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Home My WebLink About1957T0: RALPH P. BOOTH, TOWN CLL~RK, TOWN OF SOUTHOLD. APPLICATION IS HAB2EBY MADE, pursuant to the provisions of Section 1894-a of the Penal Law of the State of New York, for a permit to display fireworks as hereinafter specified: Ths display ie to be sponsored by !1'~'.CTi! '/`'~`' L'c"'ti"~-i.'r C<~~~<J ~~~ _, with principal office at ~" " ~ c.<<~,~~'<~ New York, and will be held on ~ ~ , -y ~'" 195 at (may) - (Month) (hour The following persona are to be in charge of the actual shooting of the fireworks: ~i AGE EXPERIENCE PHYSICAL CONDITION Number and type of fireworks is as fomloxs: .7 The fireworks will be stored in a covered truck prior to the shooting on the grounds. a~-- Attached hereto and made a part hereof is a diagram of the grounds on which the display is to be held. Also attached is the certificate or policy of insurance coverage. Dated: -J~.. 7a .~~ ~ j at ~ ~-. f c- ~ _, New York. Respectfully submitted. Name of Organ'i/sation~~( Title Newhouse and Hawley, Inc. CERTIFICATION OF INSURANCE This certifies that we have effected the following insurance: NAME OF ASSURED Suffolk [doSr; xty Fir ~lI=_~ Co. ~]orth FOP'> AND ADDRESS Co_antry Glui~x Cu -,-•k,~ ~~,-.~ Nn~ 1~~,~._, Pos~,~nshi~ of ~0~1 i;holi:. PERILS OR TYPE ?ublir li :- i1i ty n ?ro;~ _ rty c' , ~ ^ ' ? ' '-i1? ty OF INSURANCE on firs:ork ffi'h_bifim... Grounds of t]orth Forl~ Country Club LOCATION(S) OR Lisr~l~y On or ak~out July ~ 1957 OTHER SCHEDULES FL ~20~000/25~000.00 sub~Fet to x'100 deductible LIMITS OR AMOUNTSBL X2500.00 ~ ech claim. July 13 1956 to July 13 1957 TERM OF COVERAGE POLICY NUMBER Q84Fi9-4 This Certification of Insurance is issued at the request of: North Fork Country Glub Cut<~hngue~ Nay: Xorlr To~~.nship of .`.outhold Coanty of 6uffolk and confers no rights to the holder which would not otherwise be conveyed to the holder under the terms of the insurance; in the event of material change in coverage or cancellation of the insurance during the term thereof NEWHOUSE AND HAW LE Y, INC. , will endeavor to notify the holder, but neither the As curers nor NEWHOUSE AND HAW LE Y, INC. , accept any liability or responsibility for failure to do so. Dated at Chicago, Illinois, thislgtl1 day dun ' 19x7. NEWHOUSE AND HAW LE Y, INC. By FORM '.541 ~6oi9~~S 1 ~~ ,. -- -t LANE 1 I`~ ~ E S 9 ` `~ ^h'' o %17 ' ~ ~~ c R ti, '~_ Y' S N,J Cs W 1~` IE i'~ C _.~ ~~ (y (,v 0 O w ~~ _'~ _._ . ~ IS Pi_ A Y ~_~ _.. _ ___ ____ _ _.__ -- _ -- soa, _ _ _ _ ___ FpRm 1~10uS THE TRAVELERS Zrrye ~rabefers ifnourarae f6ompanp Frye aGrabelero 31nDemttitp (~ompanp Certificate of Insurance Phis is to certify that policies of insurance as described below have been issued to the insured named and are in force at this time If such policies are canceled or changed during the periods of coverage as herein, in such a manner as to affect this certificatq e~ritten notice will be mailed to the party designated for ~~~hom this certificate is issued. below stated below L Name and address of party to whom this certificate is issued ~ 2. Name and address of insured TOWN OF SOUTHHOLD -SOUTHHOLD,N..Y. 3. Location of operations to -l NORTH FORK COUNTRY CLUB S~S MAIN RD. CUTCHOGUE,N.Y. SOUTHHOLD,SUFFOLK CO.,N.Y. Coverages for which insoran<e is afforded Limits of Liability Policy Nom ber Policy Period* Vorkmen's Compensation and Employers' Compensation-Statutory ** iability in the state named in item 3 hereof odily Injury Liability-except automobile ** 5100, 000. each person EX eluding Protective 5300,000. each accident $LG 52621{8 7~27~56~57 - - -- 'roperty Damage Liabili}y-except automobile - - ~~ S 2~j, 000. each accident ~cluding Protective 5 aggregate *. Bodily Injury Liability-automobile 5 each person 5 each accident - ~~ 'roperfy Damage Liability-automobile 5 each accident *Policy is effective and expires at 12:01 .-~.~t., standard Lime at the address of the named insured as stated herein. **Absence of au entry in these spaces means that insurance is not afforded with respect to the coverages opposite thereto. _ _ _ __ llescription of Operations: FIREWORKS, ETC {~326S The insurance afforded is subject to all of the terms of the policy applicable thereto. This certificate is executed by The Travelers Insurance Company as respects insurance afforded by that com- panyunder the policies designated above; it is executed by "the Travelers Lxlannity Company as respects insurance afforded by that company under the policies designated above. Branch Office- - - -- - THE "II2AVELERS INSURANCE., COMPANY THE~iIiBrLKG'EL>~R~INDE'~ N~ CO\IPANY Producer M6RK W FLANAGAN Date 6~26~57JB C-5918x 11-56 axixreo ix us.e.