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HomeMy WebLinkAbout2016 Nvt, 00 ELIZABETH A.NEVILLE,MMC ISys® _ Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS ��� Fax(631)765-6145 MARRIAGE OFFICER °�° �1� Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER • = � "no www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER ,. OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PERMIT for PUBLIC DISPLAY OF FIREWORKS I, 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: MATTITUCK LIONS CLUB STRAWBERRY FESTIVAL 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 Thursday,June 16 at 9:15PM; Friday, June 17 at 10:00PM and Saturday, June 18 at 10:15PM, 2016 on the northeast side of Strawberry Fields,Route 48,Mattituck,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'setup 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. Elizabe A. Neville,Town Clerk (Town Seal) - Town of Southold Dated:June 13 2016 Suffolk County,New York THIS PERMIT IS NOT TRANSFERABLE 40E04 • ELIZABETH A.NEVILLE,MMC ;'y®� ®l/.� Town Hall,53095 Main Road TOWN CLERK S P.O.Box 1179 ca a , Southold,New York 11971 REGISTRAR OF VITAL STATISTICS 6* +s, Fax(631)765-6145 MARRIAGE OFFICER : •� ®� Telephone(631)765-1800 1 �RECORDS MANAGEMENT OFFICER 4 ,++++ www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER ,, ,.•� OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD INSTRUCTIONS FOR DISPLAY OF FIREWORKS 1. The Town may grant a permit for the display of fireworks by municipalities, fair associations, amusement parks,persons or organizations of individuals. Penal Law Section 405.00(2). 2. An "organization of individuals" is a religious, civic, or comparable organization. Op. Atty. Gen No. 2007-3. 3. Fireworks permits shall indicate that the display must be concluded by 10:00 p.m. if held Sunday-Thursday, 11:00 p.m. if held Friday or Saturday, and there shall be no time restriction if held on July 4. 4. No person shall engage in or allow the manufacture, assembly, storage or display of any fireworks or pyrotechnics display without first obtaining a permit issued by the Town Clerk. A completed application for display of fireworks must be received by the Town Clerk,a minimum of 30 days prior to the date of display. The permit application for any fireworks or pyrotechnics display shall be accompanied by the following: (a) a copy of a valid certificate of competency as a pyrotechnician for the individual supervising the firing of the display; (b) Certificate of Insurance namingthe Town of Southold as additional insured with coverage limits of$2,000,000 for public liability and$2,000,000 for property damage; (c) Detailed diagram showing location of fireworks discharge and minimum separation distances in accordance with the applicable requirements of Penal Law Section 405(2); (d) A copy of the contract with fireworks display company; and (e) All applications shall require the approval of the Fire Chief of the District in which the display will take place and the Fire Marshal before being presented for approval by the Town Board. 5. All applications for a fireworks permit shall be subject to an application fee in an amount of$100.00, together with a processing fee in an amount to be determined by the Town Board to cover the Town's costs for monitoring and enforcing compliance with the Penal Law. (The above instructions are in accordance with the Penal Law, Article 405 - Licensing and other provisions relating to fireworks.) �� i'��OF SOU,y- ELIZABETH A.NEVILLE,RMC,CMC ,' O : Town Hall, 53095 Main Road TOWN CLERK l 4i , P.O. Box 1179 REGISTRAR OF VITAL STATISTICS G Q s` Southold, New York 11971 MARRIAGE OFFICER . . g1 Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER l �i Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER �COM,� �� , southoldtown.northfork.net . .44 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD INSTRUCTIONS FOR DISPLAY OF FIREWORKS 1. Name of body sponsoring fireworks display. 