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Home My WebLink About2017 Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday,August 30, 2017 4:50 PM To: joanne@bayfireworks.com; 'Diane Radigan' Cc: Flatley, Martin; Fisher, Robert; Duffy, Bill Subject: Emailing: Pec Landing Fireworks Pe_20170830154004 Attachments: Pec Landing Fireworks Pe_20170830154004.pdf Attached, please find the 8/29/17 Southold Town Board Resolution approving the issuance of your Fireworks Permit, together with the issued permit. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage 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: Pec Landing Fireworks Pe_20170830154004 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. $°© RESOLUTION 2017-735 + a SCHEDULED DOC ID: 13314 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2017-735 WAS SCHEDULED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON AUGUST 29,2017: RESOLVED that the Town Board of the Town of Southold hereby approves the issuance of a fireworks permit by the Town Clerk to Peconic Landing at Southold,Inc. for a fireworks display on September 3, 2017 at 7:15PM (Rain Date: September 4,2017 at 7:15 PM), on the Peconic Landing's property at 1500 Brecknock Road, Greenport,New York,upon the payment of a single fee of$100 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 ELIZABETH A.NEVILLE�,MMC ��. Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 4 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS I& Fax(631)765-6145 MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER ®� Telephone(631)7 FREEDOM OF INFORMATION OFFICER www.southoldtownnygov 0 ny.go 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: PECONIC LANDING AT SOUTHOLD,INC. A PERMIT FOR THE PUBLIC DISPLAY OF FIREWORKS by said organization in accordance with the provisions of Section 405.00 of the Penal Law of the State of New York, on the time and place set forth in the application therefore, as follows: September 3,2017 at 7.15 PM (Rain Date: September 4,2017 at 7:15PM) on Peconic Landing's 060erty located at 1500 Brecknock Road, Greenport,NY 11944 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 a 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 into 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 a-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 concluded 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. ay Efizabft A.Neville, Town Clerk own of Southold Suffolk County,New York (TOWN SEAL) Date: August 29,2017 THIS PERMIT IS NOT TRANSFERABLE RESOLUTION 2017-735 ADOPTED DOC ID: 13314 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2017-735 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON AUGUST 29,2017: RESOLVED that the Town Board of the Town of Southold hereby approves the issuance of a fireworks permit by the Town Clerk to Peconic Landing at Southold,Inc. for a fireworks display on September 3,2017 at 7:15PM (Rain Date: September 4,2017 at 7:15 PM), on the Peconic Landing's property at 1500 Brecknock Road, Greenport,New York,upon the payment of a single fee of$100 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 CHIEF WAYNE MILLER 1 M� �„/ (631)477-9801 -STATION 1 1sTASST.CHIEF JEFFREY WEINGART ,; (631)477-8261 STATION 2 2ND ASST.CHIEF SUSANO JIMENEZ (631)477-1943 CHIEFS OFFICE 1845 (631)477-4012-FAX CHAPLAIN T.MURRAY Af.is, THIRD STREET•P.O.BOX 58 ASST.CHAPLAIN C.KUMJIAN GREENPORT,NY 11944 TREAS/SECRETARY J.KALIN LON6Email:gfdfire@optonline.net www.greenportfd.org Organized 1845 To Whom It May Concern, Peconic Landing will be having a fireworks display on September 3rd 2017 with a rain date of September 4th 2017. We will be standing by with at least 2 pumpers from Greenport and possibly a couple of additional apparatus from neighboring departments. If you have any questions-please feel free to contact me at the number below. RECEIVED AUG 2 9 2017 Southold Town Clerk Firematically, Wayne D. Miller Chief Engineer Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday, August 23, 2017 4:32 PM To: 'Diane Radigan'; Duffy, Bill Subject: RE: Peconic Landing fireworks Diane, Yes, it has been approved by the Fire Marshall, Police Chief and Town Attorney. I am just,waiting for the Greenport Fire Dept. Chief to bring me a letter stating they are aware of the application and have no objections. I should have it by the end of the week. As soon I receive it , I will place the resolution on the agenda for approval next Tuesday on August 29tH Elizabeth A. Neville,MMC Southold Town Clerk,Registrar of Vital Statistics Records Management Officer;FOIL Officer Marriage Officer PO Box 1179 Southold,NY 11971 Tel.631765-1800,Ext.228 Fax 631765-6145 Cell 631466-6064 From: Diane Radigan [mailto:dradigan@peconicianding.org] Sent: Wednesday, August 23, 2017 3:32 PM To: Neville, Elizabeth; Duffy, Bill Subject: Peconic Landing fireworks Hello Elizabeth and Bill, First, my apology for the insurance certificate being issued without the town listed—my error. Just checking in to see if you were able to circulate an email/verbal request for approval regarding our application for the fireworks event. We are just 10 days out and I want to be sure the town is satisfied with all requirements! Thanks, Diane DIANE RADIGAN Director of Resident Seances 1500 Brecknock Road LA :7WNG Greenport,NY 11944 Tel (631)477-3800 x373 Fax(631)477-3900 1 Neville, Elizabeth From: Neville, Elizabeth Sent: Monday, August 21, 2017 2:01 PM To: gfdfire@optonline.net' Subject: Emailing: Fireworks Aplic Pec Land_20170821125540 Attachments: Fireworks Aplic Pec Land_20170821125540.pdf Importance: High Hi Wayne, Attached, please find Fireworks Application of Peconic Landing for 9/3/17 rain date 9/4/17. Please review and send me your letter of approval of the event being held in the Greenport Fire District. If you have any questions, please call me at the number listed below. Thank you. Betty Neville Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage 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 Aplic Pec Land_20170821125540 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. i Neville, Elizabeth From: Flatley, Martin Sent: Thursday,August 17, 2017 11:56 AM To: Neville, Elizabeth Subject: RE: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust I have no objections to this application being approved. 