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2023
f PECONTC i fi i RECEIVE® JUN 2 0 2023 June 12, 2023 Office of the Town Clerk Southold Town Clerk Town of Southold 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 Sunday, September 3, 2023 (rain date Monday September 4th) as part of our annual End of Summer celebration. The event is free and open to the public. We anticipate Greenport Fire Department and Southold Police Department will be on the scene for assistance and traffic control. We give permission for Santore Fireworks to provide the actual fireworks show on Peconic' Landing's property as noted above. Many thanks, ( Ka� Diane Radigan VP Member Services 631-477-3800 x373 dradigan@peconiclanding.org ELIZAB+`TR A.NEVILLE,MMe Town Hall,58095 Main Road TOWN CLERK P.O.Box 1179 7t Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Fax(631)766-61.4 RECORDS 0�1AIvAGEMENT OPPICER IAGE OFFICER ��®j .�`�®� Telephone(831)76 1800RECEIVED l FREEDOM OF INFORMATION OFFICER � southoldtown.northf k.net ' r OFFICE OF THE TOWN CLERKJUN 2 0 2023 I TOWN OF SOUTHOLD APPLICATION PERMIT TO DISPLAY FIREWORKS Southold Town Clerk APPLICATION IS HEREBY MADE, pursuant to the provisions of Section 445.00 of the Penal Law of the State of New York,for a permit to display fireworks as hereinafter specified: DISPLAY IS TO BE SPONSORED BY Peconic Landing PRINCIPAL OFFICE AT 1500 Brecknock Rd_ egg enport NY DATE r TIME OF DINPLAY 9/03/2023 8:15 pm EXACT LOCATION°OF DISPLAY Peconic Lgnding SUFFOLK COUNTY TAY MAP NUMBER FOR SITE —— -- RAIN DATE The following persons are to be in.charge-of the actual shooting of the fireworks: Name Age Experience Physical Condition Richard Davin 53 24+-years Health:Excellent (Additional names and information may be submitted on an attached sheet Number and type of fireworks is as.follows: 1.3/1.4G .Cakes - 19 2"-3".Shells-412 4"Shells'- 102 " Manner and place of storage of fireworks prior to display. Delivery of product on day of displace 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 air policy of insurance coverage. NOTICE: Written permission,with signature of the Property Owner �must be submitted with the Application. Santore s WorldFamousFireworks LLC FEE: $100 Name of Organization See policy-for additional information TeYlUt t�iiex Terisa Clothier-Admin.Asst SW-FF By anteName o pp icant Signature of Applicant e-mail address:terisa@santorefireworks.com Telephone (dumber 518-664-9994 511.8/2023 Date of Application NYSIF No%vYark state Insurance Fund PO Box 66699,Albany,NY 12206 nysif.com - CERTIFICATE OF WORKERS' COMPENSATION INSURANCE '1 A A(A,A A A 47201 OZ97 SATCJRE'S WORLD FAMOUS FIREWORKS LLC 0 143 SUMMIT AVE BERKELEY HEIGHTS NJ 07922 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SANTORE'S WORLD FAMOUS Town of Southold FIREWORKS LLC 53095 Maki R8. 143 SUMMIT AVE PO Box 1979 BERKELEY HEIGHTS NJ 07922 Southold New York 11971 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE A2353 260-9 L105490 02/07/2023 TO 02/07/2024 6/1092023 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 YQRK 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:11WiNW1 NYSIF.CQMlCERTlCERTVAL.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:980702949 sNEW Workers' CERTIFICATE OF INSURANCE COVERAGE TVTE 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 1a.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 1c.Federal Employer identification Number of Insured or Social Security Work Location of insured(Only required if coverage is specifically limited to Number certain locations in New York State,i.e.,a Wrap-Up Policy) 472010297 1 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 id. 3b.Policy Number of Entity Listed in Box"i a" PO Box 1179 DBL 6582 92-9 Southold NY 11971 3c.Policy effective period 02J06/2023 to 02106/2024 4.Policy provides the following benefits: Z A.Both disability and paid family leave benefits S.Disability benefits only C.Paid family leave benefits only 5.Policy covers: ® A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law B.Only the following class or classes of employer's employees: Under penalty of perjury,I certify that i am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS.Disability and/or Paid Family Leave.Senefitainsurance coverage as described above. Date Signed 3/09/2023 By (5ignature of insumnce carrier's authorized re'preseMative or,NYS,Licensed