Kristin Markwica,Head of Disability Insurance Unit IMPORTANT:':tJf.Box;4A-and.5A'=are checked,.andithis!form',is::signed:by,the:in$urance carriers authorized,representative or,NYS,: Licensed;Ins6ranceAgont•ofthat,caiTier-,this certlficgte it COMPLETE.;Mail it,ditectly.to_the cbpc;Rte holder:: ; :,If.BoxAB;4C or 5B:is-ch-ecked,,,this.,certificate,is.NOT,COMPLETE•:for.purpcti oses;of,Seon 220,Subd :8•of,the NYS, Disability•9nd Paid Family Leave•Benefits'Law.:Ifmusf tie mailed'for conipletio*n,to the•Workers_'Compensation Board, DB.PlansAcceptance Unit,PO Box,5200,.Binghamt6n,•NY'l3902-5200 " PART 2.Tobe completed,by the',NYS Workers',Compensation Board(only,If Box 40 r 5B of dart l has,been checked),: State.of New York Workers',Compensation.Board According_to:information.maintained•by the,NY$:,Workers,Compensation,Board-the above=named employer;;has.,complied,with_,t.he,NYS Disability and'Paid-Farrily.Leave,Benefits.Law with respect to 6T'Of his/her employees. Date Signed BY.. . (Signature of Authoeized NYS'Workers'Compensation Board Employee) Telephone Number_ Name and%11111e,.' Please Note:Only-insurance carriers licensed to write NYS disability'and paid'family leave benefits insurance policies and NYS licensed insurance agents of those insurance can'iers are:authorized.to issue Form DB-120.-I.,.Insurance brokers are;NOT authorized,to,issue.this fo►m. D8420.1(10-17): .... ... ;certificate.,Number .693401 4 NYS 1 F New York State insurance Fund PO,Box 66699,Albany,NY 12206 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE A A^AAA 472010297 SANTORE'S.WORLD FAMOUS %.j FIREWORKS LLC 143 SUMMIT AVE 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 02/07/2023 TO 2/07/2024 5%15/2023 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.SAIDIPOLICY,INCLUDING:ANY�NOTIFICATION.OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR,WEBSITE AT HTTPS://WWW.NYSIF:COWCERT/CERTVALASP:THE NEW YORK STATE INSURANCE FUND ISNOT LIABLE IN THEEVENT'OF'FAILURE.MGIVE:;SUCH,NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR,PARTNERS AND/OR MEMBERS OF,A LIMITED LIABILITY.;COMPANY. THE POLICY INCLUDESA WAIVER OF SUBROGATION ENDORSEMENT UNDER:WHICH,,NYSIF AGREES TO WAIVEITS RIGHT OF SUBROGATION TO'BRING AN ACTION.AGAINSTJHE: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 DIRECTORjNSURANCE FUND UNDERWRITING VALIDATION NUMBER:396422630- U-26.3 NYSIF New York state Insurance Fund PO'Box 66699,Albany,NY 12206 'I nysif.com CERTIFICATE.OF WORKERS' COMPENSATION INSURANCE AAAAAA 472010297 SANTORE'S WORLD FAMOUS FIREWORKS LLC 143 SUMMIT AVE BERKELEY HEIGHTS NJ 07922 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SANTORE'S WORLD FAMOUS CROSSROADS WINE,LLC FIREWORKS LLC 31320.MAIN ROAD 143 SUMMIT AVE CUTCHOGUE NY 11935 BERKELEY HEIGHTS NJ 07922 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD D.AfE A2353 260-9 976975 02/07/2023 TO 02/07/2024 2/11/2023 THIS IS 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_REGUL:AR 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:f/WM.NYSIF:COM/CERTJCERTVAL:ASP.THE NEW YORK STATE INSURANCE FUND-19 NOT:LIABLE IN THE EVENT.OF'FAILURE TO GIVE-SUCH NOTIFICATIONS. THIS POLICY DOES NOT COVER THE SOLE PROPRIETOR;PARTNERS AND/OR MEMBERS'OFA LIMITED LIABILITY COMPANY. THE POLICY INCLUDES.A WAIVER-'OF SUBROGATION`ENDORSEMENT UNDER:WHICH,.NYSIF.AGREESTO WAIVE ITS,RIGHT OF SUBROGATION TO BRING AN ACTION.AGAINST THE;CERT1FICATE HubtR;TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON B,EHALF.OF AN'EMPLOYEEOF-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,lS ISSUED AS.A' MATTEROF 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., CE-FUND lei DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:79255942 U-26.3 �1 U.S.Department Eastern Service Center 1701 Columbia Ave. of Transportation Operations Support Group College Park,GA 30337 A1V-E2 FIREWORKS- DISPLAY NOTIFICATION Company Name: Santore's World Famous Fireworks LJLC Email Address of'Person Submitting Request: terisa(c-santoref reworks.com Cell Phone Number for On-Site Technician: Richard.Davin Event Name: Peconic Bay Vineyards .(Crossroads Wine.LLC) Display Date: 7/01/2023 Rail!Date: ,7/68/23. Display Start Time: 9:15 p.m. Duration of Fireworks Display:. 10-12 minutes.; Max Height of Fireworks:- 400'feet Address,.City and State: 31320 Main'Rd; Cutchogge'NY'l1035 41.017995N 72.487649W Latitude: (North) .Longitude: . . (West) List.the Closest Public Use AirportWithin 5 Nautical Miles.of the'Display if'the Fireworks,Will Reach or Exceed 500 Ft. Special Notes: Mease.emailyour requestAo: 9-ATO-ESA-OSG-FireworksO)faa.eov Air Traffic Organization 1701 Columbia Avenue Eastern Service Center College Park,GA 3,0337 US.