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Home My WebLink About1985{ TOWN OF SOUTHOLD PERMIT FOR PUBLIC DISPLAY OF FIREWORKS I, JUDITH T. TERRY, 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 ORIENT FIRE DEPARTMENT '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 July 4, 1985 at approx. 9:00 P.M. Rain Date• July 5, 1985 at abprox 9.00 P.M. !at the time and place set forth in the application therefor. 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 build- ing, public highway or railroad or other means of travel, and at ,.least fifty feet from the nearest above ground telephone or tele- graph line, tree 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 into the air as nearby as possible in a vertical direction, unless such fireworks are to be fired from the shore of 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 concluded shall be immediately disposed of in a way safe for the particular type of fireworks remaining, that no fire- works display shall be held during any wind storm in which the wind reaches a velocity of more than thirty miles per hour, that all the 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 constant- ly on duty during the discharge and that at least two sodaacid 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. DATED: July 1, 1985 ~ BUD TH T. TERRY, Town C rk Town of Southold, Suffo k County, ~~ New York. i ~; 5 E)A L THIS PERMIT IS NOT TRANSFERRABLE. To Judith Terry VAL STYPE & SONS, INC. Southold Town Clerk -INSYRANCt - TOwn Hall, Main Road MAIN ROAD MA7fITUCK, N. Y. 11962 Southold ~ NY 11971 PHONE 616.298-8181 REGARDING: DATE: JLno 2~, 1^,FS Dear Mrs. Terry; As per my conversation with Mrs. Neville today, please be informed that The Balboa Insurance Company is listed in the Best book. It has an A+ rating as of 1984. I hope this information is helpful to you. Very truly yours, ~~, ~~,,yy.~~~,~~~ Patricia Cannon moo! Ji!? . 11985 Two CIM# S~MA~M ?N ~~~wy~ - -~- ,~F . ,, ~: s,;~ ~, t1~ .;~,;~~,(1\ ``a r'Y 11 1 t\ ~~114 tp\\\\\ INTfRN,4T10NAlF FIREWORKS MANUFACTURING COMPANY, INC. U. S. Corporate Headquarters - P. O. Box 1463, New Castle, Pennsylvania 16103, (412) 658-6611 Outside Pa. (800) 245.0397 Southern Region - 299 N. W. 52nd Terrace, Suite 118, Boca Raton, Florida 33432, (305) 994-1588 Western Region - P. O. Box 130, Rialto, California 92376, Office (714) 822-2247/2248 -Plant (714) 822-6068 June 28, 1985 Ms. Judity T. Terry Southold Town Clerk Southold Hall 53095 Main Road Southold, NY 11971 ~U~ x iv4y ~IIM1 CIMit l~dlrM Dear Ms. Terry: Thank you for your phone call. As you requested, I have hereon attached your revised Certificate of Insurance naming the Town of Southold as additional insured. If you should have any further questions or if I can be of any further assistance, please do not hesitate to give us a call. Thank you and Best Wishes. II2S/cap Enc: revised Certificate of Insurance Yours very truly, FfIREWOf2E~S~ CO. , INC. Fsther R. Selby ~'~" Since 1893- Fireworks Manu/acture and Display ° ®ALLIED SPECIALTY INSURANCE,INC. P.O. BOX 40250 • ST. PETERSBURG, FLORIDA 33743 " To L L Fl-ce 1--£iUU•-2.31--3355 Mat i ona L 1-SUU•-2£32--6'726 Florida F'oLicy NoS P8°iV1554 Ca_r°t ificate (~la. 7 This iz; to ccar°tify I Named ZAMSELLI Instu°ed COMPANY, Anr:I P.O, HOX Address; NEW CASTI CERTIFICATE OF INSURANCE PACKAGE SHOW that poLicir_s in the name of. I 1 FIREWORKS MFG. Addikioxrat TOWN OF SOUTHOLD INC. Insured 1463 _E, PA 16103 I 1 are! i n f orcc at the! elate hcar•e+of s as 'FD L LoWS2 Kind of Insurance Policy Numbers F'oticy F'er°iod Limits t'IF2EWORKS DTSI'l_AY I 8.~,V1554 I Eff i i/1/8.~i 1 $is000s000 +~CSL LTAI3TL_I1•Y IPiSL1RANCE I I Exp 2 1/1/86 I COMPANY2 1 I 1 1Ba Lboa Insurance I I 1 Company I __----I 1 EY.C'E.:SS 1" If2E:WUf1(C I I Eff . I DTSF'LA`f L.IA&ILITY I I E xp S I 'INSURANCE GOMF'ANYY I I I I I I I I -----__._.___---._.___.._._._ i .__._____._.______.__ ~ __.__.-----__-___-.; _._._.____.________._ Gompany2 I - Effi ( - 1 Exp. • I I I Expi I .__._._.._._._.____...-----.-----1._____._______ ___1_________-----._.._1__._______.-____-- ~rCSL -- CUMPTI•!ED SINGLE LIMIT Zn fihe evcarrt of any rna•terial. change in, or canceLLatioo of, said policies, the undersigned will endeavor •to give written notice to •Lhe r+arty to whom this certificate is issued, but faiLur•e •to give 5UCh notice shall impose no obligation or• Liability upon the company. C:I:RT'1F'ICATF~ ISSUED TUi I~AI'E OF L'~TSF'L.Ay July 4, 1985 NAME Orient Fire District AND ,East Marion Fire District RAIN DATE ADIrRE:S..~,own of Southold, Count of Y DISPLAY AMOUNT Suffolk LUCATIf.1N Ut~ LrISF'LAY Orient Harbor Orient, New York This certificate neither afFirmativeLy nor negatively amends, extends or- a L•tr_rs the coverage affordecJ by any po L i cy de<acr ibed herein. NOl•E. In event rain or inclement weather prohibits this display, coverage will apply on a subse•~,uerrt date on which display is held, within thE•~ terms of •this con•h-ac•t. Cleanup and policing of the ti istp Lay arc ~tl7e responsib i L i tY of thrr Sponsor°s. The •foLlowing are additional insuxeds; Any fair or exposition, as>r;ociat inn, sponsoring organization or committcAe, the owner or LessE:e of any premi:~,cs used by the named assured, ar' any public authority grant i ng a pE91"1111 t to the named assured, bu•t only as respects accidents ar•isiny out of the business operations o•f the primary assured. ALsn, as additiorra4 named insured any independent r_nnt•ractor who fires the display on behalf of the assured. --_.__~~_1~51~_L-!Sc _ Authorized Sigxratur•e JUDITH T. TERRY TOWN CLF,RF: R[GISTRAR OI' VITAL STAI ISTICS ~r.. r a u,.. F ~_ - ~~ ~~ ~ l4t_~ ~`'a ~.. ~: ,_t ~~ ~ ~. -~~ ,mow. ~, a .