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HomeMy WebLinkAbout2001ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER 0 i o~~SUFFO(,~~oG o~ y~ y Z ~ • 'F Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631).765-1800 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PERMIT for PUBLIC DISPLAY OF FII2EWORKS .. I, ELIZABETH A. NEVII.L,E, 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 MATTITUCK LIONS CLUB. & FIREWORKS BY GIRONE 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, June 16, 2001, at 10:00 u.m. on properly owned by Mattituck Associates. Inc. 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 aze to be fired shall be at least two hundred feet from the neazest 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 he 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 he so set up that the projectile will go in the air as nearby as possible in a vertical direction, unless such fireworks aze to be fired from the shore or a lake or other large body of water, then they may he 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 he immediately disposed of in a way safe for the particulaz 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 shat] 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 sodaacid or other appmved 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. Eliza eth A. Neville~~erk Town of Southold Suffolk County, New York 6~W>'/Dl Da a ~- (TOWN SEAL) ACORD CERTIFICATE F LIABILITY INSURA E Ta DATE IMMIDDIYI') 05/10/2001 PRODUCER FAX <g S 6) 6 2 ~ 9 The Borell i Agency, Inc. Dutch Mill Road ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Malaga „ N] 08328 INSURERS AFFORDING COVERAGE INSURED Vineland Fireworks CO., Inc. INSURER A: Liberty Mutual Insurance Co. 1640 E. Garden Road INSURER B: Vineland, NJ 08360 INSURER C: INSURER 0: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER DATE IMM/DOIYY) DATE IMM/OOIYII LIMITS GENERAL LU181LITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $ CLAIMS MADE O OCCUR MED EXP (Any one person) $ PERSONALBADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC JECT AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANV AUTO (Ee ecdtlem) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANV AUTO OTHER THAN EA ACC 8 AUTO ONLY: pGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR O CLAIMS MADE AGGREGATE $ S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND C1-335-301113-010 04/01/2000 04/01/2002 TORY LIMITS ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 100,000 A E. L. DISEASE-EA EMPLOYE S 100,000 E.L. DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTON OF OPERATONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECVIL PROVISIONS i spl ay Date; June 16, 2001 ain Date: To be determined CERTIFICATE HOLDER I I ADDITONAL INSURED; INSURER LETTER CANCELLATION 8HOULD ANV OF THE ABOVE DEBCRIBED POLICIEB BE CANCELLED BEFORE THE EXPIRATON DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 1g_ DAYS WRITTEN NOTCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Matti tuck Lions Club Leis 7. Newton & Sons BUT FAI UR U H O I,.I NO OBLIGATION OR LIABILITY 212 Knapp Pl aCe OF%IN EN REPRESENTATVES. Green po rt Long Is., NY 11944 AUTOO EP ENTA } 4y,i^'Jr, za-a )nny) ) ~wi.urtu i.urtr~lw nvn Taaa CERTIFICATE C3F IN.