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:Thursday,August 17, 201711:53 AM To: Duffy, Bill<billd@southoldtownny.gov>; Fisher, Robert<Robert.Fisher@town.southold.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>;Spiro, Melissa<Melissa.Spiro@town.southold.ny.us> Subject: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust Importance: High Please respond at your earliest convenience with your comments/recommendations. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage 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: Applic Fireworks PecLndg_20170808141657 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. Neville, Elizabeth From: Fisher, Robert, Sent: Wednesday,August 23, 2017 11:58 AM To: Neville, Elizabeth Subject: RE: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust Betty I approve this application. Bob Robert Fisher Fire Marshall,Town of Southold robert.fisher@town.southold.nv.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: Neville, Elizabeth Sent:Thursday,August 17, 201711:53 AM To: Duffy, Bill<billd@southoldtownny.gov>; Fisher, Robert<Robert.Fisher@town.southoId.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>;Spiro, Melissa<Melissa.Spiro@town.southold.ny.us> Subject: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust Importance: High Please respond at your earliest convenience with your comments/recommendations. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage 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: Applic'Fireworks PecLndg_20170808141657 i Neville, Elizabeth _From: Duffy, Bill Sent: Monday,August 21, 2017 7:49 AM To: Diane Radigan; Neville, Elizabeth Subject: RE:fireworks insurance Attachments: image001 jpg; image003.png Looks good to me From: Diane Radigan [dradigan@peconiclanding.org] Sent: Friday,August 18, 2017 9:11 PM To: Neville, Elizabeth; Duffy, Bill Subject: Fw:fireworks insurance Revised certificate as requested. Thank you for your assistance and patience! Diane From:Steven Carroll Sent: Friday,August 18,2017 3:57 PM To: Diane Radigan Subject: FW:fireworks insurance From:Wyatt Schmidt [mailto:wyatt.schmidt@cookmaran.com] Sent: Friday,August 18, 2017 3:38 PM To:Steven Carroll Subject: FW:fireworks insurance Steve, Attached please find the certificate you've requested. If there are any issues with this certificate please contact me directly. I will make it a priority to correct the certificates and get it back out to you right away. For all new certificate requests please email to certificates@cookmaran.com<mailto:certificates@cookmaran.com>. For faster service please put this in the top of the body of your email request. FILENO:PECOLAN Thank you &have a great day! Wyatt Schmidt I Service Assistant I Commercial Insurance I Cook Maran 300 Hampton Road Southampton, NY 11968 Tel: 631-702-8549 Fax: 631-287-2207 wyatt.schmidt@cookmaran.com<mailto:wyatt.schmidt@cookmaran.com> Website: http://www.cookmaran.com<http://www.cookmaran.com/> [cid:image001.jpg@01D29D84.C79A5570] 1 Neville, Elizabeth From: 5Piro, Melissa _ Sent: Thursday,August 17, 2017 1:33 PM To: Neville, Elizabeth; Duffy, Bill; Fisher, Robert; Flatley, Martin Subject: RE: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust This is not Town preserved land. Melissa -----Original Message----- From: Neville, Elizabeth Sent:Thursday,August 17, 201711:53 AM To: Duffy, Bill<billd@southoldtownny.gov>; Fisher, Robert<Robert.Fisher@town.southold.ny.us>; Flatley, Martin <mflatley@town.southold.ny.us>;Spiro, Melissa<Melissa.Spiro@town.southold.ny.us> Subject: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust Importance: High Please respond at your earliest convenience with your comments/recommendations. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage 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: Applic Fireworks PecLndg_20170808141657 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 I A, • m BM9 Town Hair 63096 main-Read 'it) CLERK � j?,O.Box 1179 - co/�y„�' At ,�{�* (��s �g ao g dd,�+New r�York y 111971 o XiTAL kx-;M d V� d° -V,PS�(3�-{7,{�§i R ES L.:.._ OP R=Om8 C)Y+`1+�r1N,W C3F1�'ICET� •"► eQixtholclta�rn na �i#orls.siet /� (.I{. Ftaioj M Or 'CyMMON OFFICER AUG - 3 2017 TCVN 0766molbSouthold To ;isr APPLICATION' PERWhT TO DISPLAY VIftVVORKS fi�FPti1CATION,IS HB?,EBY MA13E; puarsusnt iothe•provisi6ns of Section 4115.0,0 of the Penal taw of the Ststo.ti#'liNaNv-York,fax a�pehnitp d,splay�rewor,ks as hereinafter specified, DISPILAY IS TO BE Si,(*S41kD BY Pecohlo landft at Southold Inc. PRINCIPAL OVFICE Art,_156.0 Bredmbck Rtiad,Greeneort, NY 17944 DATE& , " • QI1,DISPLiAY September 3, 2017 7:15^prh - MA.CT LOCATTION O DISPLAYPeaonic lan&2 property 9UPFOLIC,POUNly, TAX MAP�B�IEi FOR SITE RAIN DATE ktih& S§O' rr6er 4, zfl 17 Q 7:15 prr� Tie#allaying persons"_re to be in cbarge of the actual sha�oti�ug+af th e Di erks: Name Age- E trf*e Physical Cunditi+uo Edward Metz dcb: 2/25/58_ Itl, years + Health: Excellent - ,(A.ddationdl aiaAid"aniiinfamaatiiin M"a 'be Wbmiuc4 on ah attaoiieii sheet, Np ber and type of fireworks is a$follows: '1.3G Fireworks,: 2.5 inch=695. Calces=18 Manbef 'and ,Piave of .storage 91 fireworks prior tai diilil<ay: Deliver w111 be day of display -,:, A,tt4ched hereto and mha0p a pa#of hereof is a diag� tr�of the groumu ote.