° _.:~- OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD June 24, 1985 Dear Bob: Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 TELEPHONE (516) 765-1801 Attached is a Certificate of Insurance submitted to me by the Orient Fire District relative to their fireworks display on July 4th. Although the top area relative to Named Insured does not name the Town as additional insured, the last paragraph refers to additional insured and one of those is "any public authority granting a permit to the named assured." Is this sufficient for me to issue the permit? Please give me a call. ~~- ~` .. , APPLICATION T0: NDITH T. TERRY, TOWN-CLERK, TOWN OF SOUTHOLD APPLICATION IS I~IEFtEBY MADE, pursuant to the pro- visions of Section 405.00 of the Penal Law of the State of New York, for a permit to display fireworks as hereinafter specified: The display is to be sponsored by l/y-.Y~~ ~-: ~ ~t av~/wkr with pri/ncipal office at p~/ -sue Ov'^~ ~ New York, and will be held on ~% !~ uYs. , ~K ~~ / day month 19 ~'S~, at ; d o P.M. hour RAIN DATE: ~ u ~~ r ~ 4 ~ S - The following persons are to be in charge of the actual shooting of the fireworks: Name '' // /~//r ~1'v ~a /7~a,Kir ~Z_ U/-e~ro- y'a~o~ _ -C_ Experience S-yr s- 9 yrs /~yvq Physical Condition CeAC'/ ~~ << Number and rks use of firewo ty : is as follows akl //~// ./i0. 401 y+,/ n / (If WOV / The fireworks will be stored in a covered truck prior to the shooting on the grounds. 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 o£ insurance coverage. Respectfully submitted, name of organization / Dated: ~ti.,/dc: ~ ~ ~ I~-- at ~w w~Ad~~ New York. G flU~ ~ ~ IM IIdfARr T ~ E~xOh~ ,, _ ,' '.; ~r~~K~ Firms. ~~~~rTwi~y ~ 3 F; r e wd ~, ~ ~i c~/a ~~ `~-~ "5 •is ~a K OC Saud ~ ~ :~. ~` '% OR.( '' ''~' - ~' ~r ,i •tir •~ ~ '-~ a ~_' `'' , :~ ~ .- 3a~ ~ `~ ,' ~, r S:Yt o F •, `` ~~ ~:rtw~r S ~. .•1 .~. -- - pti srla~ ~ • . ~ ~ ~ - ~ --.. --- -_ ~„~ ~~~~ STa'~e ~ar~ ~a ao~:h ~ rs ~3ct~/ >4 ~.,,: iF: K4._ r G~~~ ~~~ ~ ,' ®ALLIED SPECIALTY IN3URANCE,INC. P.O. BOX 40250 • ST. PETERSBURG, FLORIDA 33743 '1 o L l Free 1-800-28'?--6776 F Lor i cnia L Policy No: p85V1554 L'ertificate No. 4 `CERTIFpCA~~ 8F OW This is to certify that policies in the name of: Named i ZAMHELLI FIREWOkKS MFt3. tAdditionali Insured COMPANY, INC. Insured And P.O. HOX 1463 Addr-c+ss i~W CASTLE. PA 16103 ~ ~ are in force at the date hereof, as follows: ICind of lnsuram_c Policy Numbers F•oLicY Period-_____ Lim~_s_N- `FIkEWORnS DISPLAY I 85V1554 LIABILITY 1NSUFANCE 1 COMPANY : I Ba lboa Insurance Colupany ---------------._...__.1--------- EXCESS FIREWOkICS DZSF'LAY LIABILITY INSUkANCE COttF'ANY: Company: Eff: 1/1/95 l f1~000~000 wC9l. Exp: 1/1/86 •~ I Ef f : Exp: Eff: Exp: Exp: ~C5L - COMBINED SINGLE LIMIT In the event of any material change in, or cancellation of, said policies, the undersigned will. endeavor to give written notice to the c~arty to whom this certi~Fica•te is issued, but failure to give sLLCh notice shall impose no obligation or LiabiLit'y upon the company. CkFFTIFICA'1'E.: 1SSUEI~ TO: NAME Orient Fire District ANL' st