~ORAN~E z l: nA'>~~ ~v z3, ~uut i PRODUCER 'PHIS CERTIFICATE IS ISSUEll AS A MAT F INFORMATION ONIR AND CONFHk6 Brown and Humphrey Surplus Lines Insurance Brokers NO RIGHTS FPON THE. CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMFN'U, EXTEND OR LATER THE COVERAGE AFFORDEll B1''ffl F. POLICIES AELOW. Farallon Associateslnsurance Brokers - -- 400 D'Iontgomery Street Suite 500 INSURERS AFFORDING COVERAGb; F i CA 94104 S an ranc sco, INS RF R A U d i Ll d f L d erwr , : n ters, oy s o on on U ~5-391-1053 'I [SSURN;D INSURER H: Sorema NA I Vineland Fireworks Co., Inc '. T/A Fireworks by Girone ___ INSLI2ER C: 1640 Garden Rd. Vineland, NJ OR360 INSURER D: CO}'E;RAGE;S ' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PERIOD mDI[ATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN LS SUBIECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES INCLUDING, RUT NOT LIMITED TO, THOSE FOLLOWING. LIMCfS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. ADDITIONAL CONDITIONS AND EXCLUSIONS: 1) THE INSURANCE POLICY EVIDENCED BV THIS CERTIFICATE PROVIDES LIABILITY INSURANCE ONLY, IT IS NOT A BOND OR ANV OTHER FORM 'I OF SURETY AGAINST WHICH SOMEONE WMO IS NOT AN "INSURED" HEREUNDER MAVASSERT A CLAIM OR BRING ANV LEGAL ACTION. SUB]ECi TO ITS TERMS, DEFINITIONS AND CONDITIONS, THE INSURANCE PROVIDED BY THE POLICY ONLY INDEMNIFIES AN "INSURED" FOR LEGAL LIABILITY IMPOSED UPON THE ' "INSURED". 2) THIS INSURANCE DOES NOT APPLY TO THE NAMED INSURED'S SHOOTER (S), ASSISTANT (S)AND/OR ANY OTHER PERSON (S), INCLUDING ANY '~ VOLUNTEER (S) PARTICIDATING IN ANV WAY IN THE SHOOTING AND/OR EXECUTION OF ANY DISPLAY OR SPECIAL EFFECT UNDERTAKEN BV THE NAMED INSURED I OR "PROPERTY DAMAGE" TO PROPERTY OWNED, LEASED OR RENTED BV THE NAMED INSURED'S SHOOTER (S), ASSISTANT (S)AND/OR ANY OTHER PERSON'S INCLUDING ANY VOLUNTEER (S) PARTICIPATING IN ANV WAY IN THE SHOOTING AND/OR EXECUTION OF ANY DLSPUIY OR SPECIAL EFFECT UNDERTAKEN BY THE NAMED INSURED_ ci) ~- -- ----~ i'OLii:'Y EFFHC91\'E POI.I(.4' F:~PfaAT10N L)'R T)'PR DP INSURANCE POLICY NIIMRRR DATE IMM/DD/19~ DATE IMM/DD/PY) LIMITS OF.NFRAI. LIARILITY EACH OCCURRENCE $ 1,UW,000 ®COALMERCIAL GENERAL ' ' ' 1 2 FIRE DAMAGE (Any one fa) $ 50,000 A 1.I.UFII,I 1 1 DMGLBf11001$ 0$/31 /O] /0 05/3 MEDICAL F.XP (Any one person) $ 9 000 ^ CLAIMS M.1DE ®OCCL!R. , GF.N'L AGGREGATE APPI,I F,S PERSONAL. & ADV INJIIR1' $ 1,000,OOU LOCATION GENER.1[, AGGREGATE $ 2,000,U00 PRODL"CTS-COMP/OPS AGG $2,000,OW COMRINF,D SINGLE LIMIT $1,000,000 It AL'foMOnH.E L7Ae1L1T}' EX12019-2000 10/07/00 10/(17/01 (F.e accwenq 'I ^ ,\V )' ALTO BODILY INJUR}' $ -- ^ ANF OWNED APT'OS ' (Pee peemn) ~, ® S('IIEDULN]D Alfl OS BODILY IN.IPRY $ li ® HIRED AUTOS ' (Pu oecidenq ~. ® NONAR NED .1UT06 PROPERTY DAMAGE $ ~ (Per ueidenU '--~--~ ~-F:S('ESS LIABILITY EACH OCCCIRRENCF. $q,000,00U .~ ®occuR. ^c1,.vNlsntAnE DMXSD010014 0.5/31/01 05/31/02 ®OTRIiR TARN UNINREI,L.1 AGGREGATE ___.._ $4,000,000 ~ WC STATU- O'IA- R'ORFI?RSCON•~ENSATION TORY LIMITS ER S -- '1ND EMPLOYERS' LI IBILITF F..L.EACH ACCIDENT $ , F:.L. DISEASE.