�whiih ghe > p1 is to he held: AOt attriched is;h ee titicate or polio oi�ia3surance coverage. N#3'I'1 CE -Writ#en- per»iission,*ath signature-of the Prep &t ner,-mqustbe.subm tied with the Aggslicativn, ' FEE; . $1,00 *pi pf 4r mh atiof dee isolic 4bf aldditional infoet hation Si'paturc of Wplif6a 17 Date;of Agplicptiaah ELIEZABETH A.NEVILLE,4Mq � Town Hall,53095 Main Road 'T'OWN CLERK P0.1Box i 179 Southold,New Yott 11971 REGISTRAR OF VITAL STATISU Pax(631)'765-6.145 MARRIAGE,bFFIC'E2 ' Telepjiga e{631}765-1${}(} RECORD9 MANAORMENt bFFICER www. uftldtowhny.gov FkEM) m orF INFoRmATioN oppiam OFFICE,OF E TOWN CLERK Tovvw flF SOUTHOLD -INSTRUCTIONS FOR R1_$PLAY OPFIREWORKS I. Naine of b.bdy spdnsoring firewoxlcs display. 2. The date and bane of day at which the ffe*oxks display is to be held. 3. The euct to ation plated for'the fireworlc4 display,including TAY WP2tilUI ME& 4. The age;experience and physical charaeter stics of the persons who are to .x do the actLW discharging of the firewo�& S. The numer and kind of£iaewor to be discharged. 6. The manner and place of storage of stash_firev 6M,prior to the display, 7. A.diagram of the grounds on which the display is to be held,showing the point at which the Breworks are tri�166 disetaarg4 the location of all buildlugs, highways and ofti lines 'of cvmasitariicatipn, the lines bbhiard!l hich the audienoe will be,kesirained and'lociition of all nearby ire: ,telegraph or teleph(iaie lines or other overhead obstructions: 8. :Such rather iabi ativn as the Southold Town Clerk mo deem' necessaiy to protect per"soiis and property. Vritteii permission of the property owner is required. 9. An indganity insarance policy with liability coverage and indemnity prototiorc of$1,004,000.00 per persoti,.f'or bodily iimjanry, 1,00{},000.00 pt-r acoident;$1,000,000.00 property damage. iO. The Toft Clerk of'theTown of Southold rtiaast have the insurance policy in her possession before the fk&Works permit is issued. The wed insured must read:TOWN OF SOUTHOLD. ;Thirty- l30)T6Wh 6f -Southold POLICY 11. Application for a�ewcirks perrnft must be made at least ilays in advance of the date of the fire-works d (The above instructions are in accordance with the Penal Law, .Article 405 - Licensiatg and odzer provisions relating to.fnrec�+orlts.� . , * * * RECEIPT * * * Date: 08/08/17 Receipt#: 227175 Quantity Transactions Reference Subtotal 1 Fireworks 09032017 $100.00 Total Paid: $10000 Notes: Payment Type Amount Paid By CK#83445 $10000 Peconic, Landing Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 F Name: Peconic, Landing P. 0. Box 430 1500 Brecknock Rd Greenport, NY 11944 Clerk ID: BONNIED internal ID 09032017 ELIZABETH A.t'r1l+GVIII 4E,MMC �,�p'� ` 'Ibwn Hall,5390*in goad ;r6WN CLERK RO'.Baas 1179 Sdu€hold,New Yorks 11971 REGISTRAR OR VffAL S°xA'nVICS Fax{03917� 145 Iu1ARR ACE t3 FIf:ER IWrphone(631)765-180 RECORDS MANAdEMENT0FFR WWW.Southoldt6wnnygov OFFICA OF CLERK TOWN 4F 80UTH6m POLICY&r the Uguinke of Fireworks eri s 1. The'Town.anay grani a pei t for the display offireworks°by municipalities,Fair assaciAons,snlua rrrient parks,Veisong or q rgani#tions of i divicltials. Penal Law' SbdtiOn 405M..M. 2. An-"org ization-qf igdNidua10 is a religious,+c€ e,or'comparable organizatin on. Atty. Gen No.2007A. W 3.. Fireworks pertnits shall indicate that the display roust be concluded by 10:00 p.m,ifIheld Sunda-Thursday, l 1:00 p.T."if held friday or-Satur&y,and tlieere'sht ll bee nv'fte res fiction if held.on July 4: 4. No person.shail,engage in or allow the ma iifactur atieniblY,storage or display of any fim vvrl s or p rateehnics display without first ob$aining a permit ispad by the Town derrk. A,co lebA stpplic4 lon fir display of fli Oiyork�m" lie-received liy.i e Town i�kik it Dmi—imum of All days pr of r io-the date of display. The permit appiicat', for any frew"ks or"motechnics.display shall be accompanied.hy the Nib " (a)" a copy of"axalid certificate of coinpete&y as a:p' ytrot6bhnicidn for the individual supervising the fii4ng cif the display; (b) 'Ceki.fioate of Insurance noshing the Tonin of S6ulold as addWwo insured with _coverage Iitnits of$2,001},000 for public liability-an4$2,0,00,Q00.fox prop \ damage; (G) Detailed diagram show, ng location of fireworks discharge -minithuin sel aratio*n."distances-in accordancewitli the app .cable regwirements of Penal Law. Section,ibl(2); (d) A copy of the contract with fireworks display+compmy,-.and (e All applications sWl require fhe apprpval of the Fire Chief ofthe District in .which the displays will take,place and fhb Fire I�lars6l`b'afore tieing pres�aited for approval by thuTown Board. r r S. All applications'for a.fireworks permit shall be subject to an application fee in an amount of1,00,00,together with a processing fe�ia-affi amount to be detemani€ed by the Town Board'#b co-ver the T6vh s costs for in6nit6iffig and ehfbfdng cdmOliance with,tlae Penal Taw. 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M Ec ;4101u""P'057"-Ommi M.M40 xv m€rist"s wpm pro+ nt's!;3;,€,1°ovi **gxo SW!IVI"a+.g3 tilq Rx tsssWl sRt a;a-Z�!;ung€t,; k;,UMF,rljS all 10 1 pg I COMM r+�J` s�38I1 �� ima.kYt��llC�t'fft:i'.�ft.�•s'4�'�a i.