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HomeMy WebLinkAbout2016 Neville, Elizabeth From: Neville, Elizabeth Sent: Thursday,June.16,2016 2:10 PM To: Flatley, Martin; Fisher, Robert; Doherty,Peter, Duffy, Bill; Kiely, Stephen; Kiely, Stephen; 'pmcgreev@optonline.net'; 'loper98@optonline.net'; 'erubio@grucci.com' Subject: Emailing: Fireworks Permit Orient Y20160616124901 Attachments: Fireworks Permt Orient Y20160616124901.pdf Attached please find the Fireworks Permit for the Orient Yacht Club Fireworks Display to be held at 9:15PM,Saturday, July 2,2016(Rain Date: 9:15PM,Sunday,July 3, 2016. My best wishes to all for a joyous Fourth of July Celebration! Elizabeth A. Neville, MMC Southold Town Clerk& FOIL Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 Your message is ready to be sent with the following file or link attachments: Fireworks Permit Orient Y20160616124901 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 , F "t.0 49, ELIZABETH A.NEVILLE,MMC �� Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 C Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Fax(631)765-6145 MARRIAGE OFFICER , '�° � Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER 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: ORIENT YACHT CLUB 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 at 9:15PM,Saturday, July 2,2016 (Rain Date 9:1513M,Sunday,July 3,2016 on Barge off Orient Yacht Club, 2110 Village Lane,Orient, New York, upon payment of a single fee of$100.00 and subject to the applicant's compliance with the requirements of the Town's Policy regarding the issuance of Fireworks Permits. 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 feel 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 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 in to 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 be held 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 least 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. --- ---- • ---------- --Q - • - (Town Seal) Elizabet . Neville,Southold Town Clerk Suffolk County, New York Date:6/16/2016 THIS PERMIT IS NOT TRANSFERABLE gOFFa, o RESOLUTION 2016-606 � ADOPTED DOC ID: 12019 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO.2016-606 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JUNE 14,2016: RESOLVED that the Town Board of the Town of Southold hereby approves the issuance of a Fireworks Permit by the Town Clerk to the Orient'Yacht Club, for a fireworks display on Saturday, July 2, 2016 at 9:15 PM(Rain Date: Sunday, July 3, 2016 at 9:15PM) on Barge off Orient Yacht Club, 2110 Village Lane, Orient,New York upon payment of a single fee of $100.00 and subject to the applicant's compliance with the requirements of the Town's policy regarding the issuance of fireworks permits. Elizabeth A.Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Robert Ghosio, Councilman SECONDER:Louisa P. Evans, Justice AYES: Dinizio Jr, Ruland, Doherty, Ghosio, Evans, Russell o�Og�FFD[I(CO, ELIZABETH A.NEVILLE,MMC Town Hall,53095 Main Road TOWN CLERK q P.O.Box 1179 y = Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p - �C Fax(631)765-6145 MARRIAGE OFFICERy RECORDS OF MANAGEMENT OFFICER �Oj � �a0 Telephone(63i)76b-1800 southoldtown.nortl ftt-EIVED FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK Y 2 7 IMI TOWN OF SOUTHOLD APPLICATION Southold Town Cler PERMIT TO DISPLAY FIREWORKS 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 Orient Yacht Club PRINCIPAL OFFICE AT PO Box 161, Orient, NY 11957 DATE& TIME OF DISPLAY July 2, 2016 @approx. 9:15pm EXACT LOCATION•OF DISPLAY Barge off Orient Yacht Club SUFFOLK COUNTY TAX MAP NUMBER FOR SITE 1000-24-2-28.1 RAIN DATE & TIME July 3, 2016 @ approx. 9:15pm The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition Anthony Magno, Sr. 61 38 years Excellent (Additional names and information may be submitted on an attached sheet Number and type of fireworks is as follows: Grucci Grand Illuminations-4500 2'/-3"- 1020 4"-325 5"-300 6"-275 8"-32 Total: Not to exceed 1952 Firework Shells and 4500 Illuminations Manner and place of storage of fireworks prior to display: In UN approved boxes in company vehicle. 