The URL can be used to link to this page

Home My WebLink About2007 ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PERMIT for PUBLIC DISPLAY OF FIREWORKS 1, ELIZABETH A. NEVILLE, 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: THE EVENT STORE 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 SATURDAY, OCTOBER 6~ 2006 at 10:00 P.M., on a barge on Southold Bay off Old Field Vineyard, Southold, New York 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 building, public highway or railroad, or other means of travel, and at least fifty feet from the nearest above ground telephone or telegraph line, trees 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 in the air as nearby as possible in a vertical direction unless such fireworks are to be fired from the shore or 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 conducted shall be immediately disposed of in a way safe for the particular type of fireworks remaining; that no fireworks display shall beheld during any wind storm in which the wind reaches a velocity of more than thirty miles per hour; that all 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 constantly on duty during the discharge and that at last two soda acid 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. (Town Seal) Dated: October 5, 2007 Elizabeth A. Neville, Town Clerk Town of Southold Suffolk County, New York THIS PERMIT IS NOT TRANSFERABLE ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FAX TRANSMITTAL To: From: Dated: Re: Edward Rubio Linda J. Cooper, Deputy Town Clerk October 5, 2007 Fireworks Permit for The Event Store Number of Pages (including cover): 2 If total transmittal is not received, please call 631-765-1800, Ext 210 COMMENTS: Page 1 of 1 Cooper, Linda From: Fisher, Robert Sent: Thursday, October 04, 2007 11:1 To: Cooper, Linda Subject: Old Field Vine Fireworks Permit Linda I have no objections concerning the permit application for the fireworks show off shore at Old Field Vineyard in Southold. Robert Fisher Fire Inspector robert.flsher~town.southold,ny.us 10/4/2007 POLICE DEPAI:2TMENT TOWN OF 80UTIIOLD CARLISLE E. COCHRAN, JR. Chief of Police Telephone Emergency Dial 911 RECEI¥2D TO: FROM: DATE: RE: Linda J. Cooper, Deputy Town Clerk Chief Carlisle E. Cochra~ Jr~--~'/ October 2, 2007 Request for Special Permit - Fireworks - The Event Store at the Old Field Vineyard, Southold - Saturday, October 6, 2007 I have reviewed the above request for a special permit. I have no objection to the approval of this permit. cc: Capt. Martin Flatley 41405 Route 25 · P.O. Box 911 · Pcconic, N.Y. 11958 Administrative (631) 765-2600/2601 · Fax (631) 765-2715 Page 1 of 1 Cooper, Linda From: Spiro, Melissa Sent: Wednesday, October 03, 2007 2:10 PM To: Cooper, Linda Subject: Fireworks Permits for the Event Store off Old Field Vineyard I have reviewed the Fireworks Permit application for the Event Store off Old Field Vineyard. The fireworks are located on a barge on Southold Bay off the Old Field Vineyard. Since this is not preserved land, I have no comment on the application. RECEIV~.D Melissa Spiro 2007 Southold Tc, wn Clerk 10/3/2007 ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldtown.nor th fork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: From: Dated: Re: Chief Cochran, Southold Town Police Department Robert Fisher, Fire Inspector Melissa Spiro, Land Preservation Linda J. Cooper, Deputy Town Clerk October 1, 2007 Fireworks Permits for the Event Store off Old Field Vineyard Transmitted herewith are applications for Fireworks Permits for The Event Store off Old Field Vineyard Please advise if the permit may be issued. Thank you. cc: Southold Town Board /28/2007 14:58 FAX FAX ~o01/o1~ FIREWORKS BY To: Linda Cooper From: Ashley Barone I Logistics Assistant Pages: 1 Fax: 631-765-1823 Date: 9/~/07 Phone: [] Urgent r'l For Review [] Please Comment [~ Please Rep~ Linda, Please find attached the application packet for the Event Store on October 6, 2007. If you have any other questions, please feel free to contact me. Thanks, Ashley Barone Logistics Assistant Fireworks by Grucci 09/28/2007 14:58 FAX ~002/013 September 21, 2007 TO: COMPANY: ADDRESS: EMAIL: Pt-lONE: FAX: FROlV~ TOTAL PAGES: Elizabeth Neville Office of the Town Clerk 53095 Main Rd. Southold, New York 11971 e.neville~own ,sourhold, ny. us 631-765.1800 631-765-6145 Eclwmi Rubio 9 Dea~ lv~. El~.