-EA EMPLOYEE $ E.L. DISEASE-POLICY LIMIT $ _ -"-" o~rned -- DF;SC'RIY'1'ION OF UPF.lU1TIONS/LOCATIONS/}'F.HICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL. PROVISIONS 1) blattihlck Lion CIHb 2) Lewis J. Newton & Sons 3) Town of Southold 4) Mattituck Fire Department are Additional Insureds as RcspeMs a Fireworks Display on Jnne 16, 2001 (RD TBD) at Mattihlck Strawberry Festival Cronnds, Mattituck, NY. ~ ~ CF.R'LIFICAI'F: HOLDER CANC'N;1.LATION I Matt1t11Ck Lions Cblb/LewiS J. RRDULD ANY OP THN: ABOVE DESCRIBED POLICIES BE CANCF,LLF.D BEFORE THE EXPIRATIOF DATE ' NeWYOR (C SOHS THEREOF,'f IIEISSUING CONH'ANY WILI. ENOF.AVORTO MAIL 30_DAY6 WRITTEN NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAII.IIRF. TO MAIL 6UCH NOTICE SHALL IMPOSE NO ' 212 Knapp PIaCe OBLIGATION OR LIABILITI' OF .1NY ' D UPON THE COMPANY, ITS AGENTS OR (2EPREFiENTAT'1\'FS. , '', GrfenpOrt LOng Island, NY 11944 AUTHORIZED REPRESF.NTATl\ F' r. .~C. J~rT //' ~~ ' 4. 7~ ! ~T ~ ~ J / / Il ~~ ' L31 ' ~ ~ ~ (v ,,.' J l [ ~ r i . .. ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER OgUFFO(,f-~ O~ O ~~ Gy ~ - Town Hall, 53095 Main Road P.O. Box 1179 • ~ D Southold, New York 11971 Fax (631)765-6145 ~ y ~0 ~Q (631) 765-1800 T l h l ~ ~ e ep one OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Carlisle E. Cochran, Jr. From: Town Clerk Elizabeth A. Neville Re: For your approval, request for fireworks permit Mattituck Lions Club, Sunday, June 17, 2001 Date: 5/22/01 Please advise if this meets with your approval, and of any recommendations or suggestions you might have for any conditions of granting this request before the fireworks permit is issued. Thank you. ELIZABETH A. NEVII.LE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER • o~~gOFFO~k~o ~~ G'y.~ o '~ y x W • oy~ol # ~ao~ OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD APPLICATION for PERMIT TO DISPLAY FIREWORKS Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 RECENED MAY 2 2 2001 Southold Torrn perk APPLICATION IS HEREBY MADE, pursuant to the provisions of Section 405.00 of the Penai Law of the State of New York, for a permit to display fireworks as hereinafter specified: DISPLAY IS TO BE SPONSORED BY_~L~~IIe~`ll`"t1L~/l ~~~0/lS C~ PRINCIPAL OFFICE AT / ~'ro / E, r o~ c DATE OF DISPLAY rJUne~ QaD/ TIME OF DISPLA' RAIN DATE E TI The following persons are to be in charge of the actual shooting of the fireworks: me Age Experience Ph sical Condition ~_ ~ 028 o r ,'~ ~~ Number and type of fireworks is as follows: The fireworks will be stored in a covered truck prior to shooting on the grounds. 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. ~~f o ~3~eo ~~.s~-v ~~ , D / Date Application .. .. ~7EAt~l~A7t. P~'~,~`~N .. ~: .. :.... : i: ............ . ® R ~~3.Yv`L~Y Y i A ..... ...... :... ... F ...... ...:: :. . ~~J~y~C:~U~~.. ~ i .... :: T .. ® ~ ® .. .... ....... ... , :... i -------------i :::: .::. S ::::::z::. :: . ..... ... . .. . ~~7~~~~::....: ::: m ... . .. Bt15i:NE55.:AND ~.ST:A~E AR:EA ®:: ® i 3~QN:-:Pi2QFfiT. `. ~ : : i .. .. .. :. B., ::BfRR~ .SALES. S=::SXIDDa e~ (~ ~~~ ~~~~i.T ~Y_. ~,Lr©UQ: ~~~1:i Y~~ G- .EOLO~A:S :. .. .. . : .. i~~~T~'~~~iT~ ~3F~N~i~~~~~+ ~~~t~f~~n~~~2>< _.. PRODUCER THIS CERTIFICATE IS ISSUED AS A MAT F INFORMATION ONLY AND CONFERS Brown and Humphrey Surplus Lines Insurance rokers NO RIGHTS UPON THE CERTIFICATE HOL TBIS CERTIFICATE DOES NOT AMF,ND, ' EXTEND OR LATER fHE COVERAGE AFFORDED 8Y THE POLICIES BELOW. Farallon Associates Insurance Brokers 4U0 Montgomery Street Suite 500 INSURERS AFFORDING COVERAGE i i A 41 4 San Franc sco, C 9 0 INSURER A: Underwriters, Lloyds of London 888-391-1053 INSURED INSURER B: Sorema NA .Vineland Fireworks Co., Inc T/A Fireworks by Girone INSURER