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. Orient Yacht Club FEE: $100 Name of Organization See poiicyfoe additional information By P , e'"mQl me�CCGY O " Signature of Applicant� p �r���re.�re1� Date of Application NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Division of Fish and Wildlife,Bureau of Wildlife,Region 1 SUNYOStony Brook,50 Circle Rood,Stony Brook,NY 11790 P:(631)444-0310 i F:(631)4440272 www.dec.ny.gov June 22, 2016 Vanessa Vaz Fireworks by Grucci, Inc. 20 Pinehurst Drive Bellport, NY 11713 Dear Ms. Vaz: The New York State Department of Environmental Conservation has reviewed the fireworks display information for the following show: Name: Orient Fire Department Date: July 2, 2016 Rain Date: July 3, 2016 Location: Barge off Orient Yacht Club 2110 Village Lane, Orient, NY Latitude: 41*08'2.71"N Longitude: 72*18'34.28"W Based on the information provided, we do not anticipate that the proposed show will cause any adverse impacts to threatened or endangered species. The Fish and Wildlife Service's Guidelines for Managing Fireworks in the Vicinity of Piping Plovers and Seabeach Amaranth of the U.S. Atlantic Coast recommends that the launch site be located a minimum of 3/4 of a mile from the nearest plover area to avoid direct disturbance to nesting plovers. The proposed launch site exceeds the recommended distance and there does not appear to be any threat from indirect impacts. Sincerely, Kevin Jennings Wildlife Biologist s�RevxoRtc ®epartmerrt of $TAYEDF oavoalut�ttr EYnrirflnntent@ti, Conservation DEPARTMENT OF HOMELAND SECURITY APPLICATION FOR MARINE EVENT OMB Number: 1625-0008 Expires: 9/30/2017 Date Submitted: 04/06/2016 Tracking No:139354 FORM INSTRUCTIONS 1.-Please complete either this online form or a paper CG4423. 2. This application must reach_ the appropriate Captain of the Port(selected via dropdown box) at least 135 days prior to the event. 3.' Attach a section of a chart or scale drawing showing boundaries and/or courses and markers contemplated. 4. Submit a copy of your entry requirements, and any special rules pertaining to equipment, rigs or procedures. 1. Name of Event Orient Independence Day Celebration 2. Date of Event 07/02/2016- 07/03/2016 3. Location of Event Barge off Orient Yacht Club-Orient, NY 4.Time From. 9:15 PM To: 9:45 PM Latitude: 41?08? 02.71? N Longitude: 72? 18?34.28?W 5. Name and Address of Sponsoring Organization (Include Zip Code) 6. No. of Participants 7. Sizes of Boats Orient Fire Department 2 90x30 23300 Main Road Orient, NY 11957 8. Types of Boats 9. No. of Spectator Craft Steel Barges, Steel Tug, Fiberglass Security Vessel 20 10. Description of Events A fireworks display that will be approximately 16-17 minutes in duration with a max aerial shell size of 8". 11. Will This Event Interfere or Impede the Natural Flow of Traffic? YES 11 a. If YES briefly explain: Traffic will cease within the 1000'safety perimeter during the display. CG-4423 (3/2011) 12.What Extra or Unusual Hazard (to participants or non-participants)Will Be Introduced Into the Regatta Area A fireworks display-a no wake zone will be put in place surrounding the barge. 13. Have any Objections Been Received from Other Interested Parties? NO 13a. If YES briefly explain: 14.Vessels Provided by Sponsoring Organization for Safety Purposes (number, description and length) Number Description Length 631-603-5731 Orient Fire Dept. -Bill Wysocki 15. Does the Sponsoring Organization Deem their Patrol Adequate for Safety Purposes? YES 15a. If NO briefly explain: Yes, we still request the Coast Guard's presence for this event. 16. Is a Coast Guard or Coast Guard Auxiliary Patrol Requested for Control of Spectator and/or Commercial Traffic? YES 16a. If YES how many vessels do you recommend and why?. Yes, one vessel because we would like to add additional safety although our security vessel is adequate. 17. Person In Charge Edward Rubio 18. Where Will 'Person In Charge' be During Event? Command Center 19. How Can 'Person In Charge' be Contacted During the Event? 516-658-4486 20. Person to be Contacted for Further Details(Name,Address, Zip Code) 20a.Area Code and Phone No.: 631-286-0088 Edward Rubio 20 Pinehurst Drive 20b. Email Address: vvaz@grucci.com Bellport, NY 11713 CG-4423 (3/2011) The undersigned has full authority to represent the sponsoring organization. 