~ed~ Neville., Re: The Event Store, at The Old Field Vineyard) Southold, NY October 6, 2007 at approximately 9:ISPM Attached hereto please Fad the followi~. 1) at,plication copy 2) FAA. Letter 3) Letxer to Sponsor 4) Site?lan 5) Shell Count 6) C.~ffic-~e of Inmrmce 7) Chief Pyrotechnician Data Sheet 8) Letter of permission to use land for disphy ~//,~ A~ q~e~ons ple~e ~iv¢ me a call Thankyou for all)our help, Edward Logistics Manager Fireworl~ by ~ Inc. Cell 51&658-4456 Fireworks by Grucci, Inc. One Gmcd I Brookhaven, NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-mail: embio~grucci.com THE FIRST FAMILY OF FIREWORKS 09/28/2007 14:59 FAX ~003/013 OFFICE OF -~'-~< TOWN Ct.~..~K TOWN OF SOUI'HOLD APPLICATION PERMn' TO' DISPLAY FIREWORKS APPLICATION Lq I'I~REBY MADE, pursuant, to the pmvisiom of Seainn 405.00 of thc Penal law of th~ State of New ¥~rk, for n pm'mit to display fimwor~ as hereinafter s~ecified: DISPLAY IS TO BE SPONSORED BY The Event Store PRINCIPAL O~'~1C~ AT 55 Route 48 Mardtuck. NY 11952 DATE & TIM~ OFDI~PLA¥ ~.tnhnr n. pnn~.~n.~a~or~/4~ O~P'¢/ ExAct LOCATION OF DlSiq.,A¥ Barge on SouthoId Bay off the old field vineyard ~ DATE & TI]~ N/A The felluwi~g Wr~ens .,~ to he i- .~ar~¢ of' ~,, -~,..,I sheedag of ~he flmwerb: Name Age Experience lrnYqml CondM0n ANTHONY S. CAPRI 44 lO YEARS EXCELLENT WES PHILIP JR. ,~6 3 YEARS EXCELLENT TBD (Additional nam~ and information may be ~bmJlted on m o__"~_~hed s~eet Number and type of firewoFks is as follows: Grucci Grand Illuminations- 2970, 2.5-3"- 1000, 4"-340~ 5"-~S0, 6"-160 Manner and place of meade et Ileewerks prior to tibplm/: In a DOT apProved-company Vehicle oackaaed oer DOT reoulations and 24 hour ~ecurRv from time of arrival until deoarture Attached he.to and made a part of hereof ts,a diagram of lhe gt~nds on which the display is. to be held. Also Ml~ehed Is a certificate.or poltey of in~ursmee coverage. NOTICE; Wrftteu permfe~ian, with signature of the PFoDeflv Owner, must be submitted with tlie Appileagan. By Neme of Orsaab~on Si~ of Appli~nt Date of Application 09/28/2007 14:59 FAX ~004/0~3 September 21, 2007 TO: COMPANY: ADDRESS: E-MAIL: PHONE: FAX: FROM; TOTAL PAGES: Rich Horrocks FAA North Eastern Region FAA Southern Region Headquarters System Support Eastern Service Center PO Box 20636 .~rhnra, GA 30320-0631 Rich. Horrocks~taa.gov 404-305-5619 4~34-305-5572 Edvard Rubio 1 Dear Mr. Hon'ocks: Plebe be advised of the following Fireworks display~ Evenl2 Dare Rain Dare: Location: Longitude: Time: Th~ Event Store October 6, 2007 N/A Barge on Southold Bay off The Old Field Vineyard 41° 4' 9,40'2~T 72024, 11.44'~7 9:15 PM for duration of 6 - 7 minutes The maximum altitude of the Fireworks will not exceed 900 feet, In letm' form, please acknowledge the receipt and approval of this notification. Thank you for your prompt reply. Thank You, Edward Rubio by hc. ~ 516-658-4486 Fireworks by Grucc/, Inc. One Grucd Lane Brookhaven, NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-mail: ERubio~gmcci.com THE FIRST FAMILY OF FIREWORKS 09/28/2007 14:59 FAX ~005/013 September 21, 2007 Barbara Hock The Event Store 55 Route 48 Matdtuck, NY 11952 Re: The Event Store, at The Old Field Vineyard, Southold, NY October 6, 2007 at approximately 9:I~PM Dear Ms. Hock: Endosccl, please find the Town of $outhold display permit application for the Fireworks Display specified above, Insurance certificate, site plan, shell list, chief wrotechnician sheet and copy of FAA Letter for your event. Please complete the "Sponsor" Portion of the form, sign it and return it to the Town Clerk's Office as soon as possible so they may process the perm~ The address is as follows: Elizabeth NeviUe Office of the Town Clerk 53095 Main Rd. Southold, New York 11971 If you have at~ questions, or ff I can be of furdher assistance, please do not hesitate tn comact me. Thank you for your help and cooperation in this matter. Sincerely, Edward Rubio Logistics M~ger Cen 516-658-4486 Fireworks by Grucci, Inc. One Grucci Lane Brookhaven, NY 11719 Office #: (631) 286-00gg Fax #: (631) 286-9036 E-mail: EPoabio~grucci, com THE FIRST FAMILY OF FIREWOI~I~g 09/28/2007 15:00 FAX ~oo5/o13 FIREWORKS BY GRUCCI. INC. SITE INSPECTION REPORT Program: The Event