�43i- �Eti t��"lRf� 1!WJ-3j j� !'j ojdx I� xT ftF 3Us4tif estl,(� �+ Client#:535 PECOLAN DATE(MMIDDIYYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 8/18/2017 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(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). PRODUCER NAME: Cook Maran Commercial Lines PA"/c°,"N Ext,631 324-1440 ao No: 631324-3980 Cook Maran ADDRESS: certificates@cookmaran.com 461 Pantigo Road INSURER(S)AFFORDING COVERAGE NAIC# East Hampton,NY 11937 INSURER A:Steadfast Insurance Co. 26387 INSURED INSURER B:Ironshore Specialty Insurance C 25445 Peconic Landing At Southold,Inc. INSURERC:Maine Employer's Mutual Ins.CO 11149 1500 Brecknock Road INSURER D:American Guarantee 8r Liability 26247 Greenport,NY 11944 INSURER E 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY Y GL0980820703 04/02/2017 04102/2018 EACH OCCURRENCE $1,000,000 X CLAIMS-MADE I OCCUR PREMISES Ea occurrence $100,000 MED EXP(Any one person) $10,000 PERSONAL BADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $3,000,000 X POLICY[—]ECT F LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER $ D AUTOMOBILE LIABILITY BAP980820603 04/02/2017 04/02/201 COMBINED SINGLE LIMIT 1 000 000 Ea accdent s e X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ NON-OAUTOS AUTOS $ X HIRED AUTOS X AUTOSWNED Pear a ciden DAMAGE B UMBRELLA LIAB OCCUR 003113300 04/02/2017 04/0212018 EACH OCCURRENCE $10,000,000 X EXCESS LIAB X CLAIMS-MADE AGGREGATE $10,000,000 DED I X RETENTION$1000 $ C WORKERS COMPENSATION 3102804785 04/02/2017 04/02/201 X PER OTH- AND EMPLOYERS'LIABILITYSTATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? F N 1 A (Mandatory In NH) E L.DISEASE-EA EMPLOYEE $1000000 If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 RECEIVED DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Fireworks Display Sunday September 3th,2017(Rain Date September 4th,2017). The Town of Southold is included as additional insured with respect to general liability as required by a AUG 2 1 2917 written contract. �o Southold Town Clerk CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 53095 Route 25,PO Box 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971-0000 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1119818/M809848 WSCHM POLICY NUMBER: CPP0101284-47 COMMERCIAL GENERAL LIABILITY GC 24440509 WAIVER F TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO U This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL L#ABILtTY COVERAGE PART PRODUCTS€OOMPLETED OPERATIONS L"ILITY COVERAGE PART SCHEDULE Kane Of Person Or Organization, Pe nic Landing at Soulhold Inv,Bracknock ball Foundation Inc;Pemnic Landing Housing Association CDoperalive Inc, A be 91-mm at Pacmic Landing Assisted Living Residence Ism:Panic Landing Har Health SerAc Inc;Tarn of Soultxald as respects to the negligence of the Narnad Insured wti:ls at Peconic t anding at Southold,Greenprrrt NY for the period of 09f03 ran data G5J04 Information re Sired to Cram Ir to this Schedule,if not shown above,will be shown in the Declarations_ The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions; We waive any tight of recovery we may have against the person or organizatbri shown in the Schedule above because of payments we make for injury or dasriage arising out of your ongoing operations or "Your work"done under a contract with that perm or org=anization and Included In the "products- completed p ucCompleted operations hazard", This waiver appries only to the parson or organization shown in the Schedule above. CG 24 04 05 09 Q Insurance Services Office, Inc.,2008 Page i of 1 0 1STATE Compensation 0 Workers' CERTIFICATE OF INSU RAN COVERAGE UNDER THE NY$ DISABILITY BEHEFITS LAW Soafd 1PAP,71. To be completed by Disability 8enel`tts CatTer or Licensed Insurance Agent of that Carrlt#r � i 1a_Legal Name&Addfass of Insured(ease stmt ams orgy) 11b.Business Te�tsarm Nurrrcmr yf boss d .�k � I (515)a97-5500 PYRO ENGINEERING W t)13A SAYPIPEWORKS 1rr.NYS unemployment Insurance Employer R- traffora Numbenif r 999 SOUTH OYSTER BAY RD STE 111 ins€and BETHPAGC,DIY 11714 f Work Locatlon of Institad{0aw mejuw If i swags hificap/timed to ` certarn locations rn,New York SMK i e.a Wnap-up Pa 1 Ir FedOrZi Emooyw IderrMealian Number of tnsurad or Sal Sem4rity I � 7i33 �37 i i 2,Nwe and Aditss of Enlily Requesft Prod of gage 3a.Name of 3rsirra C,n-:&- {Entity Being i i&l as the Gert S to Hol New York State Insurance Ew.d(iMl 3'b' ' try,t4isnbsr of Erdify Listed in i3ax'1 a" PECOWC LANDINQ AT 5£IUTf IOLD>INC. DIX$213 59-1 � 1600 BRECKNOr—C ROAD r i t GREENPORT,MY 11944 3n,f'ca!40acffyi6 ped K 0110412M3 to 0144f2i018 rs . icy _ ....-...,� E A+ AR of the employees afQibie wWer ting Now York Msabiey 1;-refits Law 'I] -6.Oril)y the.ft lowing+mss or daces of ms's anV4oyeSs, r i i Under pam9ty d r,I cerlify that I-am an sly repmsentafive ct rzer>ed amt of Iha imwence carrier foforoncod ekbove and that the named I insured hes NYS Dksabil4y Bits irALwance tevatage as described above. I Date Signed 411712017 By Jpssph J.Iasi E9t 'n- rsP ca3ur rrsau�iianzrd€€tres:�nticeerVYgi�c tat�em�# ^i rafbstw m cirlia} T phone�Nwribs<(864)507'4332 Tide Dkectar of NYSW Dlsatsft Bensfits tmeurance _ IMPORTANT, If Rose W is t heck-ed,ertd iris ftp i,519nef by the Insurance ca.riere atithciriaed repr@5entaflve or MYS L�,wsad t w Agent of that carder,thm certificate i,COMPLETE-mail it tftracny to the cerate holder. i tf Bax"oar''is clacked,ahs cwte is NOT COMPLETE for purposts of Ssofign 224.Sim.6 of its DisahOdy Bbnaft,Lavc I#Frivol he manes( 11 for completion to the Vfor s`4 nparrsal.bA r3bard,Da Plan:Acceptance Ung 328 State Strest.r;,chengc0tsty,NY 12345 [ART 2,To be Completed by the NYSWorkers'Compensation Board(Only if Box"4b"of Part 1 has been chocked) State of New York Workers'Compensation Beard I Acctrrdirpg to information maintained by ft NYS Wor 'Cornpensat0n ward,the above-named employer has complied with the NYS � Nsability Benefits Law with respW t0 all of hisiher employees. a 7 Date Signed By �aisrr ofta'lf$W �taissxai�c�,-d3�ii�sloys�is t Telaphwe Number T-ft Blease More:turfy insurance c yr-s Ir&nsad to twite NYS dtsa &,v b3 afflig ftumnco pokm and NYS fit rkwd insurance agents of those inswartce carni&&L-authorized is issue Fin DB-120.1. losurmce brokm are NOT aertttor&ed tis isque this fwm. DB-Imi (o-1s) Certificate Number 426027 l FMEWORKS DISPLAY HOLD HARMLESS AGREEMENT Between Peconic Landing at Southold,Inc. and PYRO ENGINEER.l1IG,INC. (Contractor) WITNESSETH: I. PYRO ENGINEERING,INC. (Contractor)agrees to indemnify and bold hammlcss Pecor&Landing at Southold,Inc. from and against any loss;damage or liability, including reasonable attorney's fees and expenses incurred by the latter entities said their respective employees,agents,volunteers or other representatives arising out of the installation,ging or disassembly of pyrotechnic equipment or device and/or the super vision and presentation thereof. 