21. Name: Edward Rubio 22. Title: Logistics Manager 23.Address (Include Zip Code) 23a.Area Code and Phone No.: 631-286-0088 20 Pinehurst Drive Bellport, NY 11713 23b. Email Address: vvaz@grucci.com 24. The person submitting the form certified that they have full authority to represent the sponsoring organization. 25. COTP Zone Submitted: LONG ISLAND SOUND PRIVACY ACT STATEMENT Privacy Act Notice Authority: 33 U.S.0§ 1233 authorizes the collection of this information. Purpose: The Coast Guard will use this information to determine whether an event poses an extra or unusual hazard to the safety of life and whether or not, and under which conditions,to permit the event on the navigable waters of the United,States. Routine Uses: The information will be used by and disclosed to Coast Guard personnel to evaluate the request.Additionally,the Coast Guard may share the information with facility operators, law enforcement or other government agencies as necessary to promote public safety during the requested marine event. Disclosure: Furnishing this information is voluntary; however, failure to furnish the requested information may delay or prevent the approval of the requested marine event. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The Coast Guard estimates that the average burden for this collection of information is 60 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Commandant(CG-5521), U.S. Coast Guard, 2100 2ND St., SW,Washington D.C. 20593-7683 or Office of Management and Budget, Paperwork Reduction Project(1625-0008), Washington, DC 20593. CG-4423 (3/2011) y ° eA.,N.Y ORIENT FIRE DEPARTMENT, INC. 23300 Main Road Orient NY 11957 i (631) 323-2445 • Fax 323-9706 D RECEIVED May 31, 2016 JON ® 6 2016 Elizabeth A. Neville, MMC Southold Town Clerk Southold Town Clerk PO Box 1179 Southold, NY 11971 Dear Elizabeth Neville: The Orient Fire Department is aware of the Orient Yacht Club fireworks application for July 2, 2016 and we currently have no objections of them having this event. Please contact me if you need anything else of if there are any questions. Sincerely, Edward Loper, Jr Chief Cell # 631-830-7401 Email - loper98@optonline.net Omen t Yacht Ctub Orient NY July 2,, 2016 Firrewor '- by Gnus +�J -FIREWORKS:BY Pt 4ti< H� i. a4 v Barge Display Site Max Shell Size 8' 1,000' Fallout Area oil * Exceeds Coast Guard Required 100' / 1" ** Exceeds NFPA 1123 Recommended 70'/ 1" Latitude: 41° 08' 02.71" N 0' 250' 500' 750' 1000' Longitude: I I I I 720 18' 34.28"W All Information contained on this document is copyright material and the intellectual property of Fireworks by Grucci Inc. Reproduction and/or circulation without approval of Fireworks by Grucci is prohibited. Rev 1 4/6/16 i � r -j I I� d ' ,I �F�V r 5a906038� u mum,•M9.TfSL 3 %;a: mmlo MAR BIO w-TMINO 22 Selz Is om-CE,a&us tit j,•.�;:�; ,wi�:t�'�v �. �"`':���tr�, �, •.�',` x^ 2t"T,1?�1�S r�r'`_`•`'''Y,ss•y�e,�%`:�-y��yr"'.'uiS; r r ,� •}'P'rr: .� ,.i°`�r f' alis M1,4 .•'`I`t°�sii.`Xii�7 > iyri�rrc,1�pp,�4� 'f4Y�1a�1 Ir�� Y I AY ���.y} f1 1 L�1£l��-il'=.l•:k��d l',.i:4�,dM�:ffY�i•.l •- ,.,i.�•-s 'i l * * * RECEIPT * * * Date: 05/31/16 Receipt#: 206055 Quantity Transactions Reference Subtotal 1 Fireworks 7/2/16 $100.00 Total Paid: $100.00 Notes: Payment Type Amount Paid By CK#2309 $10000 Mcgreevy, Colleen & Peter Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Mcgreevy, Colleen & Peter P o Box 1047 455 Lloyds Lane Mattituck, NY 11952 Clerk ID: LYNDAR Internal ID 7/2/16 RECEIVED Town of Southold Police Department Special Event Cost Analysis Jim, I Event: Orient Yacht Club Fireworks Display I Southot I Town Clerk Date(s): July 2, 2016 Location: I Orient Harbor 5�— "' 14 7 1 11 T*,, Reg""�o�u­r�s OT Hrs HH Wage Total Comments P.O. J. Helf 2 $61.17 $122.34 1- 7,7 75KE";7�4RY77 '1�17 761 777'.", rn ....... .....7 Reg Hours OT Hrs Hrly-Wage Total Comments PO Ounfrak 2 $62.12 $124.24 SBC Epple 2 $39.90 $119.70 BC O'Leary 2 $28.68 $86.04 f2edgHours OT Hrs Hrly Wage" Total Comments TG Officer TC Officer TC TC TC 7F 7! • Marine Fuel $50.00 Total Department Cost for Event = $ 11 $502.32 1 Prepared by Capt.M. Flatley 