Store Show Date: 10/6/07 Steging Area/Address: ]~arge on Southold Bay off the Old Field Vineyard. Southold, NY l~vont Cong~ot; Phone; 631-$13-2978 Fire Marshal: Phone: 631- Barbara Hock, 55 Route 48, Mallimck Southoid Town l~in Date: TBD 631-291-9159 631- Fireworks Dis ia Area Max Disolav Site NFPA 1123: 70' per inch, 4110' Safe~y Zone US Coazt GuardRe~,~lation$: 100' per inch, ~00' Safe~ Zone Maximum Aerial Shell Diameter: 6" (Inch~s) ] Can Illuminntionz bc used? Yes SITE I~SPECTION: DISTANCES: Illspccr. cd by: SC Audicncc: 700'+ Vehicles: 600' DaTe: ~f25/07 BuildinK Occupied: 800'~- Ovei'hcad Ob~'trocdons: Timo: 2:00pm Building Unoccupied; n/a Trees/Shrubs: Latitude; 41°4' 9.40"N Longlmdc: 72024' I 1.44"W Tb~ Evznt Store, Southold, l~ - 60ct07 - .~iteplan.ppt 09/28/2007 15:00 FAX ~007/o13 September212007 Re:TheEvent Store- Barge on SoutholdBayoffTheOklFieldViney~l 59600MalnRoad, Southold~NY October 6,2007 -nt9:I.~PM SHELL SIZE NOT TO F_.XCEED 6'~ SHELL SIZE: QUANTI'IW IN PCS. Orucci Grand Illuminations - 2970 2 ½ - 3" 1000 4' 340 5" 250 6" 160 8" 0 10" 0 12" 0 Assorted a~rial shells consist of CNTsanthmmm's, Comet's, Peony's, Tnanium Salutes, Palm Trees, W~iows, etc.. Ymmitun Salutes are limited to 3' only. Total: Not to exceed 1750 Amial Shelh and 2970 IIlumintt/ons Type: Fil~worim UN033~ (Display Fireworks) (F.~losive 1.30) F/reworks UN0336 (Spec/al I/fleets) (Explosive 1.4G) Tlaank You, Edward Rubio Fir~onVa by Grucd, [nc Cell: 516-658-4486 Fireworks by Gmeci, Inc, One Greed Lane Brookhaven, NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-maih ERubio@gmcci,com THE FIRST FAMILY OF FIREWORK~q 09/28/2007 15:00 FAX ~008/013 A ORD., CERTIFICATE OF LIABILITY INSURANCE Bri=con-Gallagher and Associates, Inc. 6240 SOM Center Rd. Fireworks By Grucci, Inc. and/or Pyrotechnique By Grucci, Inc. and/or Philny Effects, Inc. One Grucci Lane Brookhaven NY 11719 COVERAGES THIS-CERTIFICATE IS ISSUED AS A M~ITER OF INFORMATION ONLY AND CONFERS NO RIGHT~ UPON THE CERTIFICAT~ HOLDEI~ THIS CERTIFICATE DOES NOT AMEND, E)~FEND OR ALTER THE ¢OVER~.OE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE ~S~q~aD:A~(is Sur~luB Ins Company A o~E~ 5990~84 2/17/2007 2/17/2008 . .-- PE~L6~VI~URY ~, 000, 00~__. __ o~E~ ~ nnn nnn g A~O~Bl~ mBl~ 1~62659114 ~/17/2007 2/17/2008 C ~~AN0 I267397~ 11/29/2006 [1/29/2007 I [~Uu~sl I~ LL D o~ EAUT06151 2/17/2007 ~/1~/~008 $4,000,000 CERTIFICATE HOLDER Ron & ~ris ~ermance ~27 NcK~nle¥ Place R~gewOo~ NJ 074S0 ACDRD 25~ (7~7) CANCELLATION ACORn CORPORATION lg9 -. / 09/28/2007 15:Ol FAX ~oo9/o13 September 21, 2007 As per the document N.F.PA. 1123-2000 Code for Fireworks Display and the Town of Southold regulations, the following information is provided. Sponsor/Client Name: Ms. Barbara Hook The Event Store 55 Route 48 Mattituck, NY 119~2 Location and Date of Fireworks Display: The Old Field Vineyard, Southold, NY October 6, 2007 at approximately 9:lSPM Chief Pyrotechnician: Jeffrey Engel Health: Age Years Experience: Excellent 60 16 Product: Firework Shells 1.3G explosives, UN0335, Maximum Aerial Shell Diameter [] 6 inches, Storage will be at secured safety zone in D.O.T. approved fiberboard containers # UN-4G, and stored in company vehicle approved for this purpose. Fireworks by Grucci complies with all requirements of the NFPA 1123 and The Town of Southold. The above information is submitted and vedfied by: Edward Rubio Logistics Manager Fireworks by Grucci, Inc. One Grucci Lane Brookhaven, NY 11719 (631) 288-0088 - Phone (631) 286-9036 - Fax 09/28/2007 15:01 FAX ~010/013 September 21, 2007 U.S.C.G. Sector Long Island Sound 120 Woodward Avenue New Haver~ CT 06512 Phone: 203-46S-4596 F~ 203-4.68-44.23 Em~h Dougl~.J.Miller~uscg.mil Ev~rK: Date Rain Date: Location: Latitude: Longitude: The Event Store October 6, 2007 N/A Barge on Sour. hold Bay off The Old Field Vineyard 41° 4' 9.40"N 72°24' 1 9:15 PM for duration of 6 - 7 minutes If you have any questions or concerns, please feel free to con'mat me at the office. Thank you for your help and cooperation in having this permit approved, Edward Rubio Firewoflis by' Gmcci, In~ Cell 516-658-4486 Fireworks by Gmcd, Inc. One Greed Lane Brookhaver~ NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-maih ERubio~grucci.com THE FIRST FAMILY OF FIREWORKS SENSITIVE SECURITY INFOIt3~ATION