2. The date and time of day at which the fireworks display is to be held. Display must be concluded by 10:00 p.m. if held Sunday through Thursday, 11:00 p.m. if held Friday or Saturday, and there shall be no time restriction if held on July 4. 3. The exact location planned for the fireworks display, including TAX MAP NUMBER. 4. The age, experience and physical characteristics of the persons who are to do the actual discharging of the fireworks and a copy of a valid certificate of competency as a pyrotechnician for the individual supervising the firing of the display 5. The number and kind of fireworks to be discharged. 6. The manner and place of storage of such fireworks prior to the display. 7. Detailed diagram showing location of fireworks discharge and minimum separation distances in accordance with the applicable requirements of Penal Law Section 405 (2). 8. Copy of the contract with fireworks display company. 8. Such other information as the Southold Town Clerk may deem necessary to protect persons and property. Written permission of the property owner is required. 9. Certificate of Insurance naming the Town of Southold as additional insured with coverage limits of $2,000,000.00 for public liability and$2,000,000.00 for property damage. 10. The Town Clerk of the Town of Southold must have the insurance policy in her possession before the fireworks permit is issued. The named insured must read: TOWN OF SOUTHOLD. 11. Application for a fireworks permit must be made at least 30 days in advance of the date of the fireworks display. 12. All applications for a fireworks permit shall be subject to an application fee in an amount of$100.00, together with a processing fee in an amount to be determined by the Town Board to cover the Town's costs for monitoring and enforcing compliance with the Penal Law. (The above instructions are in accordance with the Penal Law,Article 405-Licensing and other provisions relating to fireworks.) Rudder, Lynda From: Flatley, Martin Sent: Tuesday, May 17, 2016 2:49 PM To: Rudder, Lynda; Doroski, Melanie; Fisher, Robert; Kruszeski, Frank; Spiro, Melissa; Duffy, Bill; Kiely, Stephen; Silleck, Mary Subject: RE: Strawberry Festival I have no objections to these fireworks displays taking place as scheduled. We used this plan last year and conducted a , closure of Rt.48 during the displays for a minimal amount of time. Martin Flatley, Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 Original Message From: Rudder, Lynda Sent: Tuesday, May 17, 2016 12:57 PM To: Doroski, Melanie <Melanie.Doroski@town.southold.ny.us>; Fisher, Robert<Robert.Fisher@town.southold.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>; Kruszeski, Frank<fkruszeski@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us>; Duffy, Bill <billd@southoldtownny.gov>; Kiely,Stephen <stephen.kiely@town.southold.ny.us>; Silleck, Mary<marys@southoldtownny.gov> Subject: Strawberry Festival Your message is ready to be sent with the following file or link attachments: mlc fire_20160517115106.pdf Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 Rudder, Lynda From: Fisher, Robert Sent: Wednesday, May 18, 2016 3:37 PM To: Rudder, Lynda Subject: RE: Strawberry Festival Lynda I have no problem with this application. Robert Fisher Fire Marshall, Town of Southold robert.fisher@town southold.ny.us (W) 631-765-1802- (C) 631-786-9180 PRIVILEGED AND CONFIDENTIAL COMMUNICATION CONFIDENTIALITY NOTICE:This electronic mail transmission is intended only for the use of the individual or entity to which it is addressed and may contain confidential information belonging to the sender which is protected by privilege. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this information is strictly prohibited. If you have.received this transmission in error, please notify the sender immediately by e-mail and delete the original message. Original Message From: Rudder, Lynda Sent: Tuesday, May 17, 2016 12:57 PM To: Doroski, Melanie <Melanie.Doroski@town.southold.ny.us>; Fisher, Robert<Robert.Fisher@town.southold.