6/1/2016 Page 1 RECEIVED May 6,2016 MAy 2 7 2016 • � �1 Elizabeth Neville,Town Clerk Southold Town Clerk Town of Southold 53095 Route 25 Southold,NY 11971 Phone: 631-765-1800' Fax: 631-765-6145 Email: e.neville@town.southold.np.us CC:lynda.rudder@town-southold.ny.us Dear Ms. Neville: Please find attached hereto for the Orient Yacht Club fireworks display scheduled for July 2, 2016 with a Rain Date of July 3,2016 at 9:15 PM the following: 1) Town of Southold Permit to Display Fireworks Application 2) Check for$100.00 for Permit Fee 3) Insurance Certificate 4) Site Plan 5) Chief Pyrotechnician's Data Form 6) Chief Pyrotechnician's NYS Certificate of Fitness 7) Pyrotechnic Product Count 8) FAA Notification Letter 9) U.S.Fish&Wildlife Notification 10) DEC Notification 11) US Coast Guard Marine Event Application 12) Letter to Sponsor Thank you for your help in this matter and if you should have any questions please call. Sincerely, Edward Rubio Logistics Manager Fireworks by Grucci,Inc. Cell: 516-658-4486 Fireworks by Grucci,Inc. Office#: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 Bellport,NY 11713 E-mail:info@grucci.com THE FIRST FAMILY OF FIREWORKS FDATE(MM/DD/YYYY) A�D` CERTIFICATE OF LIABILITY INSURANCE 06/0312016 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 H THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE IS INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT.If the certificate holder is an ADDITIONAL INSURED,the policy(les)must 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). RECEIVED CONTACT PRODUCER NAME PHONE FAX No) (877)234-4421 AAS Insurance Agency (A/C,No,Ext) 877 234-4420 10825 Old Mill Rd E-MAIL JUN�t - /7 ADDRESS J Omaha, NE 68154 2016 PRODUCER CUSTOMER ID# (877)234-4420 1. INSURER(S)AFFORDING COVERAGE NAIC# INSURED out O Town beck INSURER n in n INSURER B P3rt0t9ChfiiQue By GrUCCL Inc. dba PyrOtechni.Cdue By GrUCCL Inc. INSURER C 20 Pinehurst Dr INSURER D. Bellport, NY 11713 INSURER E CTL 1273 1187121 INSURER F REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: — NAMED ABOVE R THE LICY LICIES OF NCE ED BELUW HAVE SSUED TO THE NSURED PERIOI�TOD IND CATEDY THAT THE NOT STAONDING ANY REQUAREMENT,TTEFlM OR CONDITIONEOFIANY CONTRACTIOR OTHER DOCUMENT WI IND 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 ADDL SUBR POLICY EFF MPM/DD EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD EACH OCCURRENCE It GENERAL LIABILITY DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY ❑ ❑ PREMISES(Eaomurrence) $ CLAIMS MED EXP An one erson $ MADE El OCCUR PERSONAL&ADV INJURY $ - GENERAL AGGREGATE $ - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PROJECT LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY ❑ ❑ (Eaaccident) $ ANY AUTO BODILYINJURY Per erson $ ALL OWNED AUTOS BODILY INJURY Per accident $ SCHEDULED AUTOS PROPERTY DAMAGE $ Per aocident HIRED AUTOS $ NON-OWNED AUTOS $ EACH OCCURRENCE $ UMBRELLA LIAB OCCUR AGGREGATE $ EXCESS LIAB CLAIMS-MADE ❑ j $ DEDUCTIBLE - $ RETENTION' $" WC STATU- OTH- WORKERS COMPENSATION X TORY LIMITS OIVE AND EMPLOYERS'LIABILITY y/N EL EACH ACCIDENT $ 1 000 0 0 0 { ANY PRO PRIETOR/PARTNER/ a N/A 7 3_q,7 44 3 5-01-O 1 05/27/2016 05/27/2017 EXCLUDED?OFFICERMIEMBER EL DISEASE-FJi EMPLOYEE $ 1 000 O O (Mandatory In NH) Ifyes,descnbe under E L DISEASE-POLICY LIMIT $ 0 0 0 SPECIAL PROVISIO00 NS below 0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach Acord 101,Additional Remarks Schedule,if more space is required) Date: July 2, 2016 Rain Date: July 3, 2016 Location: Orient Yacht Club, Orient, NY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TkyNm Of SOlitbold EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TbP7II Hall 53095 Main Read THE POLICY PROVISIONS. 1th Hold, NY 11971 AUTHORIZED REPRESENTATIVE � PC937411 The ACORD name and logo are registered marks of ACORD ©19 8-2009 ACORD CORPORATION All rights reserved ACORD 25(2009/09) • • • • • • L�,^ !r*• -":�\ :�� ;'� ` a`.= + ' !!♦"* «51 a bLrt��,S.i �,,a«•'Zt`�1a "''♦y .n ;�.r w tt t t � ,•, h, r � ra� L��'i', +.� / y• ��'a♦`v g.«Sa. `•sS+r','�v`it ;2,..r*`\'��y/ ev 's% r^7�s. �u"aL�a''rt{,{qtr.,✓`Sr. //.�+14a _/l"f�;�r.4flr�s'�Y; !'fs.. a� � �i r� �L t ��a ��4'�`� , �J l.t�.•�!. ±..