WHEN FILLED OUT DEPARTMENT OF Homeland Sec=ff~y U,S. COAST GUARD CG-COTPIS-01 0Rev. O2-05) 1. Name of Event Thc Event Store 2. DAH~ AND TIME OF EVENT FIREWORK ADDENDUM TO APPLICATION FOR A MARINE EVENT Inslmcdons: t. ~ idde~du~l mu.s1 bc suhmilled wilh tile A~pt~c~o~ ~r Approval of Ma~ne l~V~l (CC~1423) I I 8a Total Weight of Fireworks 6b. Hazard Class of Firewmks 1000LBS [,3G 9. Quantifies and Size of Shells lo be Used and Their ma~dmum Al§rude during Ihe Display Not Io Exceed 1750 Pcs./Nol to exceed an altitude of 900' 2 ½'-3' = 1000 6'=160 12'=O 4'=340 8'=0 5'= 250 10"=0 Oclober 6, 2007 ~ 9:15pm 3. Rain Date, if any 10. Fire Department Point of Contact [including phone n umber) Town of Southold - Elizabeth A. Neville, Town Clerk 631-765-1800 N/A 4. Na me of Involved Tug(s) and Barge(s) t I. Describe in De[ail Provisions made with Local Fire Oepedmem Io Supply Fire Fighting Pratecdion During Ihe Eveof. Chesterfield Associates On-Site Fire Fighlers with Emergency Plan in place 5. Type of Deck Covedng il' Ba~e is of Wood Construction 12. List all Permits Required a~d Recciveq ~rom Lee. a], Stale, and Federal Agencies Town of Southold and FAA Steel Deck Barge 6. The Exact Locat~un of Vessel When Loadrng Fimworks 13. Licensed Fimwork~ Coat]actor (Name, Add,ss, and Phone/Fax) FL',~vodts by Gracci To Bc Oetennined I Cn'ucci in. Bmokbaven, NY 11719 631-286-008g Faa 631-286-9036 7. Dale and Time of Fireworks Load lng 14. Will Sa site bc compliant wilh 33 CFR SS t26.1.5 & 126.27 at ti~e dina of toad ing/o~oading? 1016107 YES 7:00am - 5:o0pm 8. Time Vessel(s) will Tcansit to Launch Sile ! 5. How will security be bandied at thc tgmpora~ designated waterfTom facility? (If needed includ~ attachmettts) Approximately 5:0Opm depending on tides 24 Hour Security from time of arrlval to time of departure, along with Fire Departmenl personnel WAILTONG: This record, once Idled om, contains Sensitive Secu~iLy Im'ommtien that is controlled und~ 49 CFR Pan 1520. No part of this record may be disclosed to persons without "seed to K~ow," as de~ned in 49 CFR 1520.$, except with thc written pc[miss[o~ oF thc Secretary o f Homeland SecudLy. Unauthorized tclcase may result in civil penally or other action. For U.5. Govenunent sticncies, public disclosure is governed by 5 U.S.C. $52 and 49 CFR Part 1520. Page 1 of 2 SENSITIVE SECURITY INFORMATION WHEN FILLED OUT 16. Lat/tude and Longitude of Launch Site 19. Responsible Official let the Sponsodng Organization the can be Contacted ~or Additional Infomtalion. Lal 41° 4' 9.40"N Ed Ruble Long 72°24, 11.44"W Cell Phone: 631-65g-4486 17. Melhod or Secudng Launch Vessel(s) al Ihe Launch Sfle (The Towing Vessel is 20. Name of Person Completing Addendum and Fax Number (for approved PermiD Required to Stand Off During the Fireworks display) Edward Rubio Office 631-286-{)086 Barges will be a~chered in place or held in place eslng a spacer barge Fax 631-286-2096 Ceil 516-658-4486 18. Time the Launch Vessel(s) wil Depad Display Site After the Launch TBD dae to tides sppmximalely I O:OOpm Applir. ant Read ;et,~te Signing: I cedify that above information is true and accurale. I am providing this information in order to obtain an Marine Evenl Permit to hold a fireworks display in accordance with 33 CFR Part 100. I understand that if ~ make any raise of fraudulent slatement in this application, that I may be subject to a fine or imprisonment of up to live (5) years, or both (18) U.S.C. 1001) Signature: ~/'~ ~z, Dale: 9121107 SPECIAL NOTE: THE AREA DESIGNATED BY THE COAST GUARD AS A SAFETY ZONE MUST BE MARKED WITH ORANGE BUOYS BY TIlE SPONSC;~ This Block for Coasl Guard Use Only WARNING: This record, once filled out, contains Sensilive Security Informalion thai is controlled under 49 CFR Part 1520, No parl of this record maybe disclosed to pemons withoul 'need to Know," as defined in 49 CFR 1520.5, excepl with the writlen permission of the Secretary of Homeland Security. Unauthorized release may result in civil penally or other action. For IJ .S. Government agencies, public disclosure is governed by 5 U,S.C, 552 and 49 CFR Part 1520. Page 2 of 2 ~ G~ ~PLICATION FOR ~PROV~ OF ~NE ~NT B~c ~ ~Jd ~y o~o O~ Field Via~ ~:~ PM lo 9:30 PM ~ A ~ ~ A~Y PA~OL ~ ~R ~L OF ~A~R ~e Eve~ ~ 55 ~u~ ~ ~am Ho~, E~ P~ (631 ~ ~2978 ~F~ (1) September 21, 2007 