2. 17he applicant bas famished the Certificate of lmtance with limits of liability described below: Workers Compensation/Employers Liability: $1,000.000 per occurrence. General Liability:S 1,000,000 per ocourrence Automobile Liability:$1,000,000 Unbrella/Excess Liability: $9,000,000 per occurrence A true copy of the Certificate of Insurance is attached indicating the member entity and applicable associations.recreations or corninittees fanned by the member entity to organize the"event"mast be named as additional insured on all liability policies. 3. The facilities will be used for the following purpose.and no other: EVENT: Fireworks Dis la SHOW DATE: 913/17 RAIN DATE; 914/17 Dated. ` (Contractor) Witness. i ` C"V" F `L' SPON90R: Peconic Landing at Southold Inc. Fireworks Coueganu Pyro Engineering, Inc, dbabay Fireworks 999 S. Oyster'Bay Rd.,Suite I I l Bethpage,NY 11714 P: 515-597=5500/F: 516-597-5507 Show Date(s): 913/17 Rain Bate{s). 9A/17 ' Locafion: 13recUo&Hall., 1500 Bretknock Rd.,Gr eenpoit,NY Time: 7:15 pin_ 1.Total riumlier of Mass B shells being used:-2.5"==695. Cake s=18. Maximum shell size: 2.5 inches in diameter> 2. All shells are DOT approved. 3. Display will be-fired electrically and/or-manuallly. 4. Delivery td site will be approximately:12:00 noon. Set up will take approximately 4-5 hours. 5. Al displays Will Gdiriply`vith all requirenients as set forth in NYS Penal Gode 405 and 1NFPA 1123, 1124. 6. Pyro Engineering,'Inc. has complete uiideist ding of all rules and,regulatio"ns governing public fireworks displays and this display will be in accordance with those rules and regulations. 7. Personnel rept=esentirig fireworks display cclmpany'. Lead: Edward Mets(ISYS DOL license PR-2) 8, Technician(s): tbd SighedV " Fire w m dornpai ''Re prosenta6e ,„.»w_......m..,...« ,r{,,✓.>'.-:^:Ea y .r-.y.=_. .Y'r.p,._..,....�...-.'.��»-�••w n a »�-��»i-y ✓��i,..'K} ;, STA`fiE'064F_V�t YC? Y��;3EPAPT¢utEfF+3F 1 ABC ; IIIII��II l�'III�I'11��IlI�I IIII SII � '' tri^" IF FOUND, RETURN TO. s :EUIIU_ARD'.IrMETZ° DMV# 442513396 o EYES SRO NYSDOL — L&C UNIT r ' cuss:A. ,... - HAIR BLN ROOM 161 BUILDING 12 ANY g1SPl'AY:` .61 HGT 2 n 'STATE OFFICE,CAMPUS ,� > z ','�'; � =.,. e - ,.•ti ` ••-`` TN15,CA RD-MUST BE',CARRIED ALBANY NY 12240 tt511VG:PYROT _ , f s Neville, Elizabeth From: Neville, Elizabeth Sent: Friday,August 18, 2017 10:11 AM To: Duffy, Bill Subject: RE:fireworks Bill, I advised them yesterday as soon as I received the certificate that it must state "Town of Southold is an Additional Insured" in the box "Description of Operations". I am awaiting the new certificate. Betty From: Duffy, Bill Sent: Friday, August 18, 2017 10:07 AM To: 'Diane Radigan'; Neville, Elizabeth Subject: RE: fireworks We are only named as a Certificate Holder. Please have the Certificate amended to read that the Certificate Holder is an Additional Insured for the named event. After that we are good to go on my end. If you have any questions, please feel free to contact me directly. Thanks, Bill Duffy William M. Duffy, Esq. Town Attorney Town of Southold Southold Town Annex 54375 Route 25 (Main Road) P.O. Box 1179 Southold, Nww York 11971-0959 Office: 631.765-1939 Fax: 631..765.6639 Email: bill.duffv@town.southold.ny.us ATTORNEY-CLIENT COMMUNICATION;ATTORNEY WORK PRODUCT; INTER/INTRA AGENCY COMMUNICATION; NOT SUBJECT TO FREEDOM OF INFORMATION LAW DISCLOSURE; DO NOT FORWARD WITHOUT PERMISSION Note: Service of legal documents is not permitted via electronic mail or fax. The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain information that is privileged, confidential and exempt from disclosure under applicable law. Unintended transmission shall not constitute a waiver of the attorney/client privilege or any other privilege. If the reader of this message is not the intended recipient,you are hereby notified that any review, retransmission, conversion to hard copy, copying, reproduction,circulation, publication, dissemination or other use of, or taking of any action, or omission to take action, in reliance upon this communication by persons or entities other than the intended recipient is strictly prohibited. If you have received this communication in error, please (i) 1 notify us�immediately by telephone at 631.765.1939, (ii) return the original message and all copies to us at the address above via the U.S. Postal Service, and (iii) delete the message and any material attached thereto from any computer, disk drive,diskette, or other storage device or media. From: Diane Radigan [mailto:dradigan@peconiclanding.org] Sent:Thursday, August 17, 2017 4:44 PM To: Neville, Elizabeth; Duffy, Bill Subject: FW: fireworks Attached. Thank you . From: Catherine Prewitt [mailto:catherine.prewitt@cookmaran.com] Sent: Wednesday, July 26, 2017 1:19 PM To: Steven Carroll; Diane Radigan Subject: RE: fireworks Steve and Diane, The certificate for the Fireworks event is attached. Please let me know if you need additional information for the town. Catherine From:Steven Carroll [mailto:SCarroll@peconiclanding.org] Sent:Wednesday,July 26, 20171:12 PM To: Catherine Prewitt<catherine.prewitt@cookmaran.com> Cc: Diane Radigan<dradigan@peconiclanding.org> Subject: FW:fireworks Hello Catherine: Can you address the message below regarding fireworks? From: Diane Radigan Sent:Tuesday,July 25, 2017 4:51 PM To: Steven Carroll Subject: fireworks In addition to the insurance we obtain from the fireworks company, I think we normally get additional coverage from our .own carrier. No? The date is Sunday,Sept 3rd with Monday,Sept 4th as rain date. DIANE RADIGAN PtCONIC Director of Resident Services ` tix 1500 Brecknock Road N Greenport, NY 11944 Tel.