lnsurance Agent of that insurance carrier) Telephone Number(866)697-4332 Name and Title Kristin-Markwica,Head of Disability insurance Unit IMPORTANT: if Box 4A and 5A are checked,,and this:form is signed.by-the insurance carrier's authorized representative or NYS Licensed insurance Agent of that carrier,this certlficate is-COMP4 ETE.Mattit directly to'the,certificate holder. if Box 4B,4C or 5B is checked,this certificate is NOT COMPLETE for.purposes of Section 220,'Subd.8-of the NYS Disability and Paid Family Leave Benefits Law.it rhust,be,mailed.for,ddini6iet)on)o the Workers';Compensation Board,' DB"Plans Acceptance Unit,Po Box.5200,Birigharhton,NY 13902=5200 PART 2.To be completed by the ISYS Workers'Compensation Board(Only if Box aC or 513 of part 1 has been checked) Sete of Neva York WWorkees'Compensation Board According to information maintained by the NYS.Workers'Compensation Board,the above-named employer has complied with the NYS Disability.,and Paid Family.Leave Benefits Law with respect to all of his her employees. .Date Signed By (Signature of"Authorized N}S Workers'Compensation Board Employee) Telephone Number Name acid Title. Please Note:Only insurance carriers licensed to wrib NYS disability and paid family leave benefits insurance pbiidies and NYS licensed insurance agents of thoseinsurance carritirs are.authorized to issue I=orm(7b-126.1. jnsurance brokers are Nor authorized to Issue this forrn. Ds-�ao.1 too-1.z-), Certificate.NlWbber 6,,93401 DATE tr4hNDD1YyY-1 CERTIFICATE OF LIABILITY INSURANCE 3/2212023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS 140 RIGIITS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY 09 NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES SELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEtWPEN THE ISSUING INSURER($), AUTHOPIZEb REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)Must be endorsed. if SUBROGATION 15 WAIVED,subject to the terms and conditions of the pofty,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). .......... Britton-Gallagher and Associates,Inc. PHONE One Cleveland Center,Floor 30 JA - 1375 East gin Street e� Cleveland CH.441,14 AF RDiAtti COVERAGE Everest Naijorral I n C I y ................ .......... ...... --------- 30120 INSURED 4 msumRs:Axis-Su(plus ins Company 266:0 Santore's Vilodd Famous Fireworks LLC 8415 Stillwater Bridge Road Schaghticoke NY 12154 ...... INSURERF: COVERAGES CERTIFICATE NUMBER:295421145 REVISION NUMBER, Tl-',IS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD PNDK-,,TED. NOTVATHSTANDING ANY REQIJIREWZEJi,TERM'OR CONDITION OF A14Y CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS oERT'1'FIC--iE MAY 2-E ISSUED OR MR,,Y PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERER4 IS SUBJECT TO ALL T14E TERMS, EXCLUS*INSAND CON0;T*NS OF SUCH POLICIES.LIMITS SHOWNIMAY HAVE BEEN,REDUCED BY PAID CLAIMS. FULA,T tr LALIAMEVY )11 TYPC OF JWURANCIF POLICY HUMER nn"Ywl t LIMITS_.._._ A GEREPALWABILiTy2r3242� EAr 0,_CUp.RsmCF X DAMAGE TO RENTED szoa=o OCCUR r. 0X?(Any eco PERSONAL&ADV INJURY j S 2,r-011,00 i3Ef-4VRALAC.GRE1GXi'E _S2,003.0W PRODUCTS COMP)OP AUC I Zr,0L-JjM PER: X : -Y Y SISCIAZO102-2 I-F---. - I LA Iff w(I 2191202Z 219r=4 A AUTOMOBILE LIABILITY 31 nz X ANY All-rO BODILY RV(Parrwson' I i 'w-OwNen, BODILY W-URY(Perzedderki)i AUTOS AU-1OS NON-OWNED } ITY PROPERTY DAKA S HIRFOAUT-OS AUT,CS S UhTaRELLALIAS i X i OC�UR I Y 2W2023 . Z912024 Y 11-1901-00074-109-05 CUjWkEN X EXCESS LIAS I rLAWS4&14DEI 0;:D RETENTION$ ATU- OTH-: AND EMPLOYERS*LIABILITY Y I ?'��__-_;.�t-". ___.�.....,.-_.`____._._. ANY 1 E.L,EACH ACCIOCNT S In INfAi ------------ E.I.,DISEASE-CA EMPLOYEE S NH) E.L.DISEASE-POLICY LROUT,!S DESCRIPTION OF OPERATIONS LOCATIONS IVEMCLES%(Afta0 AcORD 101,Adftiiiwl Remarks Schedule,if mom space is roqu"dl Additional Insured extension of coverage is provided by aboVe referenoed General Liability policy where required by Written agreement. ln,wn of Southold,Suffolk County,and The Greenport Fife De¢arlrnbnt Star Hose Company No.3 are named as additional insureds,but only in respect of imbilih-'caused by negligent acts or cnilssions of the named insured.Subrogation, the netjwaived to the extent required by written contract. Group bide:12 154 f CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE=EXPIRATION- DATE -tHEREOP, NOTICE WILL BE DELIVERED IN ACCORDANCE ViITH tHE PdLICY PROVISIONS. Town of-Southold 53095 Main Rd. AuTmoitao Remsrztmrm Southol.d,NY 11971 0, 088-2040 ACOP D CORPORAMN. All righfres&niod. AInOR0 25(2a-falOS) The AICORD raarrxa—11-9- of ACtDRD A��� CERTIFICATE OF LIABILITY INSURANCE DAT512212DIYYYY) .. 