Marion Fire District ADI~kES~own of Southold, County Suffolk Orient New York UAl'E: OF DISPLAY July 4, 1985 t2AIN DATE of DISPLAY AMUUNT ,~ Ll'JCA'1ION OF DISPLAY Orient Harbor '(his c:ert if ica'te neither. aff irmat ivel.y nor' negatively amends, extends or alters the coverage afforded by any policy described herein. NOl'E: T n. r+ven•t rain or • i nc: Lemc~n•t ia~a Cher proh i b i is this d i sp LaY. coverage will apply on a subse~tuerrt date nn which display is held, within 'U~e Terms o•f this contract. Cleanup and policing of the display are the responsibility of the Sponsors. 'ihe ioLlowiny are additional insureds3 Any tair or exposition, association, sponsor°iny organization or committee. the owner or Lessee of any p~'<<ni<ses used by the named assured, or any public authority granting a permit to the named assured, but.only as respects accidents arising out. of the business operations of the primary assured. Also, as add~'tional named in~~ured eny independent contractor who 'fires the display on behalf oi' the assured. ___-~~.l1 _l_~_~__~_-_/__-- Autt~orixed Signature ~ ~'/ r-{" ~ I" $ i~ Y/ `~ T 2 ~~ ~~ '~ V t°. l2 Vie, Form Approvetl: OMB No. 151!0399 (11/30/!6) - DEPARTMENT OF THE TREASURY -BUREAU OF ALCLt'HOL, TC`BACCO AND FIREARMS FOR ATF USE ONLY APPLICATION/PERMIT USER LIMITED SPECIAL FIREWORKS UNDER 16 U.S.C. CHAPTER 60, EXPLOSIVES ~ + ~ ~® ~~~ /\ N '--~ - ^•' (P/ease read lmtructlona on bock o/th4 /arm) r l ` NOTE: COMPLETE IN TRIPLICATE, USE TYPEWRITER OR PRINT WITH BALL-POINT PEN. ` 1. NAME (I/partncnhiD, include name a/each partner) ' Or/end Firms DeP~"/ Or+cltd rcl 9t, Or(ent N• y ! 195'1 04656 15877.504 2. T ADE NAME, IF A V I •r I/° (/y Car _L ~~j~~a, Cp.~~~rybr fire /7 `O 3. EMPLOYER IDENTIFICATION NO, OR SOCIAL SECURITY NO. (VOluntarY -ace 6aek o/thta loan) 6. NAME OF COUNT V ~ k 5. AODR ESS (RFD or arrest no., elfy, State, Z/P Code) / S° °~ /V ) , 1x957 l+a~ St'. Orre.lt prr h dl flon d N t t dd i It 5 ~ . rear em ow ree an (f/ no r ree a n , s 6. LOCATIO diatan<e /rom nearest P.O. or city Itmitr) 7, TELEPHONE 3~ ~ 77 BUSINESS NO. (include I~~ ~_a Area Code): RESIDENCE ' Application it made for • UgrvLimited Permit. Fas is 52.00. Cheek or money order should M made laayabls to: "INTERNAL REVENUE SERVICE" R KS WILL BE PURCHASED FROM: 8. FIREW O 9. DATE AND LOCATION OF PUBLIC DISPLAY yy ' Name: LaN'IbOI~) ~r1'AI!r~onalg ~u' ~ f9~f - relnda-l-e. ~ly•~Iq~85" 4 QQ Box IL4~3 ~ Atldreaa: N~ Cosh le I Par f(° 103 ~ Or~er,f Naa-bov~ Orrehf p/; . Telephone No.: , I ~~ ~ / tA~ /" a( C/a O (Inel.Areo COde) ]O. WILL FIREWORKS BE STORED? (See back o//hu /orm) ~ VES ~ NO 11. LOCATION AND BRIEF DESCRIPTION OF STORAGE FACT LITV C~r/ent F-~ Dept. ffdaa---g B~.la~h9 Orr.hal-d 51; Orleht, N`~• 119.7 ~ ~ 12. RESPONSIBLE PERSON(S) (See back o/ th4 /orm) FULL NAME AND POSITION SOCIAL SECURITY NO. (VOluntgry, aee 6aek) NOME AOD RESS PLACE OF BIRTH GATE OF BIRTH R®~ert Cr ec>/es, r