TO: COMPANY: ADDRESS: EMAIL: PHONE: FAX: FRONE TOTAL PAGES: Elizabeth Neville Office of the Town Clerk 53095 Main Rd. Southold, New York 11971 e.nevilleOcown, southold.ny.us 631-765-1800 631-765-6145 Edward Rubio 9 Dear Mrs. Elizabeth Neville: Re: The Event Store, at The Old Field Vineyard, Southold, NY October 6, 2007 at approximately 9:lSPM Attached hereto please find the following: 1) Application copy 2) FAA Letter 3) Letter to Sponsor 4) Site Han 5) Shell Count 6) Cextificate of Insurance 7) Chief Pyrotechnician Data Sheet 8) Letter of permission to use land for display Any questions please give me a call. Thank you for ~11 your help, Edward Rubio Logistics Manager Fireworks by Grucci, Inc. Cell 516-658-4486 Fireworks by Grucci, Inc. One Grucd Lane Brookhaven, NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-mail: erubio@grucci.com THE FIRST FAMll X OF FIREWORKS I~!!,IZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATL~T/CS MARPAAGE OFFICER RECORDS MA~A~EM~/T OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box ! 179 SoutJ~old, New York 1197! Fax (631) 765-6145 Telephone (631) 765:1800 southoldtown.northfork.net OFFICE OF THE TOWN ~ TOWN OF SOUTHOLD APPLICATION PERMIT TO DISPLAY' FIREWORKS APPLICATION IS HEREBY MADE, pursuant to the provisions of Section 405.00 of the P~nal Law of thc State of New York, for a pcm~it to display fireworks ~ hereinafter speCified: DISPLAY IS TO BE SPONSORED BY The Event Store PRINCIPAL OFFICE AT 55 Route 48 Mattituck. NY 11952 DATE & TLME OF DISPLAY Ontoh~_r fi. ?C~fl7 .q'l RPM EXACT LOCATION OF DISPLAY Barge on Southold Bay off the old field vineyard RAIN DATE & TiME N/A The following persona arc to be in charge of the actual shooting of the fireworks: Name Age Experience Ph~ical ConditiOn ANTHONY S. CAPRI 44 10 YEARS EXCELLENT WES PHILIP JR. 56 3 YEARs ExcELLENT TBD (Additional nam~ and ~formation may be submitted on an attached sheet Number and type of firework~ is as follows: Grucci Grand Illuminations- 2970, 2.5-3"- 1000, 4"-340, 5%250, 6"-160 Manner and place of storage of fireworks prior to display: In a DOT approved company Veh c e packaged per DOT regulations and 24 hour security from time of arrival until departure Attached hereto and made a part of hereof b a diagram of the grounds on which the disPlay is to be held. Also attached is a cer~cate or policy of insurance coverage, NOTICE: Written permiasion, With signatUre Of the Prooert~ OWner, must be submitted with the Application. Signature c(f ~l~'cant )~,~ ~j~C By Date of Application September 21, 2007 TO: COMPANY: ADDRESS: E-MAIL: PHONE: FAX: FROM: TOTAL PAGES: Rich Horrocks FAA North Eastern Region FAA Southern Region Headquarters System Support Eastern Service Center PO Box 20636 Adanta, GA 30320-0631 Rich. Horrocks~faa.gov 404-305-5619 404-305-5572 Edward Rubio 1 Dear Mr. Horrocks: Please be advised of the following Fireworks displays: Event: Date Rain Date: Location: Latitude: Longitude: Time: The Evem Store October 6, 2007 N/A Barge on Southold Bay off The Old Field Vineyard 41° 4' 9.40"N 72°24' 11.44"W 9:15 PM for duration of 6 - 7 minutes The maximum altitude of the Fireworks will not exceed 900 feet. In letter form, please acknowledge the receipt and approval of tiffs notification. Thank you for your prompt reply. Thank You, Edward Rubio Logistics Manager Fireworks by Gmcci, Inc. Cell: 516-658-4486 Fireworks by Gmcci, Inc. One Grucci Lane Brookhaven, NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-mail: ERubio@gmcci.com THE FIRST FAMILY OF FIREWORKS September 21, 2007 Barbara Hock The Event Store 55 Route 48 Mattimck, NY 11952 Re: The Event Store, at The Old Field Vineyard, Southold, NY October 6, 2007 at approximately 9:lSPM Dear Ms. Hock; Endosed, please find the Town of Southold display permit application for the Fireworks Display specified above, Insurance certificate, site plan, shell list, chief pyrotechnidan data sheet and copy of FAA Letter for your event. Please complete the "Sponsor" Portion of the form, sign it and return it to the Town Clerk's Office as soon as possible so they may process the permit. The address is as follows: Elizabeth Neville Office of the Town Clerk 53095 Main Rd. Southold, New York 11971 If you have any questions, orif I can be of further assistance, please do not hesitate to contact