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HomeMy WebLinkAbout1969 rc~:a a~ sosrrx~ ~'~E~°4IT -CsR 1'61D7.IC AYdPY.7\Y d'+' FiEil^'1C~tRf: I, ALRRERT 4i. RiCEA30A~, Tc+7n Clark of thi~o ^a:vn .. ; Bauthnld, duiiol~ County, mew Yozk, being kk-a officer duly dseignntng !7y the Tamrn komrd of the Togrn of iBauthold for tha purpvaa, i ~ RRY Qr~+r g~g,~q OYSTER PONDS CHEMICAL CO. A ffRF'3'!i? X'~ TiTIS P.YC DBEfpI.AY C7 1-IPt.""'3Q~1X8 by Raid oxganl:>-. atia~n in accax4ance with the prcbieiaaur of Emctic7n .1f~94-a of the Panal E~+ of ~`.he t9tate o! po^+r Ycrk~ on July t}~1969 8:3(~ P.D Rain Date-July 5,~196~ at the tix7m at4d place r,®t forth in the applioatian kherefcxr.. ! Permit granted I on canditian that thca bond (1s~8emssitY inanrance) re$.71rod shall continue in lull !ores assd effort 1n Pavor ai the i 'poan of ascmthold. Data7d at foothold, P9rov Ycark~ then 25th ____ dray of June , i 1 A~5 9 --- i vial St q. A1;'tamo7>a1, t •":atl i t47' V. 'P`aaT- aP ~9cnathoid, cs+:.,*?c, '_T "•y+~: 1:ae~ Ycrk, ~i !, A L i L r '~~ ~!", .' '~ _~~~ ~. i 1 r---- i ~~ ~ ~ p b n I ~ n 'T ~ i t I I I r ~ ~ aA ~tF~ ~rfR i~//v G• i `h, /F/f~-1~i %(~'S v~Y r ,t3q ~ i.- S 7-R e e ~- 5 ~ .c rc• 4 . I 0 ~' X Cam-- P7 ~ c?..~' i l-//~~ N t% P ~ ,Ps ~„¢ e ~.. ~ ~ ~ ~_ %~ ~ f FLOYD F KING JR. 120175 EA:JER CHANGE ENDORSEMENT ae:m atLa•zs (Ed. 11 -6a) This endorsement is made a part of Policy No. tz SMP 300849 of the HARTFORD FIRE t Noma of Isanraace Comyssy - and becomes effective on 0 7 / 04 / 6 9 at standard time at the location of the d -b d rt CDate) escn a grope v- ORIENT FIRE DISTRICT & OYSTERPONDS CHEMICAL CO. Name of Insured Location of Premises and Occupancy Policy Term: 3 years, From 2 To 7 Loss Ded. CI. No. 1 applicable; Loss Ded. Cl. No. 2 applicable; Other (specify) Forms and Endorsements applicable: It is agreed that: (a) The policy is amended as follows: SEE ENDORSEMENT ATTACHED (b) With respect [o those coverages and kinds of property for which a specific limit of liability is shown, the limit of the Company's liability shall be changed to read as stated in the Limits of Liability columns herein. Such limits are in lieu of the Limits of Liability stated in the policy and not in addition thereto. SECTION I -PROPERTY COVERAGE Coverage LIMITS OF LIABILITY PREMIUM S Daecrip- lion Loc. No. Bldg. No. previous Limit New Limit Old Rate New Rate Old Premium New Premium ^ Add'1 ^ Return - - $ $ $ $ $ - - $ $ $ $ $ SECTION II -LIABILITY COVERAGE PREMIUMS ~ Add'1 Coverage Limits of Liability Old Premium New Premium ^ Return C. Bodily Injury & Prop- $ $ $ $ $ erty Damage Liability each Occurrence Aggregate 7 5 . 0 0 D. Premises Medical $ $ $ $ $ Payments each Person each Accident FIRE ORKS DISPLAY TOTAL$ ~~'"" PREMIUM RECAPITULATION Dve at Endorsement Effective Date: ~ Additional Premium ~ Return Premium $ 75.00 ~$ Premium adiuatment if the Premium is savable in annual installments. Dates Due Original Inatallmenta Increase Decrease Revised Iaetallments $ $ $ $ $ $ $ $ Total Premium to Policy Expiration $ 7 5 , 0 0 $ s ~fiy ~J' ~!~~n Agency By ~ J/ Form MLH-20 (Ed. 11-69) FLOYD F KING JR 12 SMP 300849 ' Thisendorsementformsapaztof Policy No ............................................... issued by THE HARTFORD INSURANCE GROUP company or companies designated therein, and takes effect as of the effective date of said policy unless another effective date is stated herein. 