Q'Yeh1', N,y 11957 pa-,N ~ 9 ¢o ~~er Na~hawson Q--rent N• I193~ Rye,xy ia7/~f8 (Zoger Tabor Orrerr+ NaYa 11957 ~Ppl•ItN~ j/IS/3/ GI VE FULL DETAILS ON SEPARATE SHEET FOR ALL "V es"ANSWERS IN ITEMS 73 & 14 VES NO 13. IS APPLICANT A. Chargetl Dy information or untlerJw~3:+eMt-Igany court for a crime punishable by Imprisonment fora e ea %'s~ c`c~/J;' tl CR ANV germ ex cee m9 on y r . ;\ NAM OD IN B. A fugitive from justice F~ ~ L °~ X ITEM 12 ABOVE: C. Vntler 21 years of aqe ~"~~, D. An unlawful user of or addict 0 art a~r~any tle Dressant, stimulant or narcotic 16. MAS APPLICANT OR AN V A. Been convicte0 in any coca{t of a crime punishable Ryc~Nnprlsonment fOr a term exceaOlnq p\'o (e: The actual aentence~ai uen 6y ttie, /uIIPe doe~ny. matter-A "Ter"answer is ne ease )))udee could 1'aa"answer L regl~ r/a c~~e lon h ~/~ tljacharaed haoe aiuen a sentence o/ mo~then ortp Ala Y ~ ' PERSON , q ~ . . ~!( y • /~ set oxide, or diamisaed purauan Oan ~~paygerv(yr~O/a rehabtlitalagn dall,~ j ` ' ' ~"~ NAME IN ' ITEM 12 EVER: or been committe4 t{(any menta7~instltut ,1 , B. Been atljutlicatetl as a mental tletective }( ` 15. CE RTIFICATIONr Untler the penalties Imposed by 18 U.S.C. B4q, I tleclare that 1 have examinetl this aDPllcati rpc cots Submitted in support thereof, antl to the best Of my knOWletlge antl ballet, they are true, Correct, antl cOm plate. I also Certify dm familiar with all pu bhshetl State laws antl IOCaI ortlinantts rllatlnS to SPeClal tlrewOrks for the IOUtiOn in which I Intend to tl0 ;buslne T / AP T'S 5 NAT E ,~ ~i TITLE r 1 DAy//~ _ ~ /~/ S FOR USE OF BUREAU OF ALCOHOL, TOBACCO AND FIREARMS ~~- 16. APPLICATION IS REASONS F R TERMINATED OR DISAPPROVED APPLICATION PERMIT NUMBER ^ APPROVED ^ TERMINATED ^ DISAPPROVED SIGNATURE OF REGIONAL REGU LATORV ADMINISTRATOR DATE GTG G CIIrd 11 a f.n]• 7. NAME ORIENT FIRE DEPARTMENT Orchard St Orient, NY' 11957 2. PERMIT NUMBER 3. DATE ISSUED 6-NY-052-37-F6-90979 June 14, 1985 4. TYPE OF EXPLOSIVES 5. QUANTITY FIREWORKS N/A B. ISSUED BV REGIONAL REGULATORY ADMINISTRATOR (Addrw) 6 World Trade Center New York, New York 10048 ----- -----T-~---- Form ApvrovW: oMe No. 1512-0242 USER -LIMITED PERMIT 178 U.S.C. CHAPTER ~a, EXPLOBIVEa) In ~ccordmc~ with M~ Providom of Titb X1, Oryrdz~d Crin~ Control Act of 7970, M~ rpul~tionz IzwW MmunrHr 127 CFR Pin 66), end M~ oonditlon~ Mt forth on dt~ bck of thls pamlt, Veu m wtlrwizW to ~e4uln for uw tits. dweriDW aPIpN~ m~grkN M Inbry4q-or fonipn <ommwe~ end to trampoR ach ~zP1ozN~ m~brktM In Inbr- zten or fwl0n eomm~re~. >»~'1Neminy' on bsk. 1~ Department of the Treasury ~ Bureau of Alcohol, Tobacco and Firearms DISTRIBUTOR'S USE ONLY TRANSACTION GATE I DISTRIBUTOR LICENBE NO. RE OF REGION611iEOULATORY ADMINISTRATOR ISIONATURE OF EDITION OF 7-78 IS OBSOLETE ~-~sN~j~ ~~C~~ ~ kE~ :/ ,,, I n JUDITH T. TERRY TOWN CLERK REGISTRAR OI' VITA1, SPAT Dear Bob: June 24, 1985 Town Hall, 53095 Main Road P.o. BoX 7z8 Southold, New