me. Thank you for your help and cooperation in this matter. Sincerely, Edward Rubio Logistics Manager Cell 516-658-4486 Fireworks by Grucci, Inc. One Grucci Lane Brookhaven, NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-mail: ERubio@grucci.com THE FIRST FAMILY OF FIREWORKS FIREWORKS BY GRUCCI~ INC. SITE INSPECTION REPORT Program: The Event Store Show Date: 10/6/07 Rain Date: TBD Staging Area/Address: Barge on Southold Bay off the Old Field Vineyard, Southold, NY Event Contact: Barbara Hock, 55 Route 48, Mattituck Phone: 631-813-2978 Fax: 631-291-9159 Fire Marshal: Southold Town Phone: 631- Fax: 631- Fireworks Display Area 6" Max Display Site NFPA 1123: 70' per inch, 420' Safety Zone US Coast Guard Regulations: 100' per inch, 600' Safety Zone Maximum Aerial Shell Diameter: 6" (Inches) I Can Illuminations be used? Yes SITE INSPECTION: DISTANCES: Inspected by: SC Audience: 700'+ Vehicles: 600' Date: 5/25/07 Building Occupied: 800'+ Overhead Obstructions: n/a Time: 2:00pm Building Unoccupied: n/a Trees/Shrubs: n/a Latitude: 41 ° 4' 9.40"N Longitude: 72°24' 11.44"W The Event Store, Southold, NY- 60ct07 - siteplan.ppt September 21 2007 Re: The Event Store- Barge on Southold Bay offThe Old Field Vineyard 59600 Main Road, Southold, NY October 6, 2007 - at 9:lSPM SHEI.I. SIZE NOT TO EXCEED 6" SHELL SIZE: QUANTITY IN PCS. Grucci Grand Illuminations - 2970 2 ¼ - 3" 1000 4" 340 5" 250 6" 160 8" 0 10" 0 12" 0 Assorted aerial shells consist of CtuTsanthemum's, Comet's, Peony's, Titanium Salutes, Palm Trees, Willows, etc.. Titanium Salutes are limited to 3" only. Total: Not to exceed 1750 Aerial Shells and 2970 Illuminations Type: Fireworks UN0335 (Display Fireworks) (Explosive 1.3G) Fireworks UN0336 (Special Effects) (Explosive 1.4G) Thank You, Edward Rubio Logistics Manager Fireworks b7 Gmcci, Inc. Cell: 516-658-4486 Fireworks by Gmcci, Inc. One Grucci Lane Brookhaven, NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-mail: ERubio@gmcci.com THE FIRST FAMILY OF FIREWORKS ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (M M/D D,'Yy) 9/21/2007 PRODUCER Britton-Gallagher and Associates, 6240 SOM Center Rd. Cleveland OH 44139 INSURED Fireworks By Grucci, Inc. and/or Pyrotechnique By Grucci, Inc. and/or Philny Effects, Inc. Dne Grucci Lane 3rookhaven NY 11719 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE ~NSURERk New Hampshire Insurance Co INSURERS:Granite State Insurance Co. INSURER C: Ny State Fund - Melville INSURERD:~is Surplus Ins Company INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TSE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W~ICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUR3LNCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TEE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION A GE__NERAL M~IL~TY 6990184 2/17/2007 2/17/2008 EACH OCCURRENCE Sl , 000 , 000 I CLAIMS MADE ~ OCCUR MED EXP (Any one pemo.) $ __ PERSONAL & ADV INJURY $1, 000, 000 B AU__TOMOBILE LIABILITY CA 62659114 2 / 17 / 2007 2 / 17 / 2008 COMSlNPD SINGLE LIMIT L ANY AUTO (Pa a~idenD $1, 000, 000 I OCCUR [] CLAIMS MADE AGGREGATE $ $ 'OR"E"S:O"PE"'A O"A"D 2673978 11/29/200e i1/29/2007 X NO"Y"M'TSl' E*L DISEASE - EA EMPLOYEESUril imi t ed E.L. DISEASE - POLICY LIMIT SUnlimited D OTHER ~AU706151 2/17/2007 2/17/2008 $4,000,000 Bach Occurrence CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: ~ CANCELLATION Ron & Kris Hermance 327 McKinley Place Ridgewood NJ 07450 SHOULD ANY OF THE ABOVB DESCRIBED POLICIES BE CANCELLED BEFORB THE EXPIRATION DATE THEREOF, THE ISSUING INSURER RILL ENDEAVOR TO MAIL 30 DAYS WRI~EN NOTICE TO THE CERTIFICATB HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSH NO OBLIGATION OR LIABILITY OF A~Y KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ~~ ACORD 25~ (7/97) e ACORD CORPORATION 1988 September 21,2007 As per the document N.F.P.A. 1123-2000 Code for Fireworks Display and the Town of Southold regulations, the following information is provided. Sponsor/Client Name: Ms. Barbara Hock The Event Store 55 Route 48 Mattituck, NY 11952 Location and Date of Fireworks Display: The Old Field Vineyard, Southold, NY October 6, 2007 at approximately 9:15PM Chief Pymtechnician: Jeffrey Engel Health: Age Years Experience: Excellent 60 16 Product: Firework Shells 1.3G explosives, UN0335, Maximum