120175 EA:JER Named Insured and Address ORIE-SST FdRE DISTRICT b OYSTERPONDS CHEMICAL CO. Effective date ......... ~ 7 ~ ~ 4 ~ 6 tj.. .. ..Effective hour is the same as stated in the Declarations of the .............. Policy. THIS ENDORSEMENT PROVIDES COVERAGE OF SECTION 1894-A PENAL LAW OF THE IN CONSIDERATION OF AN ADDITIONAL PREMIUM IT IS AGREED THAT COVERAGE IS AFFORDED FOR A FIREWORK DISPLAY VILLAGE WHARF, MAIN STREET, ORIENT, THE TOWN OF SOUTHOLD. UNDER SUBDIVISION 5 STATE OF NEW YORK. UNDER SECT. II LIAB. BY THE FIRE DEPT. ON N.Y. IN BEHALF OF AS RESPECTS THIS EVENT, THE TOWN OF SOUTHOLD IS AN ADDITIONAL NAMED INSURED, IN THE EVENT OF RAIN ON THIS DAY, COVERAGE WILL BE AFFORDED FOR RAIN DATE: JULY 5, 1969 Nothing herein contained shall be held to vary, waive, alter, or extend any of the terms, conditions, agreements or declarations of the policy, other than as herein stated. This endorsement shall not be binding unless countersigned by a duly authorized agent of the company or companies; provided that if this endorsement takes effect as of the effective date of the policy and, at issue of said policy, Corms a part thereof, countersignature on the declarations page of said policy by a duly authorized agent of the company or companies shall constitute valid countersignature of this endorsement. THE HARTFORD INSURANCE GROUP n _.,. "~ HARTFOND CONN ECiICUT Form G-3310-9 B Printed in U. & A. t-'64 Hartford Fire Insurance Company New York Underwrltere Insurance Company Hartford Accident and Indemnity Company Twin City Fire Insurance Company Citizens Insurance Company of New Jersey Counk>signcd 6y .............f/.......... ...~/..... .. ~ ............... .......... .•. Authorised Agent THE HARTFORD +, INSURANCE GROUP CERTIFICATE OF INSURANCE FLOY D F KING 120175 a m Hartford Fire Insurance Company v ®New York Underwriters Insurance Company E A : J E R m Hartford Accident and Indemnity Company `-' QI Twin City Fire Insurance Company '= ®Ci[izens Insurance Company of New Jersey '~ Co. Code 'Phis is to certi[y that the company designated J herein by Co. Code has- issued to the named insured [he policies enumerated below. Named Insured and Address ORIENT FIRE DISTRICT AND OYSTERPONDS CHEMICAL CO ORCHARD ST l ORIENT NEW YORK The policies indicated herein apply with respect to the hazards and for the coverages and limits of liability indicated by specific entry herein, subject to all the terms of such policies. Coverages and Limits of Liability Hazards Policy ElfeCtive E%pire[ion Bodily Injury Liability Property Damage Liablllty Number Date Date ]~][ ~I~x *each occurrence *each occurtence aggregate General Liability Premises-Operations-Elevators 1 2sMP3oo849 7/4/69 7!5/69 $1 , 000,000 $ ,000 $ ,000 $1 r DD~00 Independent Contractors $ ,000 $ ,000 $ ,000 $ ,000 Completed Operations; __ $ ,000 $ _ ,000 $ ,000 $ ,000 Products Aggregate: $ ,000 XXXX XXXX Contractual (as described below) ___ $ ,OOO $ ,000 $ ,000 $ ,000 Automobile Liability Owned Automobiles $ ,000 $ ,000 $ ,000 XXXX Hired Automobiles $ ,000 $ ,000 $ ,000 XXXX Non-Owned automobiles $ ,000 $ ,000 $ ,000 XXXX Workmen's Compensation and Employers' Liability Compensation Statutory Employers' Liability -- $ ,000 Umbrella Ljability $ ,000,000 *If with respect to Automobile Liability the Policy Number entered above includes the symbol GB, A7„ MVP, MAG or PGB, the word "occurrence" is amended to read "accident". Location and description of operations, automobiles, contracts, etc. (For contracts, indicate type of agreement, party and ate. COVERAGE IS AFFORDED