5122/2023 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 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 13ritton-Gallagher and Associates, Inc. -NAME: FAx One Cleveland Center,Roor 20 I=Al> Ptdl-216.558-7100 191C tLn:216&58-7101 1375 East 9th Street E-MAIL ADDRESS: _ Cleveland OH 44114 INSURER S)AFFORDING COVERAGE ^NAIC 9 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:625280708 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. _ IL SR; _- _ - TYPE OF INSURANCE DD SUBR POLICY EFF POLICY EXP ..POLICY NUMBER_,_.__ _ MMIDDIYYYY IMMIDDIYY_YY. _.._ _ _LIMITS A GENERAL LIABILITY S18MLOO235-231 2/012023 2!9/2024 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY REMIDAMATO RENTED PREMISES o.curr6ncel 5500,000 CLAIMS-MADE OCCUR MED EXP(Any one person) S _ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE 52,000,000 GENLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2,000,000 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY S18CA00102-239 2!912023 21912024 COMBINED SINGLE L MtT Ea accident! $1.000,000 X ANYAUTO 86DILY INJURY tiler person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE' - $ - AUTOS Per acddent _ _ .. 5 B Uiil3RELLA LIAR � XNJ OCCUR P-001-000074909-05 2/9/2023 219/2024 EACH OCCURRENCE $4,000,000 X EXCESS(.IAB 1 CLAIMS-MADE AGGREGATE $4,000,000 ' DED I RETENTION$ WORKERS COMPENSATIONAND EMPLOYERS'LIABILITY YIN _ANY PROPRIETORIPARTNER/EXECUTIVE F-] N 1 A E.L.EACH ACCIDENT 5 OFFICERIMEMBER EXCLUDED? (Mandatary in NH) E.L.DISEASE-EA EMPLOYEE $ tf yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE,POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Sehedula,it more space Is required) Additional Insured extension of coverage is provided by above referenced General LiabIlity policy where required by written agreement Display date:9103123; Rain.date:9/04123. Location:Peconic Landing,1500 BYecknock Rd.,Greenport,NY Additional insureds-are;Peconic Landing Housing Association Cooperative,Inc.;Brecknock Hall Foundation;Peconic Landing Home Health Services,Inc.;The Shores at Pecoriic 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 QESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 'DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE.POLICY PROVISIONS. Peconic Landing at Southold,Inc. 1500 Brecknock Road Greenport NY AUTHORIZED AEPRESENT'ATIVE I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and loon are registQred marks of ACORD 410,07'08.3"N 72021'49.1"W Peconic Landing 1500 Brecknock Rd.Greenport NY 11944 Show Date:qvA Rain Date:f/t f/s AC"R ® CERTIFICATE OF LIABILITY INSURANCEFDATE(MM/DD/YYYY) 6/12/2023 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. PHONE FAX One Cleveland Center, Floor 30 A/c No Ext):216-658-7100 A/C No):216 658-7101 East 9th Street E- 1375 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:706706941 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ADDL SWBDR POLICY NUMBER MM/DD/YYYY MM DD/YYYY LIMITS A GENERAL LIABILITY _ S18ML00235-231 2/9/2023 2/9/2024 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $500,000 CLAIMS-MADE FX]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 - S18CA00102-231 2/9/2023 2/9/2024 COMBINED SINGLE LIMIT Ea accidentJ $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALLIOWNED SCHEDULED BODILY INJURYPer accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident B UMBRELLA LIAB X OCCUR P-001-000074909-05 2/9/2023 2/9/2024 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 Y I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ —.:E - - I I 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. Display,date:9/03/23; Rain date:9/04/23. Location:Peconic Landing, 1500 Brecknock Rd.,Greenport, NY Additional insureds are;Peconic Landing at Southold,Peconic Housing Association Cooperative,Inc.;Brecknock 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. DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Peconic Landing-at Southold, Inc. 1500 Brecknock Road Greenport NY AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 10580 FIREWORKS DISPLAY AGREEMENT Display Date_9/03/2023 AGREEMENT by and between Santore's World Famous