�p�r ��.T' Y S �S ��Q� !,y a,. 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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 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 NAME: Britton GallagherPHCN o E •21 - - 1 00 AIC No):216-658-71 01 One Cleveland Center, Floor 30 E-MAIL 1375 East 9th Street ADDRESS: Cleveland OH 44114 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Y State Fund-Melville 36102 INSURED INSURER B:Lexington Ins Co 19437 Fireworks By Gruccl Inc.and/or Pyrotechnique INSURERC:Everest National Insurance Company 120 By Gruccl, Inc and/or Philny Effects, Inc. INSURERD: 20 Pinehurst Drive Bellport NY 11713 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1682452223 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 CONTRACTOR 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 ADDLSUBTYPE OF INSURANCE R POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICYNUMBER MM/DD MM/DD/YYYY C GENERAL LIABILITY S18ML00093-161 2/17/2016 2/17/2017 EACH OCCURRENCE $1,000,000 DAMAGE X RENED COMMERCIAL GENERAL LIABILITY PREM SESOEa ocou encs $500,000 CLAIMS-MADE 15F]OCCUR MED EXP(Any one person) $ PERSONAL BADV INJURY $1,000,000 Liability GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $2,000,000 POLICY X PRO- 7LOC $ JECT C AUTOMOBILE LIABILITY SIBCA00044-161 2/17/2016 2/17/2017 EaaC1NE13 $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIREDAUTOSX AUTOS Per accident $ B UMBRELLA LIAR X OCCUR 013136655 2/17/2016 2/17/2017 EACH OCCURRENCE $4,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED X I RETENTION$10,000 $ A WORKERS COMPENSATION 12673978 11/29/2015 11/29/2016 X WCSTATU- I I OER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E L EACH ACCIDENT $Unlimited OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L DISEASE-EA EMPLOYEE $Unlimited If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $Unlimited DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement. Date:July 2, 2016; Rain Date-July 3,2016, Location: Orient Yacht Club, Orient, NY, Additional Insured(s) Orient Yacht Club; Orient Fire Department;Town of Southold;State of New York;Greenport Shipyard; CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orient Yacht Club THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. BOX 161 ACCORDANCE WITH THE POLICY PROVISIONS. Orient NY 11957 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Neville, Elizabeth From: Neville, Elizabeth Sent: Friday, May 27,2016 12:55 PM To: 'orientfd@optonline.net' Cc: 'peter.mcgreevy@gmail.com' Subject: Fireworks Application by Orient Yacht Club Dear Chief Ed Loper,Jr., I am in receipt of a fireworks application by the Orient Yacht Club. The'Town of Southold requires a letter from the Fire Chief of the District in which the display will take place before I can present it to the Town Board for approval. The letter can be addressed to me and dropped off at the Southold Town Clerk's Office or mailed to me at the address below. The letter must state that you are aware of this fireworks application and approve of it. Thank you. Regards, Elizabeth A. Neville,MMC Southold Town Clerk&FOIL Officer PO Box 1179 Southold,NY 11971 Tel.631765-1800,Ext.228 Fax 631765-6145 Cell 631466-6064 1 Neville, Elizabeth From: Loper, Edward G. (CTR) <Edward.G.Loper@ST.DHS.GOV> Sent: Tuesday, May 31, 2016 10:36 AM To: Neville, Elizabeth Subject: Orient Yacht Club Fireworks Attachments: Orient Yacht CIub0001.pdf Elizabeth, Please find attached the letter regarding the Orient Yacht Club fireworks application we briefly discussed this morning. I will also send this letter to you in the mail tomorrow. Let me know if you need anything else. My cell#631-830-7401 Home email-loper98@optonline.net Note :The email I am sending this from is my work email at Plum Island Animal Disease Center.You may reply to this email if you choose as I do not check my home email while at work. Thanks Ed Loper Jr Chief Orient Fire Department 1 Neville, Elizabeth From: /atley, Martin Sent: Wednesday,June 01,2016 8:40 AM JUN To: Neville, Elizabeth Cc: Kruszeski, Frank, Blasko, Regina Subject: RE: Emailing: Fireworks 7_20160531121102 Southold Town Clerk Attachments: Orient Fireworks.xls I have no objection to this