C: 1640 Garden Rd. Vineland, NJ 08360 INSURER D: i COVF,RAGF.S THIS IS TO CERTIFY THAT THE POLICffS OF INSURANCE LLSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PERIOD mDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY COMRACi OR OTHE0. DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREm 15 SUWECT TO ALL THE TERMS, EXCLUSIONS AND COND)TIONS OF SUCH POLICIES INCLUDING, BUT NOT LIMITED TO, THOSE FOLLOWING. LIMITS SHOWN MAV k1AVE BEEN REDUCED BY PAID CU1IM5. ADDITIONAL CONDITIONS AND EXCLUSIONS: I) THE INSURANCE POLICY EVIDENCED BY TH7S CERTIFICATE PROVIDES LIABILITY INSURANCE ONLY, it IS NOTA BOND OR ANY OTHER FORM OF SURETY AGAINST WHICH SOMEONE WHO IS NOT AN "INSURED" HEREUNDER MAYASSERT A CLAIM OR BRING ANV LEGAL ACRON. SUBJECT TO ITS TERMS, DEFINITIONS AND CONDITIONS, THE INSURANCE PROVIDED BY THE POLICY ONLY mDEMNIFIES AN "INSURED" FOR LEGAL LIABILITY IMPOSED UPON THE "mSURED". 2) THLS INSURANCE DOES NOT APPLY TO THE NAMED INSURED'S SHOOTER (S), ASSISTANT (S) AND/OR ANV OTHE0. PERSON (S), mCLUDING ANY VOLUNTEER (S) PARTICIDATING IN ANY WAY IN THE SHOOTING AND/OR EXECUTION OF ANY DISPLAY OR SPECIAL EFFECT UNDERTAKEN BY THE NAMED mSURED OR "PROPERTY DAMAGE"TO PROPERTY OWNED, LEASED OR RENTED BY THE NAMED mSURED'S SHOOTER (S), ASSISTANT (S)AND/O0. ANY OTHER PERSON'S INCLUDING ANY VOLUNTEER (S) PARTICIPATING IN ANY WAY m THE SHOOTING AND/OR EXECUTION OF ANV DLSPIAY OR SPECIAL EFFECT UNDERTAKEN BV THE NAMED INSURED. g0 POLICY EFFECTIVE POLICY EXPIRATION I:fR TYPE OFINSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DDIYV) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ®WbNdERCIAL GENERA[. 1 2 FIRE DAMAGE (Any one fix) $ 50,000 A LIABILITY DMGI,BO10018 05/31/01 /0 0$/3 MEDICAL EXP (Any one person) $ 5,000 ^ CLAIMS MADE ®OCCUR. GENT. AGGREGATE APPLIES PERSONAL & ADV INJURY $ 1,000,000 ~ LOCATION I GENERAL AGGREGATE $ 2,000,000 PRODUCTS-0OMP/OPS AGG $ 2,000,000 COMBINED SINGLE LIMIT $1,000,000 B AUTOMOBILE LIABILITY EX12019-2000 10/07/00 )p/07/pl (Ea nccidenq ^ ANY AUTO BODILY INJURY $ ^ ANY OWNED ACrTOS (Pee permn) ® SCHEDULED AUTOS BODILY INJURY $ ® RIRED AUT06 (Pen weideny ® NONAWNED AllTOS pROPERTI'DAMACE $ (Per nmidanq EXCESS LIABILITY EACH OCCURRENCE $q,000,000 A ®ocwR. ^cLAIMSmAnE DMXSD010014 05/31/01 05/31/02 ®OTHER TITAN UMBRELLA AGGREGATE $4,000,000 WC STATU- OTH- N'ORKERSCOMPENSATION TORY LIMITS ER $ AND LOYERS' LIABILITY E.L.EACH ACCIDENT $ EMP E.L. DISEASE-EA EMPLOYEE $ E.L. DISEASE-POLICY LIMIT $ OTHER llESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 1) Mattituck LION Club 2) Lewis J. Newton & Sons 3) Town of Southold 4) Mattituck Fire Department are AdditioHal Insureds as Respects a Fireworks Display on June 17, 2001 (RD TBD) at Mattihlck Strawberry Festival Grounds, Mattituck, NY. CERTIFICATE HOLDER CANCELLATION Mattltuck LIONS Chlb/LCWIS J. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE Newton & Sons CERTIFICATE HOLDER NAMED TO TH LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO 212 Knapp Place OBLIGATION OR LIABILITY OF ANY UPON THE COMP ITS AGENTS ORTR RESENTATIVES. Greenport Long Island, NY 11944 AUTHORIZED REPRESENTATI !CERTI :: Ate' ~ ~F INSIJR~iGE rs s nn~rl" ~~ 2111 ~ PRODUCER ~ ~ THIS CERTIFICATE IS ISSUED ASAMAT INFORMATION~ONLY AND CONFERe Brown and Humphrey Surplus Lines Insurance Brokers NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMF;ND, ' ' . CHEI