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>; Kruszeski, Frank<fkruszeski@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us>; Duffy, Bill<billd@southoldtownny.gov>; Kiely,Stephen <stephen.kiely@town.southold.ny.us>; Silleck, Mary<marys@southoldtownny.gov> Subject: Strawberry Festival • Your message is ready to be sent with the following file or link attachments: mlc fire_20160517115106.pdf Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 l Rudder, Lynda From: Spiro, Melissa Sent: Tuesday, May 17, 2016 2:37 PM To: Rudder, Lynda; Doroski, Melanie; Fisher, Robert; Flatley, Martin; Kruszeski, Frank; Duffy, Bill; Kiely, Stephen; Silleck, Mary Subject: RE: Strawberry Festival The launch site, shown as being between CR 48 and Sound Ave. is not preserved land. Thanks, Melissa Original Message From: Rudder, Lynda Sent: Tuesday, May 17, 2016 12:57 PM To: Doroski, Melanie <Melanie.Doroski@town.southold.ny.us>; Fisher, Robert<Robert.Fisher@town.southold.ny.us>; Flatley, Martin <mflatlev@town.southold.ny.us>; Kruszeski, Frank<fkruszeski@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us>; Duffy, Bill <billd@southoldtownny.gov>; Kiely, Stephen <stephen.kiely@town.southold.ny.us>; Silleck, Mary<marys@southoldtownny.gov> Subject: Strawberry Festival • Your message is ready to be sent with the following file or link attachments: mlc fire_20160517115106.pdf Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 Chief Secretary At �' ERICK R.HAASpARTM BRIAN WILLIAMS \71%5a mama 'yr First Assistant Chief k ; __ Treasurer JAMES G.RUGNETTA ' THERESA WELLS Second Assistant Chief jai ` ! Sergeant-at-Arms TED WEBBv-d �sov RAYMOND F.NINE / Home ofNY Stat \ Fireman of the Year :t Chaplain ti 1973&1974 JAMESL.MURPHY To whom this may concern, I am writing in regard of the fireworks permit for The Mattituck Lions Club's Strawberry Festival. They have my full approval to have the fireworks show. My department is prepared to stand by on all three nights of the fireworks to ensure nothing catches fire in the surrounding area. If you have any further questions, please feel free to contact me. (631)300-7523 Thank you, Erick Haas Chief of Department Mattituck Fire Dept. P.O.Box 136 • 1000 Pike Street • Mattituck,NY 11952-0666 Main(631)298-8833 • Fax(631)298-1904 • Chiefs(631)298-8852 • Fax(631)298-8858 www.mattituckfd.org colli;/� ELIZABETH A.NEVILLE,RMC,CMC 4 ;;`,,; .�' ''v,�� Town Hall,53095 Main Road `}� r P.O.Box 1179 TOWN CLERK ��; ' `=. � ; Southold,New York 11971 REGISTRAR,OF VITAL STATISTICS C s-j MARRIAGE OFFICER � .�° Q_�"� .��,�' Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER � r.. Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER jOt7EV si( southoldtown.northfork.net RECEIVED • OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD NAY 1 7 2016 APPLICATION PERMIT TO DISPLAY FIREWORKS Southold Town Clerk APPLICATION IS HEREBY MADE, pursuant to the provisions of Section 405.00 of the Penal Law of the State of New York, for a permit to display fireworks as hereinafter specified: DISPLAY IS TO BE SPONSORED BY 1"fo4140c4. G icy PRINCIPAL OFFICE AT/moi SD-bc, Po g„c ago, /-,arr®- NYi -119ft c - CI6 X 93 o'/iS DATE & TIME OF DISPLAY 6//6l/G-�t '��. GM//6 _ /o'er,, ,,,, Ci/S//s - /0:'s.,-, EXACT LOCATION OF DISPLAY Cocl..c Ave., /4,d� ��.