(631)477-3800 x373 y Fax (631)477-3900 www peconiclanding.org This message is confidential and the property of Peconic Landing. It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know 2 1 � by reply and then delete it from your system. You should not copy the message or disclose its contents to anyone. This message is confidential and the property of Peconic Landing. It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know by reply and then delete it from your system. You should not copy the message or disclose its contents to anyone. PLEASE TAKE NOTICE: The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon,this information by persons or entities other than the intended recipient is prohibited. If you receive this transmission in error,please contact the sender immediately and delete the material from any computer. This message is confidential and the property of Peconic Landing. It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know by reply and then delete it from your system. You should not copy the message or disclose its contents to anyone. 3 CERTIFICATE OF LIABILITY INSURANCE �0411W21117`�S TW9 CERT14=9 IS OWED AS A,MATTER OF INFORMATION ONLY AND C-ONFPFCS NO RIGHTS UPON THE CERTIFICATE HOL,t3ER.TM CERTIFICATE DOES NOT AFFIf TIV Y OP- NEGATIVELY AMD. EXTEND OR ALTER THE l;O>ERAGE AFFORDED BY THE POLIE3M BELOW, THIS CERTIFtCATE OF fNSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSLMG INSURER(S). A4UTHOR290 ar.PIRF N1'ATvE 0Ft PtTOOLICER,ANQ THE CERTIFICATE H©LDEM IMPORTANT. IF the certificate hotdor is an ADDITIONAL INSURED,the policy(les)must two ADIXTIONAL INSURED pmvisFons or be+andtr"d. If SUSP.00 LTtON IS WAW 3,strbpect to the termR and icanddioxs of tits policy,t:Betarl0 p l$s MW ragulm ZIP efldorzammt A statement an this cerdficate dyes rMt canfvr s tits tcs tho 0010cma haul'In llrau of such a srrse sj. aRcanu t Allind sp ty In ce,rnc- Iulrrtit a I{fir 10451 GuN etvd Pim 727-547 3070_-_ - I 727:39T-5696 Tr"suralsfar4IRL 3=6.a81a ...�.-._._-, --- ��rr�lciagis�;y{s6er�ly.trns! �I9ul1s� l��v1:E I unseal ' NsumgA T.H.E.In9rxarreCt arty ---'- _12$58 1rmsuRE0 P°:STDEP sIcIrJF4�ItdC,3h 9r JRERBc ' I.&AY gREWOR#S ANG IIV'IMATIONAL PYROTECHNIC IMPORTERS SOUTH OYSTER BAY ROAD,St1ITf4 111 8ETH PAGE-1W 1111e COVEPAGES ceRn IexrE I1l,Imam— REVISION NU ER- III$I$TC3 CERTIFY THAT—jrM POLICIES OF Ili URANCE LISTcl)OnOW HAVE N ISSUED TO THE INSURED NAMeD ABO �QfkTNE FOLrCY€rERIQD WDICATED. NOWMHSTANDING ANY PMUIREMENT,TERM OR CONDITION OF ANY CCINYRACT OR HT1-r DOCUMENT WITH RESPECT TO V6,11CH This CERTIFICATE MAY B6 11"IUE 5 OR MAY PERTASN,THE INSURANCE AFFORDED BY THE POU018S DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCL 11MONS AND CONDITIONS OF SUCH POLIOIES,Ll$tFiTS SligM UAV HAVE BEEN REDUCED SY PAID CLAWS, MISR LTK WFEWWWRANCE l03S�YrKir�lcFl QfYrrY i L A CIpD1t l2se- WJ1512017 s0&1512g,g EACH OMUFRUICE S 1,L%t10, 'x e LA 15 £ .4CWR 1�7t3 -... . - i LOW W- E�R� L-LA-10-0--900- MA ,i A- 1T1S3_9 0 ! PERSOra 1&A0ViNd Y_ .I S--'I.OW.OM -PiLAZCR£i9TEiIST1Uc5 c€' i --_.--__ � - ��a€iVEF?J+J.i4s4alTEM I 3 #U, �I�# _ �yy ICY I -•, �AA, -- -LOU V I I I i I�rtOtairf��YV' A -1' L,k1LBilY'lix� 4T11ErtI ! i ' Plx6€IRPrt�s Idly I V1,I$1 ,43t Ar7iOMOX€LIABILITY ! 1 33F ELi1 A i CPP€51012 7 E}2335C09P 07r15)2010 'taar5`h:r44 ! ! z @LILYiNjURvtvw? $ i. - - - AUTOSON AMS ! I i I B�+IY sULAYl6ar k9?ffi015 A uI REL€A Lu§a I c CI ; i ELP10,G 2-137(l ) 02195r21i17E 9 T #1$. i elF hirE ;s 4 8CD,1 7 ! 1L4s Lir F51€9�Ct 3 i ' t -CA ,=3t _..I.... ......... _ _ _ . ... -- ' - pk1 Rb;�AtPErnTtats ± i ; ' :AWEWLOv t,LIMIFr Yra9 til l.'0=1�a1Ca7att� j C ?15 17 €321# rZ€S113 a OF F E1�6ANVMPRET©EKE% CoVatage it a ided in tie Slzta(s�Qf.'CT.DE,OL.G&iL,L4.-�L s SCUIOEf�T - - �S .OitJ, lr� rfl�s,aN� I FAR,tAl).NC.NJ.NV.NY.RA,RI,SC,T?: VA TINS 2 F—LoIs�14Ss,FAr= $ i.fJSISi. yycc� a I FIOUCY DOES NOT PPOVIDE IDISA,S1LITif BENEFITS IN l4Y,. -_ _-_ '0-CRIPTIQI40F€ WIT w i I ! ! El-DISEASE-FDUGYLIhdT I S 1,004,000 A ExcerisbeNlityl0cmr I IPI trS� lr(GL) 'IVI&POi7 DWISMIS EACHOCCURRENCE :59,000, ;AGGREGATE 49.II00,I flE3Lhgl�'.ItS�t3F OPR'Str�r�16SF�R'6�115 P 1r€E3I01.P3 lftG[3R�101,3id�liarral aaraa�€tn� ,mel �0 lira�racm�r�4l } ()1sAAY Dab:GM3 Rain Orate:tM Loca ion. Pecork LaMingat SuId,Gmrgmit NY RE-Gene€al taatiRYL Itte frdIGMng are n&110d as adifitional insLnd h,respects to ifs r1eglrgenca ta#tI`g nmnsd kmumd: Pemrft LaNing at Souftid Inc;Rm--kncek Hall Fc undaWn Mc, PacoAic Lareingl4oustagAssodafim CooperuNvo krc;The Shoms ai Fecanic Lar€tin�Fy3*t--d LMng Residerm Inc,Peconic Lanifing Hom Health Se.1ces Ism;Tom of Snulhdd MDW Haat bm Agreeinent part cnbrw herween€he named I€s irecf a the aftgmal lnsumd app a_ Fuller thim Jusurwme trill to deemed t be primary vr4 rw-)-c Ab1btrtOrywith r8Sg8d to thO Inas t30s 4(SUth addilmned 01sLmrad if yr.n aid 1aJ such a condition in the wrill en r,DWar twith.9uch add ftrkqI hmred. CERTIFICATE HOLDER CANCELLATION Pewrvc Lando at Scuff Ino TNrty(3€I)Maya[fie of Cmice fabon Applies 15008reemaek SHOULD ANY OF THr;ASOW X9390 POLICIES IECANCELLED WORK Gr enpad NY 11944 THE EXPRAM Ni BATE THEREOF, M0110E VALL BE $r E FN ACCORDANCEWVYNTINEIOLICYPROVI NS, idle ��P �TAYtHE Cert TM313s s A t 01988-2015AGORDCORPORATMN. All ratamserved. Ar-O RD 25(20103) Tha ACORD name and logo are rs W4§f1 n"k5 of ACORD POLICY UMBER:CPP01012 7 COMM,ERCLAL""RAL LIABILITYCG 20 26 0104 � THIS ENDORSEMENT CHANGES THE POLICY. PLEASE REAS!IT CAREFULLY, ADDITIONAL. INSURED - DESIGNATED PERSON OR ORGANIZATION ' is endorsement