fireworks display being approved, contingent with U.S.Coast Guard approval. I have scheduled the necessary manpower for the event and the cost analysis is attached. Martin Flatley,Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 -----Original Message----- From: Neville, Elizabeth Sent:Tuesday, May 31, 2016 4:32 PM To: Flatley, Martin<mflatlev@town.southold.nv.us> Subject: RE: Emailing: Fireworks 7_20160531121102 Thank you, Marty. Betty -----Original Message----- From: Flatley, Martin Sent:Tuesday, May 31,2016 4:15 PM To: Neville, Elizabeth Subject: RE: Emailing: Fireworks 7_20160531121102 I'll have it to you before the end of the week Betty. Martin Flatley,Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 -----Original Message----- From: Neville, Elizabeth Sent:Tuesday, May 31, 2016 3:16 PM i Neville, Elizabeth From: Fisher, Robert Sent: Tuesday,June 07, 2016 9:21 AM To: Neville, Elizabeth Subject: Orient Yacht Club Fireworks Betty I thought I had replyed.Sorry for the delay. I have no reservations about this event or the location. Robert Fisher Fire Marshall, Town of Southold robert.fisher@town.southold.ny.us (W) 631-765-1802 - (C) 631-786-9180 PRIVILEGED AND CONFIDENTIAL COMMUNICA TION CONFIDENTIALITYNOTICE' 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 ore not the intended recipient,you ore 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 a-mail and delete the original message. From: Neville, Elizabeth Sent: Monday,June 06,2016 2:08 PM To: Fisher, Robert<Robert.Fisher@town.southold.nv.us> Subject:Orient Yacht Club Fireworks Hi Bob, I am checking my file for the Orient Yacht Club Fireworks Application. I don't believe I received a response from you on this? Please advise. Thank you. Betty Neville Elizabeth A.Neville, MMC Southold Town Clerk&FOIL Officer PO Box 1179 Southold,NY 11971 Tel.631765-1800,Ext.228 1 Neville, Elizabeth From: Neville, Elizabeth Sent: Tuesday, May 31, 20161:43 PM To: Spiro, Melissa Subject: RE: Emailing: Fireworks 7_20160531121102 Tracking: Recipient Delivery Spiro,Melissa Delivered:5/31/20161:43 PM Thank you, Melissa Betty Neville -----Original Message----- From:Spiro, Melissa Sent:Tuesday, May 31, 20161:42 PM To: Neville, Elizabeth Subject: RE: Emailing: Fireworks 7_20160531121102 This is not preserved property. -----Original Message----- From: Neville, Elizabeth Sent:Tuesday, May 31, 20161:20 PM To: Flatley, Martin<mflatlev@town.southold.nv.us>; Fisher, Robert<Robert.Fisher@town.southold.ny.us>;Spiro, Melissa<Melissa.Spiro@town.southold.nv.us> Subject: Emailing: Fireworks 7_20160531121102. Attached, please find a request for a fireworks permit by the Orient Yacht Club for July 2,2016 for your review and recommendation. Betty Neville Elizabeth A. Neville, MMC Southold Town Clerk& FOIL Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext. 228 Fax 631765-6145 Cell 631466-6064 Your message is ready to be sent with the following file or link attachments: Fireworks 720160531121102 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 To: Flatley, Martin<mflatlev@town.southold.nv.us>; Fisher, Robert<Robert.Fisher@town.southold.nv.us>;Spiro, Melissa<Melissa.Spiro@town.southold.nv.us> Subject: RE: Emailing: Fireworks 7_20160531121102 Thank you for the update. The next Town Board is June 14th. Betty Neville -----Original Message---- From: Flatley, Martin Sent:Tuesday, May 31,2016 2:36 PM To: Neville, Elizabeth; Fisher, Robert;Spiro, Melissa Subject: RE: Emailing: Fireworks 7_20160531121102 Betty, I am working on this application.We will need to supply marine units to secure this zone around the fireworks display and I am working on their scheduling now.Although the Orient FD may feel their fire boat can provide security around this site,they do not,have the authority to do so. Once I set this up, I will talk to Orient FD about working together on this project. Martin Flatley,Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York,11958 631-765-3115 -----Original Message----- From: Neville, Elizabeth Sent:Tuesday, May 31,20161:20 PM To: Flatley, Martin<mflatiev@town.southold.nv.us>; Fisher, Robert<Robert.Fisher@town.southold.nv.us>;Spiro, Melissa<Melissa.Spiro@town.southold.nv.us> Subject: Emailing: Fireworks 