( Nk 111 f.,t SUFFOLK COUNTY TAX MAP NUMBER FOR SITE /00 0 - I a 1- - a- - a. ( RAIN DATE & TIME il/o,v l' The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition 5• FA:4 rc,C y ‘G 3S xetri 127 e (Additional names and information may be submitted on an attached sheet Number and type of fireworks is as follows: SY.5 - / `` S(4G1r, g7-0 - P(6 `` s(4!p- - ? `' s(o/rJ 3o - 3 `` ��,..:�� c4e('r, 1° - 71” Sfiec:,r s e kc Manner and place of storage of fireworks prior to display: F;"n•c,.0.4 Attached hereto and made a part of hereof is a diagram of the grounds on which the display is to be held. Also attached is a certificate or policy of insurance coverage. NOTICE: Written permission,with signature of the Property. Owner, must be submitted with the Application. ric c Com/ Ccs Name of Or ization B Y Signature of Applicant • STATE-OF NEW.YORK wok,,NEj,At,., E►ty .DIV.ISION OF - „..I _ , , ` - - - , :DEPARTMENT'OF LABOR :,: 7 -�i' L}'' 8 ' ---SAFETY AND,HEALTH •: ' : : - -- - - _ _ E LICENSTO",DEAL IN OR•MANUFACTURE:EXPLOSIVES ;' ' • Expires: , 4/3012017- . ,. -_ - - , - __ _ - 'American Fireworks Display _- -'. _ - _ - - ,' .__ : .l _ . - ;PO Box 980-. - - THIS LICENSE BE• ' . . . „ -- "Oxfordi NY, 13830 .: , : .-.P,OSTED'IN YOUR=PLACE - - ; .OF BUSINESS - -- ' '- . , --• - - Kevin Jon Fritschler: . • - License No D - -5171, • _ - is hereby licensed to deal in or manufacture:explosives in compliance with the.requirements of the Labor Lav and-. ,- . r Industrial Code Rules.,Any,change in the conditions under which this license'is granted,may cause it to be-, - _ - • revoked:- . _ _ ' .- ` Eileen M.Frank();ActintiDirectorr-'- ''FOR - : "- ' : -THE"COMMISSIONER•OF LABOR -' = `- ' 'Every person selling,-delivering;or giving away any,explosives must,keep at the principal Place-of business within' - - - - "- - the state,a'recordof each transaction,including:.._' _- _ '--' __ • ' 1. -- '' _ ' - - _, - • 1Y; ,theNAME'or TYPE and QUANTITY of explosives SOLD,-DELIVERED or'GIVEN: Note:No license'IS _ _ -• - needed to purchase smokeless powder,or black powderin quantities not exceeding fivelpounds for-use in,,'- -_ , ---. firing antique firearms:or-artifacts or replicas thereof,'However,•dealers MUST post alt such_transactions o`n °;„_' ' -- - ; _ -the°Dealer-Manufacturer Report of.Explosives Transactions". ;-:, - - - • _ • ' _ _- ' ' .7)-- the DATE OF EACH SALE,'DELIVERY or GIFT. - '. _ " - ; ' = - , - 3)--- ,the-NAME,LICENSE NUMBER,and-BUSINESS ADDRESS-of the purchaser,donee,or person to whom, -'',- ' ' ,- theexplosives Were delivered,and the firm,if any,_represented=by such person,,.. _ - , 4)- - the NAME,ADDRESS and-LICENSE'NUMBER of the person TAKING THE EXPLOSIVES'AWAYfrorra '_ -- •: - - - ,the seller Pr donor:, ,' ; U.S.Department ofJustice reuer�a1 r xprnsives Licenseirerl'nir Bureau of Alcohol,Tobacco.Firearms and Explosives (18 U.S.C. chapter 40) . . - I'IIIIIMlirfr,'tm'411Mq lulu tmn89)I»ttlfiil In accordance with the prof inions of Title XI.Organized Crime Control Act of 1970,and the regulations issued thereunder(27 CFR Part 555),von may engage in the activity specified in this license or permit within the limitations of Chapter 40,Title.'8_,United States Code and the regulations issued thereunder,until the expiration date shown. THiS LICENSE ISNOT TRANSFERABLE UNDER.27 CFR 555.53;,,,Se "WARNINGS"and"NOTICES"on remerre. Direct ATT All -Chief:FELL ,_, _„ , i...,�Pcmmit Correspondence To 2-1 l Needy Road - -~. Number' _ 6-NY-017-51-7G-00982 Martinsburg.WV25-1U5-9=131,' _ - Chid_Federal F.splosiv es Licensing Center(FELC -` S' Expiration: July �, 2017. ��fLs`'l •: _ F Dale Name , AMERICAN FIREWORKS DiSPLAY'LLC Premises Address(Changes?Notify the FELC at least 10 days before the tnare.)_ ,_' , . - 105 COUNTY ROUTE 7 , = MCDONOUGH, NY 1380' ' , - ' -' , . , . Type of License or Permit ,i._,', 51-IMPORTER OF EXPLOSIVES . '` Purchasing Cenilication Statement . Mailing Address(Changes? Notify the FELC army changes.) Tin licensee or pernrnte'e named above shall use ii eOpv'of this license or permit to assist a _ transferor of esptu n a.to verify the identity and the.iigensed status of the liecnsee or -• - "' permittee as provided by 27 CFR Pan 555. The sicriaiure'an cacti cony must bean orieuial- • ' '' - simiature -A laxed.scanned or e-mailed copy ol'the license orpeinit With a signature —, - " AMERIGAN.FIRE1lVORKS DISPLAY LLC intended to be an original signature is acceptable. Time sig attire mast be that ofthe Federal PO BOX-980 Explosive ,Licensee(FEL)or a re.sponsihle person ofilic FEL, I certify,diat this is a true OXFORD, NY•`13830- copy ata license or permit rowed to the licence or petmiitter named above toen gage in the-:-: „,-; ,' - , business or operations specified alias e under"Type of license or l?aril."