COVRRAGE AFFORDEU BY THE POLICIES BELOW EXTEND OR L.4TER -- Farallon Associates Insurance Brokers 4(10111ontgomery Street Suite 500 INSURERS AFFORDING COVERAGE ~ San Francisco, CA 94104 INSL72ER A: Underwriters, Lloyds of London 888-391-1053 INSURED INSURER B: Sorema NA Vineland Fireworks Co., Inc T/A Fireworks by Girone INSURER C~ 1640 Garden Rd. - Vineland,NJ 08360 INSURER D: j C'OVERAGI:S THIS is TO CERTIFY THAT THE POLICniS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PERIOD INDICTED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDIITON OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN LS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES mGLUDING, BUT NOT LIMITEC TO, THOSE FOLLOWING. LIMBS SHOWN MAY :IAVE BEEN REDUCED BV PAID CLAIMS. ADDITIONAL CONDITIONS I AND E%CLUSIONS: 1) THE INSURANCE POLICY EVIDENCED BY THLS CERTIFICATE PROVIDES LIABILITY INSURANCE ONLY, 11 IS NOT A BOND OR ANY OTHE0. FORM OF SURETY AGAINST WHICH SOMEONE WHO IS NOT AN "INSURED" HEREUNDER MAYASSERT A CLAIM OR BRING ANY LEGAL ACRON. SUWELT TO rI5 TERMS, DEFmITIONS AND CONDITIONS, THE INSURANCE PROVIDED BY THE POLICY ONLY INDEMNIFIES AN "INSURED" FOR LEGAL LUBILITY IMPOSED UPON THE "INSURED". 2) THLS INSURANCE DOES NOT APPLY TO THE NAMED INSURED'S SHOOTER (S), ASSLSTANT (S) AND/OR ANY OTHER PERSON (S), INCLUDING ANY PARTICIPATING IN ANY WAY !N THE SHOOTING AND/OR EXECUTION OF ANV DLSPLAY OR SPECIAL EFFECT UNDERTAKEN 8Y THE NAMED mSURED OLUNTEER S ( ) i V OR "PROPERTY DAMAGE" TO PROPERTY OWNED, LEASED OR RENTED BY THE NAMED INSURED'S SHOOTER (S), ASSISTANT (S) AND/OR ANY OTHER PERSON'S INCLUDING ANV VOLUNTEER (S) PARTICIPATING IN ANY WAV IN THE SHOOTING AND/OR EXECUTION OF ANY DLSPLAY OR SPECIAL EFFECT UNDERTAKEN BV THE NAMED INSURED. ('O POLICY EFFECTIVE POLICY EXPIRATION L'i'R Ty"PE OF INSURANCE POLICY NUMBER DATE (MM/DDM) DATE (MM/DD/)'Y) LIMfI'S L GENERAL LIABILITY EACA OCCURRENCE $ 1,OW,000 ' ®CONIMERCIAL GENF.R.4L FIRE UAMAGE (Any one fire) $ 50,000 A LIABILITY DMGI,B010018 05/31/01 05/31/02 MEDICALEXP(AnyRneperaon) $ 5,000 I ^ CLAIM6 MADE ®OCCUR. GFN'I. AGGREGATE APPLIES PERSONAL & ADV INNRY $ 1,000,000 LOCATION GENERAL AGGREGATE $ 2,000,000 PRODUCTSLOMP/OPS AGG $ j,000,000 F- CONAiINED SINGLE. LJMIT $1,000,000 ~ B I AriTOMOatLELIAaILITY EX12019-2000 10/07/00 10/07/01 (Eascevlent) ^ ANY AUTO BOUILY INJURY $ ^ ANY OWNED AUT06 (Pev permn) ® SCHED[II,F,D AUTOS BODILY INJURY $ ~ ® HIRED AUTOS (Per oc~id.oq ® NON-0WNED .4I1'1'OS PROPERTI' DAMAGE $ '. ESCESS LIABILITY EACA OCCURRENCE $4,000,000 I ~ ®occuR. ^CLAIMSMAI)& DMXSD010014 05/31/01 05/31/02 ' ~OTHER'fIIAN l1MBRP1I,1.A AGGREGATE $4,000,000 I WC STATU- OTH- WOR%ERS COMPENSATION TORY LIMITS ER $'- ~,, AND E1..F,ACH ACCIDENT $ EMPLOYERS' LIABILITY E.L. DISEASE-EA EMPLOYEE. $ E.L. DI6EASF-POLICY LIMIT $ ~ oTnea i UESC'RIP'1'ION OF OPERATIONS/LOCATIONSNEHICLES/E:XCLGSIONS ADDED BY ENDORSEMENT/SPECIAI, PROVISIONS 1) Mattituck Lion Club 2) Lewis J. Newton & Sons 3) Town of Southold 4) Mattituck Fire Department are Additional Insureds as 11 Respells a Fireworks Display on June 17, 2001 (RD TBD) at Mattitnck Strawberry Festival Grounds, Mattituck, NY. ~~ CERTIFICATE HOLDER CANCELLATION MathtUCk LIOHS Chlb/LCWIS J. SHOCLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE. EXPIRATION DATE " ' CTEN NOTICE TO INE THEREOF, THE ISSIIINC COMP,tNY WILL ENDEAVOR TO MAIL 30 DAYS WRI NeWYOn & SOHS CERT[FICAT F, HOLDER NAMED TO TH 'LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE. NO ~, 212 Knapp Place OBLIGATION OR LIABILITY ON ANY UPON THE COMPA IT'S AGENTS OR421(j?RE6ENTATIVES. Grecnport Long Island, NY 11944 AurHOmzED REPRESENTATI ' ~ ~ ~ .