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TOS RALPH Y. BOOTH, TOWN CLSRE, TOWN OF SOIITHOLD.
APP LICATIOIf IS HBRBBY MADE, pursuant to the proeisio». of
3eetion 1894-a of the Papal Law of the State of ltew York, for a
permit to display fireworks as here Lsaftor speeitieds
/~ The disply it to be sponsored b7 ~~ a~-~..:~
<~X~c~i-- ,with prinoipal ottia• at ~ ~~ ,
liew York, and will be held on ~ , „__ 1955 at
a~y '- i osit6,
,._
our - P.K.
R'he following persons are to be in eharge of Oha actual
shooting of the tireworlus
~ ~ 81[PEItIBECE .~~YSIOAL OOUDITION
f~'
.3 6
Nueberi sad type of fireworks is as tollowas
~ ~
The fireworks x111 be stored Sn a eo~ered truek prior to the
shooting oa the grounds.
Attashsd hereto sad made a part hereof is a diagrasu of the
grounds oa whieh the display is to 'be held. Also attaohad is the
aertitieats or pokey of iasuraaoe aowerage.
f S".
lfow York.
Respeettully subpittdd,
Effective from .T~y R~ y l O S S Amending Policies numbered.~,~ ~ ~~(+ ~,~r7
' At 12:01 tevd.rd ltime Q i~7~ 77'~l
Issued to
The Travelers Insurance Company Additional Premi. +n~~ eturn Premi++*n
The Tmvelera Indemnity Company Additional Premi +m Return Premium
The Travelers Fire Insurance Company Additional Premium Return Premi++m
It is agreed that as of the effective date hereof these policies are amended in the following particulars:
To include the following classification:
Fireworks Exhibitions - sponsorts risk only Code r~326S
To include the interest of the Town of Southhold, Suffolk Co.,
N.Y. as respects above classification.
lOf additional Interest
The provisions of this endorsement to expire 7-5-55
Changes affecting insurance afforded by The Travelers Insurance Company are eaecuted for that company
only. Changes affecting insurance afforded by The Travelers Indemnity Company are eaecuted for that company
only. Changes affecting insurance afforded by The Travelers Fire Insurance Company are eaecuted for that com-
pany only.
If any additional premium is noted above, this endorsement is issued in consideration thereof.
If any return premium is noted above, the receipt thereof is acknowledged upon acceptance of this endorsement.
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1 / 20 C ) b. e:'ti'.~(6Na.e:p ~ . W . ~ Se"~ /`~`^~ ~•
Date of Iesue~ysj~ cue
Branch Offs Producer
o ~,
Countersigned byJCJ ~-
"~+M
THE TRAVELERS
Frye ~rabe[erst iinguranre (lCompanp
~Grye ~Grabe[erg ~nbemnitp (lCompanp
Certificate of Insurance
This is to certify that policies of insurance as described below have been issued to the insured named below
and are in force at this time. If such policies are canceled or changed during the periods of coverage as stated
herein, in such a manner as to affect this certificate, written notice will be mailed to the party designated below
for whom this certificate is issued.
ame and address of party to whom this certificate is
~ ~
_ Town of Southhold
Southold, N.Y.
North Fork Country Club
S/B Main Rd.
Cutchogue, N.Y.
~ ~
to
Southold, Suffolk Co., N.Y.
4. Coverages for which insurance is afforded Limits of Liability Policy Number Policy Period*
Workmen's Compensation and Employers' Compensation-Statutory **
Liability in the stare named in item j~ hereof
3
Bodily Injury Liability-except automobile **
$ 100 , OOO each person
1.'Y~cluding Protective
-- -- -- - - - - ------- ----------------- $ 300,000 each accldent
- ---- - --
SLG 3 5C95$7
7-27-54/55
Property Damage Liability-except automobile **
$ 2 5 t OQO each accident
~~cluding Protective $ aggregate
**
Bodily Injury Liability-automobile $ each person
$ each accident
---------------------------------------------------------------- -
Properfy Damage Liability-automobile $ each accident
*Yolicy is effective and expires at 12:D1 ast., standard time at the address of the named insured as stated herein.
**Absence of an entry in these spaces means that insurance is not afforded with respect to the coverages opposite
thereto.
Description of Operations:
FireT~orks, etc. #3265
Liability for damage to property caused by ^ Blasting or Explosion, or ^ Collapse of or Structural Injury to
(Enter X in block applicable)
any building or structure is excluded from operations classified as
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-
pany under the policies designated above; it is executed by The Travelers Indemnity Company as respects insurance
afforded by that company under the policies designated above.
Mark ~~d. Flanagan
Branch Office Brooklyn
- 4-55mjo
"1'HE 'I'RAN S INSURA CE I
THE TR RSS I
., ~- ~-
C-SO18s Rev. A-54 exinreo ie us.n.
T ~'
~rt~rrwritPrs ttt ~'ilm~a's, ~inrc~nn
INof Incorporated)
CERTIFICATION OF INSURANCE
This certifies that the following insurance has been effected with certain
Underwriters at Lloyd's, London:
NAME OF ASSURED
AND ADDRESS Suffolk Novelty Fireworks Co., North Fork Country
Club, Cutchogue, Near York, Township of Southold.
PERILS OR TYPE Public Liability and Property Damage Liability
OF INSURANCE on Firework Pahibitions.
LOCATION(S) OR Grounds of North Fork Countxg Club.
OTHER SCHEDULES Display on or about July 3rd 1955
LIMITS OR AMOUNTS PL 10,000/25,000.00
PD 2500.00
TERM OF COVERAGE July 13 1954 to July 13 1955
POLICY NUMBER 28459-2
This Certification of Insurance is issued at the request of:
North Fork Country Club
Cutchogue, New York
Township of Southold County of Suffolk
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 cover-
age or cancellation of the insurance during the term thereof NEWHOUSE AND
HAWLEY, INC. , will endeavor to notify the holder, but neither Underwriters at
Lloyd's, nor NEWHOUSE AND HAW LEY, INC. , accept any liability or responsi-
bility for failure to do so.
Dated at Chicago, Illinois, this 3
Inr_
day of June 1955