__1 '' ' Licensee Perimttee Responsible Person Signature Position'Title' -- Printed Name Date ATF Farm ur�tt,5-1•0wil5Pal I Pre+,tisusEdition isi,*.s ktc cu1er,.Vnsiiratewsaurlit rz .n5eoaI17 greeAl,,,sstso:ces-a 437a”a‘/ � rsruaai'r,si ,ns Rev ^,n},eK ictlt Federal Explosives License(FEL)Customer Service Information Federal Explosives Licensing Center i FELC i Toll-tiee Telephone Number (877)283-3352 ATF homepage:vvin ve.at f:eov 244 Needy Road Fax Number. (304)616-440 I Martmsbure.WV 25405-9431 E-mail: FELC'r'iatf.tnv Change of address (27 CE!?555.54(a)?In. Licensees or permittees mai'during the term of their current license or permit remove their business or operations to a new location atwhich they intend regularly-to carr on such business or operations, The licensee or permittee is required to give notification of the new location of the business or operations not less than 10 days prior to such removal with the Chief.Federal Explosives Licensing Center The license or permit will be valid for the remainder of the term of the original license or permit. (The Chief,FELC,shall,if the licensee or permittee is not qualified,refer the request for amended license or permit to the Director of Industry Operations for denial in accordance with§555.54.) Right of Succession (27 CFR 555.59) (a)Cenamn persons other than the licensee or permittee:mat secure the right to early on the Same explosive materials business or operations at the same address shown on.and for the remainder of the term of a current license or permit Such persons are. (I)The surviving spouse or child.or executor.administrator.or other legal representativ e ofa deceased licensee or permittee:and(2)A receiver or trustee in bankruptcy,or an assignee for benefit of creditors. (b)In order to secure the right provided by this section.the person or persons continuing the business or operations shall furnish the license or permit for for that business or operations Ibr endorsement of such succession to the Chief.FELC.within 30 days from the date on xx hick the'successor begins to carry on the business or operations. Cut Here < (Continued on reverse side! I Federal Explosives License/Permit(FEL)Information Card i I License•Permit Name:AMERICAN FIREWORKS DiSPLAY LLC l t Business Name: , . I t License Permit Number.6-NY-017-51-7G-00982 i 1 LicensePermit Type:51-IMPORTER OF-EXPLOSIVES I I Expiration: July 1,2017 i I I Please Note. Not Valid for the Sate or Other Disposition of Explosives. I 1 - , A' -- 2,-,-- .. . / 1 , — ,f --- _- •-'''' ....-- -,-----'-. _.,-- „,„ --- .- -- 00' Fireworks Launch Site 4110. ..-- — - , -- -- -- t - /gio / ,,,,, .-/ H6.1 iff . /--,q't k I -,, • • - s, 1 ( : ir''''%%,-44°,0''„, ',. • , A.--, '' ''':•-;',,rio: ' , . --- -,.. .r -'1%-''.' ' ,•'''''' 1 lift§lktr, /, , ,1-,,,:' '`........,,,,, ,,,.. ,..,,, -,,,,* •.- -...,„,..„ , '°., •, , .............. ...."*""'"* "."."*."." - -- CD , . .. _ 1 Ii 10 2015 Google 14 . . - .©2015 Europa Technologies ;a: Google earth . . 