madfies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE, Name sof Additional Insumd Person(s)Or Organization(s) Peconic Landing,atSr hold inc;"Brecknock Mali Foundation Inc.Peconic Lanftg Housing Association Cooperative Inc,The Btiores at Peconlo Larding Assisted Living Residence Inv.Peconic Landing Home Health Services Inc:Town of Southold but as respects the negligence of the named insured only, Display Date:09/03 Rain Date: 091€4 Location of Display: Peconic Landing at Southoid,Greenport NY A1C?COVERAGE APPLlES TO LI ILITY RESULTING FROM THE SOLE NEGLIGENCE OF THE ADDITIONAL INSURED- Information NSUI D_Information required to complete this SoheduW if not shown aka.vAl he shown in the Declarations. Section 4 — Who 1s An Insu d is amended to in- clude as an additional insured the person(s)or orpni- zation(s)shown in the Schedule.but only with respect to liabifity for %tidily i€jury% "property darrklge9 or "personal and advertisl injur ' caused, in ale or in part, by your acts or omissions or the act's�or ornis- sfons of those acting:on your behalf: k In the performance of your arigaing op turns;or S. In connection vft your premises owned by or rented to you. CG 20 26 07 040180 Properties,Inc„2004 Page 1 of 1 I3 Neville, Elizabeth From: Jo-Anne Triolo <joanne@bayfireworks.com> Sent: Tuesday, August 08, 2017 2:24 PM To: Neville, Elizabeth Subject: Re. Peconic Landing Certificate of Insurance Attachments: NYS DOL LIcense Edward Metz.pdf I downloaded a copy. This is the best I can do. When I scan the copy, it comes out blurred. License#PR-2. Expires 08/18. On Tue, Aug 8, 2017 at 2:03 PM,Neville, Elizabeth<E.Nevilleatown.southold.ny.us>wrote: Joanne, No, not the Certificate of insurance. I need the Pyrotechnics' Competency Certificate. The copy sent is so small and blurred that all of the information cannot be read on it. Please enlarge it and send it again. Thank you. From: Jo-Anne Triolo [mailto:ioanne@bayfireworks.com] Sent: Tuesday, August 08, 2017 1:59 PM To: Neville, Elizabeth Subject: Peconic Landing Certificate of Insurance Good afternoon Elizabeth. Attached is a copy of the Certificate of Insurance for the Peconic Landing display in Greenport. Let me know if you need anything further. Sincerely, Jo-Anne i Jo-Anne Triolo Pyro Engineering Inc. dba Bay Fireworks 999 South Oyster Bay Road, Suite 111 Bethpage,NY 11714 516-597-5500 Phone/ 516-597-5507 Fax Jo-Anne Triolo Pyro Engineering Inc. dba Bay Fireworks 999 South Oyster Bay Road, Suite 111 Bethpage,NY 11714 516-597-5500 Phone/ 516-597-5507 Fax 2 � � '}F4� C1'U,^dlrF, Ei�„'$� �#jyy(, •• 40jCI'i+�' WWI 442613399 iF $'cmm, RGA' LAR UMTMOM 16'1 Mtn sCM 12KUR ASPLAY Auv= vV 12240 � iRD mm 86 Neville, Elizabeth From: Neville, Elizabeth Sent: Tuesday, August 08, 2017 3:21 PM To: Duffy, Bill; Fisher, Robert; Flatley, Martin; Spiro, Melissa; Dinizio,James; Doherty,Jill; Evans, Louisa; Ghosio, Bob; Ruland, William; Russell, Scott Subject: Emailing:Applic Fireworks PecLndg_20170808141657 Attachments: Applic Fireworks PecLndg_20170808141657.pdf Attached, please find an application for a fireworks permit submitted by Peconic Landing for 9/3/2017; RD 9/4/17. Please review and send me your written comments/recommendations. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage 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: Applic Fireworks PecLndg_20170808141657 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. Neville, Elizabeth From: Neville, Elizabeth Sent: Friday, August 18, 2017 10:11 AM To: Duffy, Bill Subject: RE:fireworks Bill, I advised them yesterday as soon as I received the certificate that it must state "Town of Southold is an Additional Insured" in the box "Description of Operations". I am awaiting the new certificate. Betty From: Duffy, Bill Sent: Friday, August 18, 2017 10:07 AM To: 'Diane Radigan'; Neville, Elizabeth Subject: RE: fireworks We are only named as a Certificate Holder. Please have the Certificate amended to read that the Certificate Holder is an Additional Insured for the named event. After that we are good to go on my end. If you have any questions, please feel free to contact me directly. Thanks, Bill Duffy William M. Duffy, Esq. Town Attorney Town of Southold Southold Town Annex 54375 Route 25 (Main Road) P.O. Box 1179 Southold, Nww York 11971-0959 Office: 631.765-1939 Fax: 631.765.6639 Email: bill.duffy@town.southold.ny.us ATTORNEY-CLIENT COMMUNICATION;ATTORNEY WORK PRODUCT; INTER/INTRA AGENCY COMMUNICATION; NOT SUBJECT TO FREEDOM OF INFORMATION LAW DISCLOSURE; DO NOT FORWARD WITHOUT PERMISSION Note: Service of legal documents is not permitted via electronic mail or fax. The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain information that is privileged, confidential and exempt from disclosure under applicable law. Unintended transmission shall not constitute a waiver of the attorney/client privilege or any other privilege. If the reader of this message is not the intended recipient,you are hereby notified that any review, retransmission, conversion to hard copy,copying, reproduction, circulation, publication, dissemination or other use of, or taking of any action, or omission to take action, in reliance upon this communication by persons or entities other than the intended recipient is strictly prohibited. If you have received this communication in error, please (i) 1 by reply and then delete it from your system. You should not copy the message or disclose its contents to anyone. This message is confidential and the property of Peconic Landing. It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know by reply and then delete it from your system. You should not copy the message or disclose its contents to anyone. PLEASE TAKE NOTICE: The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review,retransmission, dissemination or other use of, or taking of any action in reliance upon,this information by persons or entities other than the intended recipient is prohibited. If you receive this transmission in error,please contact the sender immediately and delete the material from any computer. This message is confidential and the property of Peconic Landing. It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know by reply and then delete it from your system. You should not copy the message or disclose its contents to anyone. 