~ - ACORD~ CERTIFICATE LIABILITY INSURA DATEIMM/DD/YY) 05/10/2001 PRODOCER (856)694-2222 FAX (856)69 79 The Bo relli Agency, Inc. Dutch Mill Road ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Malaga „ N] 08328 INSURERS AFFORDING COVERAGE INSURED Vineland Fireworks Co., Inc. INSURERA Liberty Mutual Insurance Co. 1640 E. Garden Road INSURER B: Vineland, N7 08360 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANV 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 BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OFINSURANCE POLICY NUMBER DATE IMM/DDNY) DATE (MM/DDMy) OMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $ CLAIMS MADE O OCCUR MED EXP (Any one person) $ PERSONALBADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC JECT AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT ANV AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per amident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANV AUTO OTHER THAN EA ACC $ AUTO ONLY: qGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR O CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATON AND ' C1-33S-301113-010 04/01/2000 04/01/2002 TORY LIMITS ER A EMPLOYERS LIABILITY E. L. EACH ACCIDENT $ 100,000 E. L. DISEASE-EA EMPLOYE $ 100,000 E.L. DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEMICLES/EXCLUSIONS ADDED BV ENDORSEMENT/SPECIAL PROVISIONS ispl ay Date; June 17, 2001 ain Oate: To he determined CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER CANCELLATION SNOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION GATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL ~_DAYS WRITTEN NOTCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Matti lock Lions Club SE NO OBLIGATION OR LIABILITY B U T F AILURE TO MAIL SUCH NOTICE SHALL I M P O Leis J. Newton & Sons ~~, ~~ pp rr y~ r~ ~~*• JJII OKA~f ~ ERTS'm'R REPRESENTATVES 212 Knapp P1 ace . Green po rt Long Is., NY 11944 AUTH DREP ESENTA a 1 ACORD 25-S (7/97 J - ~' --CTACOKU CUKYUKAIIUK'19tltl ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER • ~o~gUFFO(,~~o o Gyp H 2 ~ • `F oy~01 ~ ~a~! OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SPECIAL PERMIT C~ Town Hall, 53096 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631)765-6145 Telephone (631) 765-1800 A Special Permit is hereby granted in accordance with Chapter 27, Section 27. I B. of the Code of the Town of Southold, to Mattituck Lions Club to hold their "Annual Strawberry Festival and Country Fair from Fridayrt;etr June 15, 2001 through Sunday, June i7, 2001, on the property of Mattituck Associates, north side of County Road 48, Mattituck, provided they file with the Town of Southold a One Million Dollar Certificate of Liability Insurance naming the Town of Southold as an additional insured. June 14, 2001. (Insurance Certificate one) cc: Chief of Police Conway Superintendent of Highways Building Department Elizabeth A. Neville Southold Town Clerk * Notice - If a tent is to be erected, you must first obtain a permit from the Southold~'own Buildipe Department.