300 )114. • -ge earth feet met90 ers AcisPR®® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D/Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement,on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Glenn Harris Allied Specialty Insurance, Inc. PHONE FAX 10451 Gulf Blvd tNC.No.Ext): 727-547-3093 E-MAIL (A/C,No): ADDRESS: gharris ,alliedspecialty corn Treasure Island, FL 33706-4814 INSURER(S)AFFORDING COVERAGE MAIC# INSURERA: T.H.E.Insurance Company 12866 INSURED INSURER B: American Fireworks Display, LLC P 0 Box 980 INSURER C: INSURER D: Oxford, NY 13830 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR tNSD-WVD POUCY NUMBER (MM/DDIYYYYI (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAA�LL/LIABIUTY CPP0105319-00 03/17/2016 03/17/2017 EACH OCCURRENCE $ 1,000,000 /X CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ N/A _ PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE _ $ _ POLICY PRO-JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER Protection&Indemnity $ 1,000,000 A AUTOMOBILE LIABILITY CPP0105319-00 03/17/2016 03/17/2017 (EaaxNdenDSINGLELIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNEDSCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) S XHIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY . AUTOS ONLY (Per accident) $ _ $ A UMBRELLALIAB X OCCUR ELP0012117-00(GL) 03/17/2016 03/17/2017 EACH OCCURRENCE $ 4,000,000 X EXCESS UAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED RETENTION$ $ A WORKERS COMPENSATION Xj STATUTE I ER AND EMPLOYERS'LIABILITY Y/N WCP0005259-001 03/22/2016 03/22/2017 ANYPROPRIETOR/PARTNERIEXECUTIVEN/A EL EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L.DISEASE-EA EMPLOYEE $ 100,000 Ir yes,desuibe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 A Excess VL ELP0012118-00(VL) 03/17/2016 03/17/2017 Each Occurrence 4,000,000 Aggregate 4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,AddlUanal Remarks Schedule,may be attached If more space Is required) Display Date:6/16/16,6/17/16,6/18/16 Rain Date: Location: Sound Ave.,Mattituck,NY RE:General Liability,the following are named as additional insured in respects to the operation of the named insured only. Reithoffer Shows,Inc;Mattituck Lions Club,Town of Southold,NY;County Of Suffolk,NY;JIMD Corp.(Property Owner) CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Route 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHO(--1114(_ IZEgREPRESENTATIVE I r stifA..._ ©1988-20154CORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Rudder, Lynda From: Rudder, Lynda Sent: Tuesday, May 17, 2016 12:57 PM To: Doroski, Melanie; Fisher, Robert; Flatley, Martin; Kruszeski, Frank, Spiro, Melissa, Duffy, Bill; Kiely, Stephen; Silleck, Mary Subject: Strawberry Festival Attachments: mlc fire_20160517115106.pdf Your message is ready to be sent with the following file or link attachments: mlc fire_20160517115106.pdf Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file / attachments. Check your e-mail security settings to determine how attachments are handled. 2 * * * RECEIPT * * * Date: 05/17/16 Receipt#: 204798 Quantity Transactions Reference Subtotal 1 Fireworks Strawberry $100 00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#0915 $100.00 Suglia, Benjamin W Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Suglia, Benjamin W Po Box 890 Mattituck, NY 11952 Clerk ID: LYNDAR Internal ID Strawberry Type. ' Returned Issue Date 'Returned Check,Charge -- 1052516 105/25/2016 . Edit Payment I Breakdown Search I E This license has been renewed E Inactive Permits l Client Information /Notes Full Name ISuglia.Benjamin W Home Phone 1 1(631) - Home,Address] Po Box 890 �. • DMV Lic# F Mattduck NY 11952 Mailing Address F Birth Date // Not Used I Not Used I Piot Used I Not Used I Not Used I Not Used I ' E Not Used I j./ ,. 7,1 < '14?0 001 Returned Check 1 Fee Check .h9tge H Fee Amount' Effective Date 105/25/2016 . ( Quantity. 1 00 ^, Expiration Date[// 7.1 T akal:l i Clear { 20.00 1 1 Last Changed By- Bonnie Doroski • --- — —' Town of Southold P.O Box 1179 Southold, NY 11971 (631) 765-1800 RECEIPT #Strbfest 06/03/2016 Suglia, Benjamin W Po Box 890 Mattituck, NY 11952 Received $ 100.00 for Fireworks, on 05/25/2016. Thank you for stopping by the Treasurer's Office. As always, it is our pleasure to serve you. Elizabeth A. Neville Southold Town Clerk