York 11971 TELEPHONE (516) 765-1801 Attached is a Cel-tificate of Insurance submitted to me by the Orient Fire District relative to their fireworks display on July 4th. Although the top area relative to Named Insured does not name the Town as additional insured, the last paragraph refers to additional insured and one of those is "any public authority granting a permit to the named assured." Is this sufficient for me to issue the permit? Please give me a call. ~~~ r7~a~ G'~ ,. •~ ALLIED SPECIALTY INSUR,ANCE,INC. ® P.O. BOX 40250 • ST. PETERSBURG, FLORIDA 33743 'I o l l Free 1-800-iR?-6776 F Loi i coin L Policy Not P65V1554 Certificate No. 4 ` CERT I F IPCA~E~EF ~I N~SURANCE This is to certify that policies in the Warne oft I Named ZAMHELLI FIREWORKS MFG. !Additional Insurer•1 COMPANY. INC. Insured And P.O. FsOX 1463 Address I NEW CASTLE. PA 16103 ! ! ar•e in force at the date hereof, as follnwst ----------------- t<ind of lnsurance F'olicY Numbers Policy Period------ Limi s `FIREWORKS DISPLAY I 65V1554 1 Eff. 1/1/65 I f1~000-000 wC6L LIABILITY 1NSURANCE 1 i Expt 1/1/66 '• ` COMPANY t I I I Balboa Insurance I I ! CoewanY ~ r 1---------------- EXCESS FIREWORKS I I Efft DZSF'LAY LIAErILITY I ; Exp t INSLlRANCL" COt1F•ANY t I ~ j Eff 2 Compa ny t ~ I E:xp t ; 1 Expt +s•CSL - COMPINELr SINGLE LIMIT In the event o•f am' material change ins or cancellation of, said policies, the undersigned will endeavor to give written notice to the p~ar•ty to whom this certificate is issued, but 'failure to give such notice shall !mr>os~ no obligation or Liability upon the company. CERTIFICATE 1SSUET.r TOt LrAI'E: OF DISPLAY July 4, 1985 NAME Orient Fire District RAIN DATE ANIr st Marion Fire District ADIrRE~,~own of Southold, County of DTSF'LAY AMOUNT Suffolk Li]CA'1'ION OF DiSF'LAY Orient Harbor Orient, New York 'this certificate neither affirmativc~l.y nor negatively amends, extends or aLtern the coverage afforded by any potic.Y described herein. NOl'Et Tn.crvtnf rain ar•inctemcnt i.~_ather° prohibits this display. r_overaye will apply on a subse•tuerrt date on which display is held, within the terms of this contract. Cleanup and policing of the display are the r•espon:,ibi lily nF th'~+ Sponsors. 'Ihe toLLowiny are additional insureds; Any lair or exposition. associations sPOnsoriny organization or committee, the owner or Lessen o'f any pr'r:mises used by the Warned assured, or any public authority granting a permit to the named assured, but only as respects accidents arising out of the business operations of the primary assured. Also, as addrtional named in~~ured any independent contractor who 'fires the display on behalf of the assured. - AutFrorixed Signature ..I:y r~~tt 1`~elll9t%r rev ~~'PVf12.S~. Form Approved: OMB No. 1512.0399 (11/30/e6) DEPARTMENT OF THE TREASURY -BUREAU OF ALCOHOL, TOBACCO ANO FIREARMS fOR ATF USE ONLY APPLICATION/PERMIT USER LIMITED SPECIAL FIREWORKS UNDER 18 U.S.C. CHAPTER 40, EXPLOSIVES ~, + / ~® ~~~ /\ /~ / '~' ' ° IPlaaee reed Imtrucflonr on back o/ th4 Iorm) • ' ' NOTE: COMPLETE IN TRIPLICATE. USE TYPEWRITER OR PRINT WITH BALL-POINT PEN. ' 1. NAME (1/DOrtncnhly, include name o/each Dartner) ' Or/u~+~ FjrG DQPf', Orobarcl 9f; D~~ent IY.y !1457 0465615877504 2.T ADyE~NAME, IF A~NS'V ~f ~{ I/p ,Jry CCY 5Tq` ~a/1QY1'11C•dl v0•,~'+1'f6r fll'8 (~. 