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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 FIESTA TIMES SHOW & SOUTHOLD-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 FRIDAY, AUGUST 17,-1979 - .10:30
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 Southo
DATED at SOUTHOLD, New York,
this 17th day of August 197.9.
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DITH T. TERRY; T Clerk
Town of Southold, Suffolk
County, New York.
~ ~S '~ A L
~~ FRANK B. HALL & CO.
Formerly tllorrh H. Kaliff fr Soo
1100 N.E. Loop 410
San Antonio, Texas 78205 -Telephone 512 -825-1211 oc I-800-531-7354
CERTIFICATE OF INSURANCE
This is to certify that policies in the name of:
r ~ r
Named ZAMBELLI FIREWORKS MFG. CO., INC. Co-Insured
Insured AND SPONSORS, PROPERTY OWNERS
and OR MUNICIPALITIES AND ADDITIONAL and
INSUREDS
Address P. 0. Box 801, New Castle, Pa. 18103 Address
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are in force at the date hereof, as follows:
J
Kind of Insurance Policy Numbers Policy Period Limits
FIREWORKS DISPLAY Eff: 3.15-79
LIABILITY INSURANCE GLA 466482 E~#X~Tfi-3~ ;t00,D00.00 CSL"
Company: Exp: 3-15-80
Empire Fire & Marine
Insurance Company
Exp: 3-15.80
EL 101911 ]~~K ;900,000.00 CSL•
Company: Eff: 3-15-79
Excess Insurance
Company, Ltd.
Eff: TOTAL LIMITS:
Exp: ;1,000,OOD.00 CSL•
Company:
csc - t:omomett sntgle umrt
In the event of any material change in, or cancellation of, said policies, the undersigned company will endeavor to give written notice to the party
to wham this certificate is issued, but failure to give such notice shall impose no obligation nor liability upon the company.
CERTIFICATE ISSUED T0:
NAME DATE OF DISPLAY August 1$i 1979
AND Fiesta Time Shows
ADDRESS Southhold Fire Department RAIN DATE
Southhold, Long Island, New York
AUTHORIZED SIGNATURE
D(SRf®Tt A'MOt~
LOCATION OF DISPLAY Fire Dent Grounds- Ro r P #
This certificate of insurance neither affirmatively nor negatively amends, extends or alters the coverage afforded by any policy described herein
NOTE: In event rain or inclement weather prohibit this display, coverage will apply on subsequent date on which display is held, within the terms of
this contract. Cleanup and policing of the display are the responsibility cf the Sponsors.
The following are additional insureds: Any Fair or exposition, association, sponsoring organization or committee, the owner or lessee of any premises
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
..~usiness operations of the primary assured. Also, as additional named insured any independent contractor who fires the display on behalf of the
:;,.::tired.
N° _ 3852
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~'Y1rEE ~=r P~.~c
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the CrystaLine A)anufacturinq Company, Inc.
700 Boisseau Avenue Southold, New York 11971
~ ~ ~ ~ ~ ~ ~ Tel.: (516) 765-1844
ESTABLISHED 1920
august 15, 1979
To slhom It May Concern:
Permission is granted to the Southold Fire Department
to use our premises for the purpose of a firz-works
display. Icy only condition is that a bond (indemnity
insurance) covers me
the Town of Southold.
The same insurance also covers
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~. G. I'dorkus
President
ftGid/an
APPLICATION
T0: JUDITH T. TERRY, TOWN CLERK, TOWN OF SOUTHOLD
APPLICATION IS HEREBY 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 ,F/~ST~} T//11.~f Sl~~
~8- SGrnT1fGAD ~//+.~ ~~PT ~ with principal office at COf{
New York, and will be held on
d y month
1g~, at d 3~ ~~ P.M.
hour RAIN DATE:_
The following persons are to be in charge of the
actual shooting of the fireworks:
Name ~ ~N y ~ Experience Physical Condition
-fir C~i~'PT CbIT-% i ~ 0?0 ~.,,~~ GAG ~ O
~~'~I Nil .C ~T~~= Qk <- 3~" ~~~~~ Cs- 6a />
Number and tyke of fireworks is as follows:
k'r~ G!~-~ , c` H~ ~ L f
<lv 'tom ~JA ~ F SNE~ ~ J
The fireworks will be stored in a covered truck
prior to the shooting on the grounds.
Attached hereto and made apart 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 organizatio
By ~
Dated:
at
New York.
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