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,aviationsafety, 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 contact,Leidos'Flight Service at 1=877=4-US-NTMS. (1-877-487-6867)at-least 24 hours(tiut:not more than 7 days)in advance to-request a Notice to Air Missions(NOTAM).Yowwill 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-Fireworks@faa.gov Sincerely, Matthew N. Cathcart Manager,0peratio3s"Su1Dport Group FRLYOh'i!S z^,lSPLAYt?Gfi' EnlA'? 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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-Fireworks(a,faa.gov Sincerely, Matthew N. Cathcart Manager,Operations Support Group - .. . a_ - ... :.ti 'Yx 4.al_f a't.:'+TAt••1'tea .. ..,... .. •..: r'y ♦ .Y;'r.- ±5 G+1u....v y.x+s.'S>1f'Y'F.'Rw k'c•h - r rV �X•"F`i 3.:r t+9: .. .1'�'.f R�,=^,.I yR)''.•'Sv K+N,+''.ir.f`.. . , . ':J a '•'p.�b b aY ta�G'I:rSY'.l :"-:?d''Ft irt7�h'H . ,Tt ♦':....'i' ' `.Y.v n.:N`'.:-15 Y..vg.)�yy:AT1 A+.r►h9'f.f .r::. 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''W.i"K'B+,WMRP.dd "9Crt•.g',Yl4tr� ... ?=:CY�F! 1:f.7"4'":'O�fNP•f:"'+f.YiM.�R,'Nf:Mtr. r ^:`t�,Y'f+l�•S� yXar#.dSa Ria.Mxn n_•r.._ro rc*.W wi SaU la.9C:••E-,.<v��:m+: ' f t 1 5 Noncarrow, Denis To: fireworks Permit Cc: Sabrina Born (sabrina.born@town.southold.ny.us); Mudd,Jennifer, Franke, Diana Subject: Fireworks/ Crossroads Attachments: cross roads_20230601150920.pdf Please see this app and let us know. Thankyou Denis Noncarrow Southold Town Clerk. Town of Southold, New York www.southoldtownny.gov denisn @southold townn y.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 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 06/01/23 Receipt#: 311193 Quantity Transactions Reference Subtotal 1 Fireworks 7.1.2023 $100.00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#1183 $100.00 Crossroads, Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Crossroads, 9 W 57th St Ste 4500 New York, NY 10019-2701 Clerk ID: DENISN Internal ID:7.1.2023 Noncarrow, Denis From: Flatley, Martin Sent: Thursday,June 1, 2023 3:16 PM To: Noncarrow, Denis; Ginas,James; Spiro, Melissa;Town Att;Verity, Mike;Visser III, Fredric Cc: Born, Sabrina; Mudd,Jennifer; Franke, Diana Subject: RE: Fireworks/ Crossroads I have no objections to this event being approved 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:Thursday,June 1, 2023 3:08 PM To: Flatley, Martin <mflatley@town.southold.ny.us>; Ginas,James<jginas@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us>;Town Att;Verity, Mike<Mike.Verity@town.southold.ny.us>;Visser III, Fredric <fredv@southoldtownny.gov> Cc: Born, Sabrina<sabrina.born @town.southold.ny.us>; Mudd,Jennifer<jennifer.mudd@town.southold.ny.us>; Franke, Diana <dianaf@town.southold.ny.us> Subject: Fireworks/Crossroads Please see this app and let us know. Thank you Denis Noncarrow Southold Town Clerk. Town of Southold, New York www.southoldtownny.gov 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 Southold Town Board - Letter Board Meeting of June 6, 2023 RESOLUTION 2023-534 Item# 5.28 ADOPTED DOC ID: 19230 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2023-534 WAS - ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JUNE 6,2023: 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 Peconic Bay Vineyards (Crossroads Wine LLC), for a fireworks display on Saturday, July 1, 2023 at 9:15 PM (Rain Date: Saturday, July, 8th at 9:15PM) at 31320 Main Road, Cutchogue,New York upon payment of a single fee of$100.00 and subject to the applicant's compliance with any conditions and requirements of the Town of Southold policy regarding the issuance of fireworks permits. Denis Nonearrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Sarah E.Nappa, Councilwoman SECONDER:Jill Doherty, Councilwoman AYES: Nappa, Doroski, Mealy, Doherty, Evans, Russell Generated June 7, 2023 Page 42 SO��g�FfO(,f'�, - DENIS NONCARROW �Gy� Town Hall,53095 Main Road TOWN CLERK p - P.O.Box 1179 y Z Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Q Fax(631)765-6145 MARRIAGE OFFICER 'y RECORDS MANAGEMENT OFFICER �0,� � Telephone 765-1800 FREEDOM OF INFORMATION OFFICER www.southoldtldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PERMIT 2023 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 BAY VINEYARDS (CROSSROADS WINE LLC) 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 1st 2023 with a Rain date of Saturday,July 81h 2023.Time is 9:15pm. Location will be at 31320 Main Road Cutcho2ue 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 feet 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 into 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 last 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, and subject to any Executive Orders issued by the Governor and to the applicant's compliance with the requirements of the Town's policy regarding the issuance of fireworks permits. Applicant to Notify FAA 24 Hours before event. --------------------------------------------------------------- (Town Seal) Denis Noncarrow, Southold Town Clerk Town of Southold,New York Dated: June. 61h,2023 THIS PERMIT IS NOT TRANSFERABLE