Fireworks,LLC whose address is 846 Stillwater Bridge Road,Schaghticoke, 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 hereinafter set forth; NOW,THEREFORE,In consideration of the terms,conditions and covenants hereinafter set forth,the parties hereto do mutually agree as follows: 1. FIREWORKS DISPLAY: On,9/03/2023(hereinafter"the Display Date"),Santore shall provide the fireworks and equipment for the display at the Fireworks Display location.The display will be under the supervision of a Santore trained.technician.Itis agreed That Santore shall be the sole fireworks supplier. d producer lar the,evenf 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). start Time of Display:Approx. :J t(Pleaseinsert)or as,directed,by client(not iater,than ordinance permits). ALTERNATE DATE: 8/04/2023 Rain date 2.COST AND PAYdl1ENTS:: FIREWORKS•DISPLAY PRICE:. :X7;540 OQ The total{Fireworks Display Price plus all oiher applicable charges)sum of--.57 5• ob:oa.-sh"alt be,due,snd payable as follows. a.The sum of: $3,750.'00 orf the execution:of contract. There'Witf.be':an'additional,f4e for permit costs.(administration included)to be reimbursed. . b.Balance evening of thwdisplay$3',750.00). Please Note SPONSOR is',responsible..for'the.payment of;alfgpuernmental fees;and`aaxes„incfudfng;but not limited to, sales, use;excise,license,permit,;entertairitnerit,;,orotherfees;iaxes�'o surcharge's'imposed;ar`otPtetvviseapplied totfiisexhibition. Also, please see Section 16(c' beldw: 3. POSTPONEME/VT/RES6HEDULING: °: Ifshow;is; ost oned-as<' enbelnw- ' Description, %:of Firewoft Dis`i ':Price Additional,Gosts If notified by 6:01`AM on 910312023 . An :31d--Ra Vendor.Expenses Wherfireworks-tech.leades:facilit a Anv' rt',UendorExsnses_.. . Any request made by SPONSOR for rescheduling/canceling shall.be directed to fnscta-.frri�rR az :;.coyn°r by phone{518)664- 9934:.Itis undersf6od alid:agreecl.ttiat.;$SN3ORE'•shall have;rio,of ligation to'.iesched'tre;a: isptay-e cepCas raquged by;inclement weather or seasons beyond.the contrbl`of SAN TORE : ' .;... 4,SPONSatiSAGEN7:'. .GE{.C'FHOAIE:.. O; �,t f� Diane Raiiiaan.:; sFi'a I be designated a, SFONSQR'S agenf#6;wham:al(q"uestioit'sand mqurnes shall;6e relayed:"$ponsoi'sa a"Rt shall:6;e'the=bt7! .a'ertt o:S authorized to make decisions;on behalf of SPQ(1150,R"orao'regUest`[esehetlialirig:ofahe Ctteworks; ispla"on al)e;.parf of SPOtUS0R: Please initial each nage. " Initial here: S, RE i • Santore DISPLAY SITE PLAN QUESTIONNAIRE All items listed below are subject to all governing Federal,State,Municipal and local laws,rules,ordinances,regulations and codes,now or hereinafter in effect,and to the conditions and limitations contained in the permits required or to be obtained by Sponsor. SPONSOR: v' Display Date 9/03/2023 Rain Date: 9/04123 Budget:$7,500.00 Display Location:—Near Brecknock Hall(as per site map) Time of Display: rn (Note: The actual start and stop time of the display will be determined by the goveirn ental authorities having jurisdiction over the display). IMPORTANT. PLEASE PROVIDE A SITE PLAN.FOR YOUR EVENT LOCATION, INDICATING WITH ANXTHE EXACT SPOT WHERE FIREWORKS ARE TO BE SET-UP. Local Fire Marshal: Telephone No:- ",n, � ON - "orc./I Phone No: Crew/Contact Person: Telephone No: CeIlPhone,No: 5# The Following information is necessary In.arder for us.to.provide your community or organization with a display that conforms with fireworks safety regulations and for the,issuanc6pFyour insurance certfricafe. DISTANCES,IN FEET,FROM THE-FIRINOA SPECTATORS,AUDIENCE OR PARKED CARS ........................ .......... ........... OCCUPIED BUILDINGS(HOMES,APARTMENTS,"ETC.)..................................... . PUBLIC BUILDINGS(SCHOOLS, HOSPITALS;,CHUAPHES,ETC.)....................... TEMPORARY EVENT SET-UPS(!DQN=9.4IONSvT NTa,:ET ........................... MAIN PARKING AREAS........ .............. ......... HIGHWAYS OR ROADS.................I .......................... ........ ....... I...... OVERHEAD OBJECTS(POWER:LINES;,LIGHT FUELSTORAGE................................................... ................................... PLEASE PROVIDE-DIRECTIONS fR9M.,NE4f�p -,'TO'DISPLAY SITE'; -s6,- . . . , ST INTERST.T14 '�j MAP,wd&Lp HELPFUL. ;iT BtF Local MotWSIHIOWS: Signature VA &4� &)"441,c-,td, :- Date Pbacc initial oath poyo, Initial here: odor AT RE- 1. If the fireworks are to be displayed on or near the water,the following may be r8quired: (Requests for permits must be filed at least 60 days prior to the Display Date(135 days prior for 41h of July events).. 