7_20160531121102 Attached, please find a request for a fireworks permit by the Orient Yacht Club for July 2,2016 for your review and recommendation. Betty Neville Elizabeth A. Neville, MMC Southold Town Clerk& FOIL Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext.228 Fax 631765-6145 Cell 631466-6064 Your message is ready to be sent with the following file or link attachments: Fireworks 720160531121102 2 6EoacCsCERTIFICATE OF LIABILITY INSURANCE` oo ie 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 pollcy(Ies)must 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 RECEIVED CONTACT ARS Insurance Agency RECEIVED NN GGLLJJ PHONE o,Ext) 877 234-4420 (ac,No) (877)234-4421 10825 Old Mill Rd �r E-MAIL Omaha, NE 68154 ^� 20 ADDRESS a�_ PRODUCER CUSTOMER ID# (877)234-4420 INSURER(S)AFFORDING COVERAGE NAIC# INSURED SOUthold Town Cerk INSURER r.al Indemnity Co. 28258 Pyrotechnigue By Grucci, Inc. INSURERS dba Pyrotechnigue By Grucci, Inc. INSURER 20 Pinehurst Dr INSURER D Bellport, NY 11713 INSURER E CTL 1273 1187121 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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY ❑ ❑ DAMAGE TO RENTED CLAIMS PREMISES(Ea occurrence) $ MADE M OCCUR MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE- $ — - -- - GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 17 POLICY PROJECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO ❑ ❑ (Ea accident) $ ALL OWNED AUTOS BODILY INJURY Perperson) $ SCHEDULED AUTOS BODILY INJURY Per accident $ HIRED AUTOSPROPERTY DAMAGE Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE ❑ ❑ AGGREGATE $ DEDUCTIBLE '-'- $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY y/N X TORY LIMITS ER ANY PROPRIETOR/PARTNER/ 73-474435-01-01E L EACH ACCIDENT $ 3_000,000 AAEXECUTIVEOFFICER/MEMBER ® N/A 05/27/2016 05/27/2017 EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ 1,000.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach Acord 101,Additional Remarks Schedule,if more space Is required) Date: July 2, 2016 Rain Date: July 3, 2016 Location: Orient Yacht Club, Orient, NY CERTIFICATE HOLDER CANCELLATION TCN111 Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOP7n Hall 53095 Maria Road THEIPOLICY PROV S ONS.RATION DATE OF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH South Hold, NY 11971 AUTHORIZED REPRESENTATIVE /) CJ V PC937411 ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD ©19 8-2009 ACORD CORPORATION. All rights reserved May 6,2016 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: Orient Yacht Club Location and Date of Fireworks Display: Barge off Orient Yacht Club 2110 Village Lane, Orient,NY 11957 July 2,2016—Rain Date July 3,2016 @ Approximately 9:15 PM Chief Pyrotechnician: Health: Age: Years Experience: Anthony Magno Excellent 61 38 Product: Not to Exceed 1952 Firework Shells and 4500 Illuminations 1.3G&1AG explosives, UN0335,Maximum Aerial Shell Diameter= 8 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 (631) 286-0088—Phone (631) 286-9036—Fax (516) 658-4486- Cell Fireworks by Grucci,Inc. Office#: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 Bellport,NY 11713 E-mail:erubio@gmcci.com THE FIRST FAMILY OF FIREWORKS ink., May 6,2016 �I I DISPLAY: Orient Yacht Club FROM: Edward Rubio Re: July 2,2016 Fireworks Displays / Rain Date:July 3,2016 SHELL SIZE NOT TO EXCEED 8" SHELL SIZE: QUANTITY IN PCS. Grucci Grand Illuminations - 4500 21/2- 3" - 1020 4" - 325 5" - 300 6" - 275 8" - 32 10" - N/A 12" - N/A 24" - N/A Grucci Grand Illuminations = Gerbs,Mines, SPX,Comets,Roman Candles Water Falls, Strobe Pots 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. Total:Not to exceed 1952 Firework Shells and 4500 Illuminations Type: Fireworks UN0335 (Display Fireworks) (Explosive 1.3G) Fireworks UN0336 (Special Effects) (Explosive 1.4G) Thank You, U,"J Edward Rubio Logistics Manager Fireworks by Grucci,Inc. Cell: 516-658-4486 Fireworks by Grucci,Inc. Office#: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 Bellport,NY 11713 E-mail: erubio,_gruccl.com r THE FIRST FAMILY OF FIREWORKS Attachmetit 1 fa, Eastern Service Center 1701 Columbia Ave. U.S.Department Operations Support Group College Park,GA,30337 of Transportation AJV-E2 Company Name: Fireworks by Grucci Email Address of Person Submitting Request: vvaz@grucci.com Event blame: Orient Yacht Club Display Date: July 2, 2016 Rain Date: • July 3, 2016 Display Start Time: 9:15 PM Duration of Fireworks Display: 16 - 17 minutes Max Height of Fireworks 8" max with height of 800' Barge off Orient Yacht Club City or Town and State(Physical Address): 2110 Village Lane, Orient, NY 11957 Latitude. 