3.EMPLOVER IDENTIFICATION NO.OR SOCIAL SECURITY NO. (VOlunmrY -ace bock o/thU loan) 4, NAME OF COUNTY 1 k ~ 5. ADDRESS (RFD or rtreet no., city, State, ZfP Code) ro $u N, y, !1957 llar~ Sh. Qrlent Qrr dlreetlon and t i it h ON t dd 5 C J / . ~ reu em ow ( / no a ree o n , s 6. LO ATI - dGfanee Irom neareat P.O. or clly limits) ), TELEPHONE ~~ - 77 Q7 BUSINESS NO. (include IIP~ 3~a Area Coda): RESIDENCE Application is made for a User•Limitad Permit. faa is 52.00. Cheek or money order should be made peysble to: - "INTERNAL REVENUE SERVICE" R KS WILL BE PURCHASED FROM: !, i1REW O 9. DATE AND LOCATION OF PUBLIC DISPLAY yy ' Nam.: L.a/l'16~11~ S'rl~rna~-~ona~e ~~( ~ 148E - relnda+t •~u~r~lg8s 4 RQ Box I L4 ~3 / Address: ~~ Ca 5'} le I Par ((0103 t~ pr~e>ti-F Fla,-bov; Orleh$ /~% . ra.Pnone NO.e ~!!t?-6,58-~6/l (Incl. Ane Code) ,. 10. WILL FIREWORKS BE STO RED7 (Sae back of thu /arm) ~ VES ~ NO 11. LOCATION AND BRIEF DESCRIPTION OF STORAGE FACT LITV Oren t F-~ Dept. Flda~---s B~. I~ ~ h 9 ` /' 119.7 a ~ O--chard St; Orient, K' 12. RESPONSIBLE PERSON(S) (See back oI th4 /arm) FULL NAME AND POSITION SOCIAL SECURITY NO. (Voluntary, see back) HOME ADDRESS PLACE OF BIRTH DATE OF BIRTH Robert C' eeves, r L1'Yeht, N,Y 1195 pDa',K i 3 ~o fl:~er N~+laaso-+ Q,.lenfi'; N. 1 Iqs~ Rye.Ny i a9/y8 Kotler Tabor I Orle1,+ N'yr 1195'/ GILAp„pDjfirN~ j/IS/3/ i GIVE FULL DETAILS ON SEPARATE SHEET. FOR ALL "Vez" ANSWERS IN ITEMS 13 & 14 VES NO I 13. IS APPLICANT A. Cnarged by information or untlerjntpillwieh_`iR any court for a crime punishable by Imprisonment for a " , • c c;iJ<' ~ ~- /~ CR ANY G - ~ ~ term exceed mg one Year _ : PERSON NAMED IN B. A fugitive from justice ~ ~,\ r `, J~ ITEM 12 ABOVE: C. Untler 21 years of age ~"'I!, ) D. An unlawful user of or addict d ari a~~~any depressant, stimulant or narcotic 14. HAS APPLICANT A. Been convictetl in any Cou{{t Of a Crime punishable qy''+A+LI DrisOn meet fOr d term ezceedlnq !A'o fa: The actual s¢n t¢nce`eiun by ttic/u~¢e doe~t-nq! matter-A "1'er"answer is ~ne{'ease ud¢e could J ~ ~ OR ANV y~lsehar¢ed, hm'e ¢ioen o rent¢nce of mo~than one.Yee)r. A~aq;~'1'ea"anrwer is rea~ r/a cd.(~~ion h ff ~ ' ~ ~ ~ ~ j PERSON agerdyrjfola rehobi(italipn dotu set aside, or diamiased pursuant~to an 2;~D h ~~ /~ ! NAME IN ITEM 12 EVER: 8. Been adjudicated~es d mental Defective Or been committed Many mentaFinstitut )t I 1t ; ~ \ ! 