2. Coast Guard Application and Permit Ito' Handle Hazardous Materials. 3. Coast Guard Marine Event Permit. c.SPONSOR RESPONSIBILITIES AND EXPENSES The fottowlnservices need to be rovided and Paid for b the SPONSOR in additlon to the Fireworks Disniau wrier} z 1) 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 DUD SEARCH ON THE MORNING AFTER THE DISPLAY. r)—�a ',a–r'#ease rsvide- ,ardsElf sa„3, �'—�"•""�p��� l--aot-ia3wdle-GrevvoFka):. . AMR of Show site)- if you' f P•Fiiitiit'f i z'r- '�`����,,,���7—.c�II�-'a,h�.•�`':,•,,,•,,w,.r„far FrtsverneFt-en sand Yes• Ne i d.RADIO SIMULCAST EXPENSES(if applicable): , lay date: 3) 3peakeFsy6teFnfbFV4l2v!eMRg stands. e,INSURANCE: Please list below the additional insured,as they should.appear;on the,insurance.certificate: 1. Peconic Landing at;Southold,,inc..., .3;;,.,rec noc ,a .,,oup 2.Peconle Landing Housiri Association Coo erafive;ifn ..4.,' �• 1� �C�{i� �*i 1< Ssi 57 dZf1 C� it . Name of$ onso[i' Date; - :santbre Sl natti"re:' Date 2. By: Robert'JS ion' ,.... ...:....::... Si o b'fi IfofSponsor(Signature) Print Name.' - .. ..,.,. .. _ ,•.:.......... :. .':; ,: Sled- 'd .s.¢••^. ." Titleofaut 'o, re resets#ivE.of:S onsor ,...: " • Title.; ,:';, „°*r:. a/a/,H/■/ ./'// /6/a/-M-Ii.Y9�i"Y1�//1/0///-4/ t.//://-/t-/iw'1'!://•R ow,R 16 a a 6;6 mO Please id al each page. Initial here: IL. RE U.S. Eastern Service Center 1701 Columbia Ave. Department of Operations Support College Park,GA Transportation Group A!V-E2 30337 FIREWORKS DISPLAY NOTIFICATION Company Name- Santore's World Famous Fireworks Email Address of Person Submitting Request: asantoreirt@,santorefireworks.com Cell Phone Number for On-Site Technician:Richard Davin,(631)889-9938. Event Name:Peconic Landing Display Date:9/0 3/2 3 Rain Date:9/04/23 Display Start Time: • pm �I t 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' 0 8.3" (North)Longitude:7 2 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 Ft. Special Notes Please email your.request to: 9-ATA-E -050-Fir--gr�S5 f9£1. AV 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 World Famous Fireworks Email Address of Person Submitting Request: asantoreir(ja-,santorefireworks.com Cell Phone Number for On-Site Technician: Richard Davin, (631.)889-9938 Event Name: Peconic Landing Display Date:9/-0 3/2 3 Rain Date: 9/04/23 Display Start Time: 8:15 pm 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° 07' 08.3" (North) Longitude:7 2' 21' 49 . 1" (West) List the Closest Public Use Airport Within 5 Nautical Miles of the Display if the Fireworks Will Reach or Exceed 500 Ft. Special Notes Please email your request to: 9-ATO-ESA-OSG-Fi reworks@faa.gov Air Traffic Organization 1701 Cblumbia Avenue Eastern Service Center College Park.GA 30337 U.S.Department of rronsDortation 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-FireworksPfaa.gov Sincerely, Matthew N.Cathcart Manager,Operations Support Group, AC�® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/31/2023 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 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 CO T NAME:CT Nella Campbell The Graham Company PHONE FAX The Graham Building E: •215-701-6300 A/c No): 1 Penn Square West AoDR1ESS: Campbell Unit@grahamco.com Philadelphia PA 19102- INSURERS AFFORDING COVERAGE NAIC# INSURER A:Ironshore Specialty Insurance Cc 25445 INSURED PECOLAN-01 INSURER B:Liberty Mutual Fire Ins.Co. 23035 Peconic Landing at Southold, Inc. 1500 Brecknock Road INSURER C:Great American Alliance Insurance Company 26832 .Suite A INSURER D: Greenport NY 11944 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:508099761 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 EFF POLICY EXP LIMITS LTR POLICYNUMBER MM/DD MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY HC7SACRFE5001 4/2/2023 4/2/2024 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED CLAIMS-MADE FIOCCUR PREMISES Ea occurrence $250,000 MED EXP(Any one person) $10,000 PERSONAL BADV INJURY $INCLUDED GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 X POLICY F—]IRI I r7 LOC PRODUCTS-COMP/OP AGG $INCLUDED OTHER: $ B AUTOMOBILE LIABILITY AS2-Z21-095799-013 4/2/2023 4/2/2024 COMBINED SINGLE LIMIT $1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ A UMBRELLA LIAR HC7SACRFFA001 4/2/2023 4/2/2024 EACH OCCURRENCE $10,000,000 X EXCESS LIAB HOCCUR CLAIMS-MADE AGGREGATE $10,000,000 DED RETENTION$ $ C WORKERS COMPENSATION WC E968225-00 4/2/2023 4/2/2024 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVEN/A E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER 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 HC7SACRFE5001 4/2/2023 4/2/2024 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1 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-Fireworks(a,faa.gov Sincerely, Matthew N. Cathcart Manager, Operations Support Group Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 06/20/23 Receipt#: 311943 Quantity Transactions Reference Subtotal 1 Fireworks 9.3.23 FW $100.00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#000001134 $100.00 Peconic, Landing At Southold Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Peconic, Landing At Southold 1500 Brecknock Road Greenport, NY 11944 Clerk ID: SABRINA Internal ID:9.3.23 FW = Flrsf National Bahlcof Loflg-Island tt _ - 140 East Main StrQer 1 g 7rC0�� — _ _ River 6d, f�lY X1301 ��- _� econt-c L-L dinat Southold, Inc 1 �; 000000'l 34 15l)0 13rccknocic Road r Greenport; NY 11944 a• ti4_ c —Y_`H�_��� �r- TM 06/15/2023: "'One hundred and 00/100 dollars. .. . . . . .. . . . ... . . . . ***,***1 0 .P ay to the order of . . . . . . .. . . . . .. . . . . . . ... . . . . . . . .. . . . . . . $ ; Void After 90 Days. TWO SIGNATURES REOUIRED'OVER$35,000.00. Town of Southold Q P.O.BoO 179 Southold NY 1 7= AUTHORIZED SIGNATURE' 110000000 1 1 3 4ll' 1:0 2 L 4L 13 3 Si: 6 1700 1 2 6 8u■ Born, Sabrina From: Born, Sabrina Sent: Tuesday, June 20, 2023 2:33 PM To: Blasko, Regina; Flatley, Martin; Ginas, James; McCullough, Lillian; Norklun, Stacey; Spiro, Melissa;Visser III, Fredric; McGivney,Julie; Mirabelli, Melissa; Paul DeChance; Squicciarini, James Subject: Fireworks Appl-Peconic Landing Attachments: Fireworks-Peconic Landin_20230620142215.pdf Good Afternoon, Please see attached, a fireworks application from Peconic Landing. Please provide approval/disapproval and any questions or concerns. Thank you, SaAw4xvow Sabrina M. Born Sub-Registrar& Deputy Town Clerk Senior Account Clerk Southold Town Clerk's Office 53095 Route 25 P.O. Box 1179 Southold,NY 11971 Ph: 631-765-1800 ext. 1226 Fax: 631-765-6145 Your message is ready to be sent with the following file or link attachments: Fireworks-Peconic Landin_20230620142215.pdf Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 Born, Sabrina From: Flatley, Martin Sent: Tuesday,June 20, 2023 3:20 PM To: Born, Sabrina; Blasko, Regina; Ginas, James; McCullough, Lillian; Norklun, Stacey; Spiro, Melissa;Visser III, Fredric; McGivney,Julie; Mirabelli, Melissa; DeChance, Paul; Squicciarini,James Subject: RE: Fireworks Appl-Peconic Landing I have no objections to his application 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: Born,Sabrina <sabrina.born@town.southold.ny.us> Sent:Tuesday,June 20, 2023 2:33 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>; Ginas,James <jginas@town.southold.ny.us>; McCullough, Lillian <lillianm@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us>; Visser III, Fredric <fredv@southoldtownny.gov>; McGivney,Julie<juliem@southoldtownny.gov>; Mirabelli, Melissa <melissa.mirabelli@town.southold.ny.us>; DeChance, Paul <pauld@southoldtownny.gov>; Squicciarini,James <jacks@southoldtownny.gov> Subject: Fireworks Appl-Peconic Landing Good Afternoon, Please see attached, a fireworks application from Peconic Landing. Please provide approval/disapproval and any questions or concerns. Thank you, .SaA6pr4ffgaw Sabrina M. Born Sub-Registrar& Deputy Town Clerk Senior Account Clerk Noncarrow, Denis From: Visser III, Fredric Sent: Monday,June 26, 2023 8:33 AM To: Noncarrow, Denis Subject: Peconic Landing Fireworks Attachments: peconic land ingsitemapR23.pdf;ATF 1080 - 2024.pdf; Davin COF 22.pdf; License2023Manufacture and deal with explosives NYS.pdf; Davin - 2022.pdf, Peconic Landing FAA'23 R.pdf Good Morning, Here is the supplemental information for the fire work show at Peconic Landing,the fall out zone is over the west roadway I just ask them to secure the road for the duration of the fire work show. I have no opposition to this FW show Thank you, Fredric Visser, Fire Marshal Town of Southold Phone: (631)765-1802 Web: https://southoldtownny.gov/1736/Fire-Marshal Email: Fredv@southoldtownny.gov PO Box 1179 54375 Main Road Southold, NY. 11971 �1 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 World Famous Fireworks Email Address of Person Submitting Request: asantorejr a,santorefireworks.com Cell Phone Number for On-Site Technician`: Richard Davin, (631)889-9938 Event Name: Peconic Landing Display Date:9/0 3/2 3 Rain Date:9/04/23 Display Start Time: 8:15 p 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. 