FOR SETTING OFF A FIREWORKS DISPLAY ON VILLAGE WHARF, MAIN ST. ORIENT, N.Y. IF BY CHANCE THIS EVENT IS RAINED OUT, COVERAGE WILL BE AFFORDED FOR JULY 5, 1969 10 DAYS ~ TOWN OF SOUTHOLD If policy is canceled, written notice will be given to: (l $ 0 U T H 0 L D , N . Y . Date By ............................................................................................................ Authorized Representative Form AL-@-0 Pranced in U. S. A. 7 '67 • APPLYCATIGl7 TOa ALSffitT N. AICEMODID, "1'~PN CLERK, '!'OIPN Qp' 800'PHU3,D APPLtCi-TIOI~ I® ~SY MADB. pursuaAt to the pro- visions o! section 1894-a of the Penal, ran a! the State o! Keo- Y~prk, tar a persdt to display lire+aorks as hesainalter specified: The display is to sponsore8 by ~y_ S~~ /~j~j/~S -r'H~( (~, '~, • with Principal o!lica at ~~('/~N7~ >~ Nov 7ork, sad will be held oaa y~~, ~~ ~ t~-Y) sa~th) 196_2, at ~' 3o P.1~[.. - ~'r9/.r/ Di}TE (hour) -rif ~~ 3 / 96 j The lolloving persons are to ba in charge o! the actual shooting o! the lirewarlula Naune ~a Exneriencs Physical condition if o8~_;,T. nrzu >.(A~~ 5~S ~_2,y,~.~ Got~o f~, i~°~-!~!O~ ~~ /,3 '' tree d RDG,E~ V T,.9~ ~, - // ~' Goo D Ntuober sad typo of lireworks is as lolivwso -~LL.~ffl___.J~Ya.L~ - L.c S .E,C~S ,,,, -1~~~111f.~.T.E D, L _.~~....,....,,..~..~...... ~....,.M..~....~....~......~.~~.... The lirewarks will bb stored in a covered truck prier to the shooting on the groaads. Attached hereto amd sada a part hared! is a diagram of the gronnd• on Nhich the display is to be held. Also attached is the certificate ar policy o! insurance coverage. kespectfully submitted, (n/an~o o! alrganisation) natea~__~u~r%E ~ ~~~ 9 at ~'~'~~T Now Yar' `'.~,,,. ~V 4.a' F~ ~. x _ rr'w i_ y ;... - .FIRE WORKS INSTRUCTIONS h~ Name of body sponsoring. display. 2. The date. and time of day at which the: display is to be hell. 3. The exact location planned fora the display.,, 4. The age experience-and physical. characteristics of the persons who are to ,do the actual sischarginq of the , fireworks: 5. The number and kind of fireworks to be discharges. 6. The manner and place'of storage of such firewosks prior to the display. 7. A diagram'of the grounds on which .the idisplay is'to be held. showing the point at which the frewor&s are to`be discharged, •. the location of all buildings„ highways and other. lines of communicat,ion,.the lines behind which the audience will be restrained and location of all nearby trees, telegraph lines or other overhead-obstructions.. '; 8. Such other nfotmation as the permit authority may deem necessary to'protect persons `and property. 9. Bond. of not less than $50,000 per person for bodily injury, $100,D00 per accident,-$25,000,pevperty damage,. shall run to the Town of Southold for use and benefit of person who is injured ox person whose property is injured. Bond must be conditioned for payment of all damages which may be caus«- ed to .persons or property by reason of display of fireworks and aiiging f~com acts of permtee,'agents, employees; cones tributors or-.sub-»contributors. (Subdi:vision 5.of Section 1894»x) (Penal Law of the State of New York} , l0.In 11eu of Bond, Town may accept an indemnity insurance p~licy with liability coverage and indemnity protection equivtslent to said Bond. l1. The Tobin . o£ 'Soutkiold must have:~pili~c'~ in its, possessign p~rm't i$ issued."~ Tne. ntuned insured must re~as ''TOWN QF SOUTF~hD. 12.Last y to ~`le applict~gn-~o,T~7itth -di~g~ay is ~ne ~., i`9~~G..-- Z .