15. CERTIFICATION-Untler [he penalties imposed by 1B U.S.C. 844, I tleclare that I have examined this applirati d dot cots Submitted I{ in Support thereof, antl to the belt of my knowletl9e antl belle!, they ere true, Wrrect, antl CDm Dlete. I a150 certify am familiar with dll I Ou bbzhetl State laws antl local ortl finances relatln5 to specie! fireworks fOr the Laotian in which I Intentl t0 do.busine Ti AP T'S 5 NAT E y J TITLE S 1 DA y~ ~ ~ FOR USE OF BUREAU OF ALCOHOL, TOBACCO AND FIREARMS ~~• 16. APPLICATION IS REASONS F R TERMINATED OR DISAPPROVED APPLICATION PERMIT NUMBER ^ APPROVED RM NATE ^ TE I D PPR VED ^ D ~ ~' ISA O ~ ! SIGNATURE OF REGIONAL REGULATORY ADMINISTRATOR DATE i 4 ~ o 1. NAME ORIENT FIRE DEPARTMENT Orchard St Orient, NY' 11957 2. PERMIT NUMBER 3. DATE ISSUED 6-NY-052-37-F6-90979" June 14.,.1985 4. TYPE OF EXPLOSIVES 6. QUANTITY FIREWORKS ~- ,N/A 8. ISSUED BV REGIONAL REGULATORY ADMINISTRATOR IAdarp.) 6 World Trade Center New,YOrk, Newyork 10048 7. NATURE OF REGION EGULATO ADMINISTRATOR t ATFFORM 470915400.6) (6r83) EDITION OF 7.78 IS OBSOLETE ~ ~, `i . ,~ Form Approval: OMB No. 15~Z-11242 USER -LIMITED PERMIT 11B U.S.C. CHAPTER 40, EXPLOSIVE In xcortl~ne~ wiM Mo PrqulUom of 71t1~ X1, Orpr~Wd Crkm Cont Aet of 1970, tho rpulotiom laual MonunMr IZ7 CFR hrt 66), Ms oondition~ tat forth on the Dack of thh D~rmlt, You m wlhorit to ~equln for up tn~. dpcribal o~PlotNtr m~prk~h ti tntNStlp fonipn comm~rco end to tr~mport ach ~zplocN~ m~prMh In Mt snn or fwipn eommwcw S~~'MV~minp" on bRk. ..... ~' Department of the Treasury ®, Bureau of Alcohol, Tobacco and Fiream-s DISTRIBUTOR'S USE ONLY TRANSACTION DATEDISTRIBUTOR LICENSE NO. SIGNATURE OF DISTRIBUTOR APPLICATION T0: JUDITH T. TERRY, TOWN CLERK, TOV7N OF SOUTHOLD APPLICATION IS HFRRBY MADE, pursuant to the pro- visions of Section 405.00 of the Penal Law of the State of New York, for a permit to display fireworks as hereinafter specified: The display is to be sponsored by . ~1v- Yu~~ ~-.' gyn. ~r/av~`wK r ,.with pri//ncipal office at Qv~,(,d-~'?~ Dv ~- ~ New fork, and will be held on % /~ur9. , J~--I ~/ - day Tmonth 19 ~5~, at - =d ~ P.M. hour RAIN DATE: _ .Tu /~ S i 4 ~" 5 The following persons are to be in charge of the actual shooting of the fireworks: Name ''// /fir Irv ~a /7~a,~ty ~~ Experience S-yrs• yYS / ~y~s Physical Condition ~eec~/ ~~ r~ Num ber and rks ewo pe of fir t y o ws : is as fohl L 7LCN.1 //'~// / / -r~~t/aiV bd / %~•r/ray ~ n // ` / ~1f~[ WOY ^-S l ~ . ~y~ / y ~ 7~V SRO/ s The fireworks will be stored in a covered truck prior to the shooting on the grounds. 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. Respectfully submitted, name of organization By ~ rr ~ti•Y/= Dated: ~ii.NL' 02 y- f I ~-~~ at ~~o k. 0 New York. EUTABETN ANN NEVIUF ` ppTARY PUBUC, Stets of New Na S?$125fi50, ~ ~, Term Fxpiree Mucb 30.1 ~ 1~ ~• •• • .' i ~ ~ ~- 3 F; v e Wd ~, ~~ ~i c~/a ~ ~ A T / ~ ~6K5 ~'S faK~ Sa~~ ~ / /~ ~~~ :a. \\ '% f, ~ , : ~ ` QQ ~ ~y. ~ ~{ /}"R. ' ~~ ~_ r .l ~~ •.. ' '~ 3' -; `, S;Te. o F •,~ ~ ~ ~S ~ . ~` .~ .-cw~~ ~. `.. '~.. ,~ ~.. Low eat S7a~e 7a ~ ~a 1rc~:N p rs (3ay