11947 N (North) Longitude:72.36313W (West) List the Closest Public Use Airport Within 5 Nautical Miles of the Display if the Fireworks Will Reach or Exceed 500 Ft. Special Notes Please email your request to: 9-ATO-ESA-OSG-Fireworks@fa a.gov Expires:. 1213172023' SH 862.(3/22) Q:1�.R ; �)L I DIVISION of SAFETY HEALTH W.�,•'AR E' .Y••4 fiHIS LICENSEMUST BE. paPartriienG ;` ,PASTED IN YO.UR'FLACE ;I LICENSE AND'CERTIFICATE UNIT ilri of:Lafior OF BUSINES'S STATE OFFICE CAMPUS,BLDG.1 'ALBANY,:NY 1,2226 LlCeflSe No. p_57.96 L�.CEN.S'ETO DEAL-IN O`R'MAN.U.FACTQc_M'EXPL-OSIVES Saritore's W. .orld.Famous.Fi ewotks,'LLC :84.6:Stillwater Bridge'Rd'" 4 ,Schadhticoke,!NY 12154 August N. San'tore;.Jr. I Is he'rebplicensed;to-deal'iii qt man ufacture'expiosiv_es in compliance with-the requirements of the.Labor•Law.and ,i Industriai'C6daiRdies,Ahy_=changb:in:the:conditions undeEwNdh thisaicen'se.is granted AM 'to,itaa-be_reuoked. jEyery,person selling;deliyefing got givingaway any,exploslves must keep'at the principal,pl�a�of business within' I . ahs state;a;record of eacti'fransaction,'Including:. i I • 1J the NAME,orTYPE and'QUAN717Y'of:6zplosives SOLD;'•DELIVERED.or,GIVEN.:Note:.iNo license is need8dao'purch2se smokeless,powder,;or black}powder_aridguantity is not exceeding five pounds';for use :iri firing antique filearrris.or;arEifact§,or repllcasthereof,'Howeyer,dealers MUST post all such transactions ' on''the•';pealer•ManufacturertReport of;Fxplosives,Tcansactioris 2) the gA7E:OF EACFi'SALE; DELIVERY'-or-GIFT, _ 3) the'NAME,!LICENSE NUMBF✓R�fand•BIJSINESS ADDRESS of-'(f4:purchaser,donee,or pegs9610 whom' I tfie,ezplosivas;irlere;deliVered"and the firm;df;any;rep[es'ented'bysuch person. 3 4) 'the NAME,'ADgRESS;and`LICENSE,NUMBER':oRh6;psr§omTAKtNG THE FJCI?LO'SIVES AWAY 1 from tNTseller-or I ; AmpM ips,Director; . . t�FOt<I.13I�:4F•�ABaR�----- ----___------ -. --- -- - • -- - - l U.S.Department of Justice Federal Explosives License/Permit Bureau of Alcohol,Tobacco,Firearms and Explosives (18 U.S.C. Chapter 40) anitttmno¢nnwFnr;ivuFra►®¢tannmmim 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,TitleA 8,United States Code and the,regulations-issued thereunder,until the expiration date shown. THIS LICENSE IS NOT TRANSFERABLETTNDER 27•CFR'5515.53_,See See"WARNINGS".and'NOTICES"on reverse. Direct ATF ATF-Chief,FELCI is"ense,Permit Correspondence To 244 Needy Road Number= s ; Martinsburg;WV 25405-9431, Chief Federal Explosives Licensing Cent'e (FELL); `' .':„ Expiration: Date e Name J SANTORES WORLD FAMOUS,FIREWORKS;LLC t Premises Address(Changes?Notify the_FELCt :at least40 days-beforethemove.)_..'...'_ 846 STILLWATER BRIDGEROAD_-,,',' :a r SCHAGHTICOKE, NY 12154-".., Type of License or Permit i ? 20-MANUFACTURER OF EXPLQS.I,VES !; :. ' Purchasing Certification.§iatementF `:.?'`' c`. Mailing Address(Changes?'Notify the FELC of any changes.) The licensee or permittee named above shall use,a copy-,`of this license or pecmitto;assist,;a;.. transferor of explosives to verify the identity and the licensed status of fhe licensee dr permittee as provided by 27 CFR Part 555. The ii ulaiilre bir"each ccmy mnst.be an',drieinal SANTORES.;VVO`FtL17"FAMOUS FIREWORKS LLC sienature. A faxed,scanned or e-mailed copy ofthe' licenge,or.pemiit with a signature intended to bean original signature is•acceptable. The,sigriature rhust::be:that of the Federal 7 43 SUMMIT;AVE r r .. , . .: A t.. Explosives Licensee(FEL)or a responsible person oftli.kL-:,I' ertif,&V'it•tliisisatrue BERKELEY_HEIGHTS, NJ 07922- copy of a license or permit'issued to the licensee or permittee namedaliope.tgengage iri the - i ` business specified oro operations ecif`ied above under"T e of License or Pei7ltit?