Aerial Shell Diameter = 6 inches. Storage will be at secured safety zone in D.O.T. approved fiberboard containers # UN-4G, and stored in company vehicle approved for this purpose. Fireworks by Grucci complies with all requirements of the NFPA 1123 and The Town of Southold. The above information is submitted and verified by: Edward Rubio Logistics Manager Fireworks by Grucci, Inc. One Grucci Lane Brookhaven, NY 11719 (631) 286-0088 - Phone (631) 286-9036 - Fax September 21, 2007 LTJG Doug Miller U.S.C.G. Sector Long Island Sound 120 Woodward Avenue New Haven, CT 06512 Phone: 203-468-4596 Fax 203-468-4423 Email: Douglas.JaMiller@uscg.mil Dear Lt. Millen Event: Date Rain Date: Location: Latitu&: Longitude: Time: The Event Store October 6, 2007 N/A Barge on Southold Bay off The Old Field Vineyard 41° 4' 9.40"N 72°24' 11.44"W 9:15 PM for duration of 6 - 7 minutes If you have any questions or concerns, please feel free to comact me at the office. Thank you for your help and cooperation in having this pennit approved. Sincerely, Edward Rubio Logistics Manager Fireworks by Grucci, Inc. Cell 516-658-4486 Fireworks by Grucci, Inc. One Grucd Lane Brookhaven, NY 11719 Office #: (631) 286-0088 Fax #: (631) 286-9036 E-mail: ERubio@grucci.com THE FIRST FAMILY OF FIREWORKS DEPARTMENT OF Homeland Secudty U.S. COAST GUARD CG-COTPIS-01 (Rev.02-05) SENSITIVE SECURITY INFORMATION WHEN FILLED OUT FIREWORKS ADDENDUM TO APPLICATION FOR A MARINE EVENT Instructions: 1. This addendum must be submitted with the Application for Approval of Marine Event (CG4423) 2. A~ach a section ofa cha~ or chart ohotocoov showin~ the display site. 3. Address questions concerning request to Sector LIS, Marine Event Permit Coordinator at (203) 468~[596. 1. Name of Event 8a Total Weight of Fireworks 813. Hazard Class of Fireworks The Event Store 1000LBS 1.3G 2. DATE AND TIME OF EVENT 9. Quantities and Size of Shells to be Used and Their maximum Altitude during the Display Not to Exceed 1750 Pcs./Not to exceed an altitude of 900' October 6, 20071~ 9:15pm 2 ~" - 3" = 1000 6" = 160 12" = 0 4' = 340 8"=0 5"=250 10"=0 3. Rain Date, if any 10. Fire Department Point of Contact (including phone number) Town of Southold - Elizabeth k. Neville, Town Clerk 631-765-1800 N/A 4. Name of Involved Tug(s) and Barge(s) 11. Descdbe in Detail Provisions made with Local Fire Department to Supply Fire Fighting Protection During the Event. Chesterfield Associates On-Site Fire Fighters with Emergency Plan in place 5. Type of Deck Coveting if Barge is of Wood Construction 12. List all Permits Required and Received from Local, State, and Federal Agencies Town of Southold and FAA Steel Deck Barge 6. The Exact Location of Vessel When Loading Fireworks 13. Licensed Fireworks Contractor (Name, Address, and Phone/Fax) Fireworks by Gmcci To Be Determined I Gmcci Ln. Brookhaven, NY 11719 631-286-0088 Fax 631-286-9036 7. Date and Time of Fireworks Loading 14. Will thc site be compliant with 33 CFR SSI 26.15 & 126.27 at thc time ofloading/offioading? 10/6/07 YES 7:00am - 5:00pm 8. Time Vessel(s) will Transit to Launch Site 15. How will security be handled at the temporary designated waterfront facility? (If needed included attachments) Approximately 5:00pm depending on tides 24 Hour Security from time of arrival to time of departure, along with Fire Department personnel WARNING: This record, once filled out, contains Sensitive Security Information that i: controlled under 49 CFR Part 1520. No part of this record may be disclosed to persons without "need to Know," as defined in 49 CFR 1520.5, except with the written permission of the Secretary of Homeland Security. Unauthorized release may result in civil penalty or other action. For U.S. Government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 CFR Part 1520. Page 1 of 2 SENSITIVE SECURITY INFORMATION WHEN FILLED OUT 16. Latitude and Longitude of Launch Site 19. Responsible Official for the Sponsoring Organization the can be Contacted for Additional Information. Lat 41° 4' 9.40"N Ed Rubio Long 72024, 11.44"W Cell Phone: 631-658-4486 17. Method of Secudng Launch Vessel(s) at the Launch Site (The Towing Vessel is 20. Name of Person Completing Addendum and Fax Number (for approved Permit) Required to Stand Off Dudng the Fireworks display) Edward Ruble Office 631-286-0088 