41° 08' 02.71" (North) Longitude: .72' 18' 34.28" (west) List-the Closest Public UseAirportWithin-25 Nautical Miles of the Display if the Fireworks Will Reach.or Exceed 500 Ft. ISP Special Motes: L,�U�iiawuiltt isuiiut'I1CSh1Uj}�1i]IdL3i11111e4Y0T1�i�oc.Laules iu� U�U � i02�10.�locC�%•Ti0 12/6/2013 May 5,2016 TO: Mr. Steve Papa COMPANY: U.S. Fish&Wildlife Service E-MAIL: steve papkfws.gov PHONE: 631-776-1404 x 201 FAX: 631-776-1405 FROM: Edward Rubio TOTAL PAGES: 3 Dear Mr. Papa: Attached please find site map and the plover protection plan for the Fireworks Display noted below: EVENT: Orient Fire Department LOCATION: Barge off Orient Yacht Club 2110 Village Lane, Orient,NY LATITUDE: 41'08'02.71"N LONGITUDE:72° 18'34.28"W DATE: July 2,2016 RAIN DATE: July 3,2016 TIME: . Approx. 9:15 PM DURATION: 16- 17 minutes We would appreciate your assistance in getting a notice out to the Coast Guard with copy to us of your agency having no objections to this site being used. Thank you for your help and cooperation in this matter. Sincerely, 4 Edward Rubio Logistics Manager Fireworks by Grucci,Inc. Cell: 516-658-4486 Fireworks by Grucci,Inc. Office#: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 Bellport,NY 11713 E-mail:info@grucci.com THE FIRST FAMILY OF FIREWORKS May 6,2016 TO: Kevin Jennings COMPANY: Bird Conservation Biologist NYS DEC Region 1 50 Circle Road SUNY Stony Brook Stony Brook,NY 11790 PHONE: 631-444-0308 FAX: 631-444-0272 EMAIL: Kevin.lennings@dec.gy.gov FROM: Edward Rubio TOTAL PAGES: 2 Dear Mr.Jennings: Below please find display information for a coming contracted fireworks display with our site plan for this event attached. EVENT: Orient Yacht Club LOCATION: Barge off Orient Yacht Club 2110 Village Lane, Orient,NY LATITUDE: 41'08'02.71"N LONGITUDE:72° 18'34.28"W DATE: July 2,2016 RAIN DATE: July 3,2016 TIME: Approx. 9:15 PM DURATION: 16 - 17 minutes We would appreciate your assistance in getting a notice out to the Coast Guard ASAP with copy to us of your agency having no objections to this site being used. Thank you for your help and cooperation in this matter. Sincerely, �("/ , Edward Rubio Logistics Manager Fireworks by Grucci,Inc. CELL: 516-658-4486 Fireworks by Grucci,Inc. Office#: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 Bellport,NY 11713 E-mail: erubioggmcci.com THE FIRST FAMILY OF FIREWORKS ACO. DATE(MM/DDNYYY) � CERTIFICATE ®F LIABILITY INSURANCE 06/03/2016 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 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 RECEIVED NAMEACT i PHONE _FFAX ARS Insurance Agency (A/C,,No,Ext A/C,No 877 234-4420 ( ) (877)234-4421 10825 Old Mill Rd E-MAIL Omaha, NE 68154 JUN — 7 2016 ADDRESS I PRODUCER CUSTOMER ID# (877)234-4420�,` INSURER(S)AFFORDING COVERAGE NAIC# INSURED Out Town CLrk INSURERA: Cntinental indemnity Co. 28258 Pyrotechnigue By Grucci, Inc. INSURER B• dba Pyrotechnique By Grucci, Inc. INSURER C: 20 Pinehurst Dr INSURER D Bellport, NY 11713 INSURER E. CTL 1273 1187121 INSURER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDNYY MM/DDNYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY ❑ ❑ DAMAGE TO RENTED CLAIMS PREMISES(Eaoccurreme) $ MADE OCCUR MED EXP(Anyoneperson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OP AGG $ POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO ❑ ❑ (Ea accident) $ ALL OWNED AUTOS BODILY INJURY Perperson) $ SCHEDULED AUTOS BODILY INJURY Peracgdent $ HIRED AUTOSPROPERTY DAMAGE Per accident $ NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ i t RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TO Y LI TS E ANY PROPRIETOR/PARTNER/ E.L EACH ACCIDENT $ 1 0 0 01000 i A EXCLUDED OFFICER/MEMBER N/A 73-474435-01-01 05/27/2016 05/27/2017 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 1 000,000 If Ves,describe under