= P YP LicenseQ/Permittee Responsible Person Signature Position/Title.' ' Printed Name Date ATF Foini s400.1415400.15 Nat 1 Previous Edition is Obsolete SANTORESWORLDFAMOUS FIREWORKS UGNOSnu%VATE3IGRIGGEFOAo,1TiG43NF•08340-0C-01080:M1arcM11.ZU420-MAIIUFACTUREROFEKPLOS1VES Revised September 2011 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)616-4401 Martinsburg,WV 25405-9431 E-mail: FELC@atf.gov Change of Address (27 CFR 555.54(x)(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 Chiu 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,FELC;shall,if the licensee or permittee is not qualified,refer the request for amended license or permit to the Director of Industry Operations for denial in accordance with§555.54.) Right of Succession (27 CFR 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)Iitformation Card I l L LicenseJPermitName:SANTORES WORLD FAMOUS FIREWORKS LLC I I I I Business Name: License/Permit Number:6-NY-063-26*-01060 License/Permit Type:20-MANUFACTURER,OF EXPLOSIVES I I Expiration: March 1,2024 I I I I Please Note: Not Valid for the Sale or Other Disposition of Explosives. I I I ----------------------------------- , ..�'l -vv Y. r " f3..1'&►.fi~..L.:,t:5.1 ROTA'A dat, F-J:nl t,. ' � ,�.�.».. COARPFEEiCtAt DRIVER LICENSE, PURPOSESi 161 229 777: i DAVIN t RIGHAliDN 241 Po BOX F { fAORICIiES!yY1�J65' MAZEtAT %s.a 04106t2026: ,+S i 041221,196.8 0:4122120257tD D srAT1 QW~vcaax-"bEaxrMr OF.I.ABCR, I e r, '`' F S PYRflTEChIld10AItCER7lFIC1TOkCtJtlPLTLN,CE" Y+t, RICHARD,M,DAV,IN CLASS:B . NoIN'PROXIMATEWDIENCEpNLY, " THIS CARD MUST-BECARRIED WHEN USING"PYROT t"=",t'0 PiY';+:w" `i NYC&NYS CERTIFfCATIONS REQUIRED IN,NYC' r • RFiitlStlltttilitEitt}j� " CSR",TiFN SUED BY.FDNY, , C"E .IT `.8168941 5& r r" R. }SSLIE p'IISlOSl2022. "EXPIRES"'05!08!2023' NA1ti1RE-"Ric,"ARFD WDAVIRi wt3Df2:'.M43RDCI-IES,IVX•'IY9SSr E' .. FE `& 5:�- "` 'CAT-E20'' "T`%PE Fitness" _ PYRP3TE+CMIVIC FIREWORKS, 'EMPLOYER t~"YRCD.ENG3I111EERI11iGr ". w WORKn. Via'"• �� � :� ���~ .9k?5 .��^"fir"�4p �•� � M' � i AT i l li jr RIGHAR Jit� PO BO1 14308 Ey; £Ts ttay j., ' loo LICENS <a .9 a 1. ,••§:',�. s ':Y..�?,� .• x �,. µ� .w�' .,5 �'%�`''-;`5y'ti"""ry i.:t� �'S,'PJ.,' H6•.,f,a:4y^¢. '4 by w•; ntl^.%� - �{'.• s a aw ��a 3'�A+`-Ti�.ia�M r, ^tel- `ds `..•h'` R;7 ','CERTIFICATE IS ED' Y',. `P1:`. Y., qV r'I;SSUED".45106f2Q22" :EXPIRES':RStQ$12023° xF� e r � � e, 'NAME";Ri�`H. MM. n A ass�HQt�lE`:PG?.,.BQ•X'v4;!". xe . .,.AQC1 ', R: MGRICHES„•NY 11$55 _ E « EMPLO, YEE, xp , fF r ,r,"FEE.'$ 5 CAT:E20, YPE Fiti►ess: pYROTECHNlC:FIREWORKS ;�7•.,.�„ w @ i'• .,t.;Aar.+-.�'d'., • RANG!R� P eR0`ENGiNEE W C?RK ,. ri f -i' r 'at r , r i CATV "•f r,. x -tz e'•' "•aF �.xr.� 4 .s. , Peconic Landing 1500113recknock Rd Greenport NY 11944 Launch coordinates — 41.11947 N 72.36313 W 9/03/2023 9/04/2023 J'r r w e � o s Measure astavrr Tofal Asfan<e 24NStl1�41i m1 t`. Red circle = Fallout Zone 280' Red Triangle =launch location 4" Max shell All measurements meet or exceed NFPA 1123 o�oSUFFot,��o DENIS NONCARROW �� Gy Town Hall,53095 Main Road TOWN CLERKp- P.O.Box 1179 cn Z Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Q .lC Fax(631)765-6145 MARRIAGE OFFICER 4 RECORDS MANAGEMENT OFFICER ��,( .� Telephone(631)765-1800 FREEDOM OF INFORMATION OFFICER www.southoldtownny.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 Sunday. September 3rd, 2023 at 8:15 P.M. (Rain Date: Monday, September 4th, 2023 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 there shall be at least two such operators constantly on duty during the discharge and that at least two soda-acid o oth r approvqd type fire extinguishers of at least two and one-half gallons capacity each shall be kept at sue wide 7separFed:points as possible within the actual area of the display. nis Noncarrow,, Town Clerk Town of Southold Date: July 5th,2023, THIS PERMIT IS NOT TRANSFERABLE Southold Town Board - Letter Board Meeting of July 5, 2023 RESOLUTION 2023-586 Item # 4.6 �yM�3 ADOPTED DOC ID: 19281 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2023-586 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JULY 5, 2023: RESOLVED that the Town Board of the Town of Southold hereby approves the issuance of a fireworks permit by the Town Clerk to Peconic Landinlz at Southold,Inc. for a fireworks display on September 3rd, 2023 at 8:15PM (Rain Date: September 4th,2023 at 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. Roadway in Peconic Landing to be secured during show. �L ;��t1 ` 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, 2023 Page 16