Barges will be anchored in place or held in place using a spacer barge Fax 631-286-2096 Cell 516-658-4486 18. Time the Launch Vessel(s) will Depart Display Site After the Launch TBD due to tides approximately 10:00pm Applicant Read Before Signing: I certify that above information is true and accurate. I am providing this information in order to obtain an Marine Event Permit to hold a fireworks display in accordance with 33 CFR Part 100. I understand that if I make any false of fraudulent statement in this application, that I may be subject to a fine or imprisonment of up to five (5) years, or both (18) U.S.C. 1001) Signature: Date: 9/21/07 SPECIAL NOTE: THE AREA DESIGNATED BY THE COAST GUARD AS A SAFETY ZONE MUST BE MARKED WITH ORANGE BUOYS BY THE SPONSOR This Block for Coast Guard Use Only WARNING: This record, once filled out, contains Sensitive Security Information that is controlled under 49 CFR Part 1520. No part of this record may be disclosed to persons without "need to Know," as defined in 49 CFR 1520.5, except with the written permission of the Secretary of Homeland Security. Unauthorized release may result in civil penalty or other action. For U.S. Government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 CFR Part 1520. Page 2 of 2 Department of Homeland Secmity Date Submitted USCo~t Guard APPLICATION FOR APPROVAL OF MARINE EVENT 9/21/07 (CG4423) (Rev 10/2005, Sector LIS) D~te Received by Sector LIS (Previous versions are not acceptable) INSTRUCTIONS 13 Have any objections been received from other interested parties? If YES, explain: 1. This application must be received by the office in Block 22 at least 135 day~ prior to the event, or at least 60 days if the same event (same location) was held one year prior. No 2. At~ach a selection of a chart or a scale drawing showing boundaries and/or courses and markers contemplated. 14 Vessels Provided by Sponsoring Organization for Safety Pu~oses (number and description) 3. Sub,fit a copy of your entry requirements and any spedal rules penai,l,g to eqtupment, regs or procedures 4. Please complete in manner that allows for local reproductiom Mail or fmx complete YES, THEY WILL SUPPLY ONE VESSEL TO PATROL THE AREA application to address/number in Block 22. 1 NK,V,.E OF EVENT 2 DATE OF EVENT 15 Does The Sponsoring Organization Deem Their Patrol Adequate For Safe~y and security Proposes? The Event Store October 6, 2007 If NO, explaim KD N/A NO 3 LOCATION OF EVENT 4 - TIME (Street, Finish) Barge on Southold Bay off Re Old Field Vineyard 9:00 PM to 9:30 PM IS A COAST GUARD ALPXIL/ARy PATROL REQUESTED FOR CONTROL OF SPECTATOR 59600 Main Road, Southold, NY AND/OR COMMERCIAL TRAFFIC~ If YES, how many vessels do you recommend 5 NAME AND ADDRESS OF SPONSOPdNG ORGANIZATION ('mdude zip code AND Fax) 16 PEPSON 1N CHARGE ('Include Contact Information During event) The Event Store tiff Route 48 Mattituck, NY 11952 Ed Rubio Cell: 516-6584486 Barbara Hock, Event Planner Phone (631)813-2978 Fax (631)291-9159 6 EXPE~Si LI~ NO. PAKi'i~511,ANTS 7 SIZES OF BOATS 17 W~ XXrlLL "PERSON IN CI-IARGE- BE DURING THE EVENT? 1 - 50' To~dx~ At the command center unknown 2 - 30' x 130' Barge 8 TYPES OF BOATS 9 EXI~ECTED NUMBER OF: 18 PERSON TO BE CONTACTED FOR FURTHER DETAILS (Include Name Address, Zip Code, Phone and Steel deck barges ~. SPECTATORS (LAND): 500 Edward Rubin, Logistics Manager Firewodes by Grucci b. SPECTATOR CIKAFT: 0 1 Grucci Lin, Brookhave~x, NY 11719 631-286-0088 or Cell 5164584486 Pax 631-286-9036 10 DESCRIFIION OF EVEIqT The tu,d~, ~ir~,ed has the authority to represent the spunsormg orgamz~ion A public Fireworks Display approzim~ely 6 -7 minutes in duration vfith arnmonmm aerial shell 19 SIGNATURE 20 TITLE 11 ~ffiI-LTI-IIS EVENT INTEKFEKE ORIMI)EDE THE NATU~LttL FLOW OF TRAFFIC? 21 ADDRESS (mdude Zip code andPhone) If YES, explaim 1 Grucci Iaz, Brookhaven, NY 11719 Yes, traffic will have to cease within the 600' from the pier during the display 631-2864088 or Cell 516-6584486 12 WHA'I PSXIKAORUNUSUALHAZAILD croPAKi'i~S~i, Ai,,rrSORNONPAi/ii~JLPANTS) 22 MaiITO: WILL BE INTRODUCED IIwro THE REGATTA AREA Commander, USCG Sector Long Island Safety zone may re-direct vessel traffic Ama: Marine Event Permit Coordinator 120 Woodward Avenue New Haven, CT 06512-3698 Or Fax To (preferred): (203)468-4423 (1)