3 notify us immediately by telephone at 631.765.1939, (ii) return the original message and all copies to us at the address above via the U.S. Postal Service, and (iii) delete the message and any material attached thereto from any computer, disk drive,diskette, or other storage device or media. From: Diane Radigan [mailto:dradigan@peconiclanding.org] Sent:Thursday,August 17, 2017 4:44 PM To: Neville, Elizabeth; Duffy, Bill Subject: FW: fireworks Attached. Thank you . From: Catherine Prewitt [mailto:catherine.prewitt@cookmaran.com] Sent: Wednesday, July 26, 2017 1:19 PM To: Steven Carroll; Diane Radigan Subject: RE: fireworks Steve and Diane, The certificate for the Fireworks event is attached. Please let me know if you need additional information for the town. Catherine From:Steven Carroll [mailto:SCarroll(@Peconicianding.org Sent:Wednesday,July 26, 20171:12 PM To:Catherine Prewitt<catherine.prewitt@cookmaran.com> Cc: Diane Radigan<dradigan(@peconiclanding.org> Subject: FW:fireworks Hello Catherine: Can you address the message below regarding fireworks? From: Diane Radigan Sent:Tuesday, July 25, 2017 4:51 PM To: Steven Carroll Subject: fireworks In addition to the insurance we obtain from the fireworks company, I think we normally get additional coverage from our own carrier. No? The date is Sunday,Sept 3rd with Monday,Sept 4th as rain date. DIANE RADIGAN a PPCONIC I Director of Resident Services 1500 Brecknock Road Greenport, NY 11944 Tel:(631)477-3800 x373 Fax, (631)477-3900 �.� www.pecornclandin4 or9 This message is confidential and the property of Peconic Landing. It may also be privileged and otherwise protected by work product immunity or other legal rules. If you have received it by mistake please let us know 2 Neville, Elizabeth From: Neville, Elizabeth Sent: Thursday,August 17, 2017 4:16 PM To: 'Diane Radigan' Cc: Duffy, Bill Subject: FW: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust Diane, Please see the requirement below from the Town Attorney regarding the certificate of insurance submittted. We must receive a Certificate of Insurance from Peconic Landing as the property owner. The certificate you submitted was from the Fireworks Company. Please forward the certificate from Peconic Landing at your earliest convenience. Thank you. Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage Officer PO Box 1179 Southold, NY 11971 Tel. 631765-1800, Ext.228 Fax 631765-6145 Cell 631466-6064 -----Original Message----- From: Duffy, Bill Sent:Thursday,August 17,2017 3:46 PM To: Neville, Elizabeth Subject: RE: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust Betty, The applicant provide insurance from the pyrotechnic company naming the Town as additional insured. However, I would want the property owner/applicant to name the town as additional insured on their policy. Once that is provided, I would have no objection. bill William M. Duffy, Esq. Town Attorney Town of Southold Southold Town Annex 54375 Route 25 (Main Road) P.O. Box 1179 Southold, Nww York 11971-0959 Office: 631.765-1939 Fax: 631.765.6639 Email: bill.duffy@town.southold.ny.us ATTORNEY-CLIENT COMMUNICATION; ATTORNEY WORK PRODUCT; INTER/INTRA AGENCY COMMUNICATION; NOT SUBJECT TO FREEDOM OF INFORMATION LAW DISCLOSURE; DO NOT FORWARD WITHOUT PERMISSION Note: Service of legal documents is not permitted via electronic mail or fax. The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain information that is privileged,confidential and exempt from disclosure under applicable law. Unintended transmission shall not constitute a waiver of the attorney/client privilege 1 Neville, Elizabeth From: Duffy, Bill Sent: Thursday,August 17, 2017 3:46 PM To: Neville, Elizabeth Subject: RE: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust Betty, The applicant provide insurance from the pyrotechnic company naming the Town as additional insured. However, I would want the property owner/applicant to name the town as additional insured on their policy. Once that is provided, I would have no objection. bill William M. Duffy, Esq. Town Attorney Town of Southold Southold Town Annex 54375 Route 25 (Main Road) P.O. Box 1179 Southold, Nww York 11971-0959 Office: 631.765-1939 Fax: 631.765.6639 Email: bill.duffy@town.southold.ny.us ATTORNEY-CLIENT COMMUNICATION;ATTORNEY WORK PRODUCT; INTER/INTRA AGENCY COMMUNICATION; NOT SUBJECT TO FREEDOM OF INFORMATION LAW DISCLOSURE; DO NOT FORWARD WITHOUT PERMISSION Note: Service of legal documents is not permitted via electronic mail or fax. The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain information that is privileged, confidential and exempt from disclosure under applicable law. Unintended transmission shall not constitute a waiver of the attorney/client privilege or any other privilege. If the reader of this message is not the intended recipient,you are hereby notified that any review, retransmission, conversion to hard copy, copying, reproduction,circulation, publication,dissemination or other use of,or taking of any action,or omission to take action, in reliance upon this communication by persons or entities other than the intended recipient is strictly prohibited. If you have received this communication in error, please (i) notify us immediately by telephone at 631.765.1939, (ii) return the original message and all copies to us at the address above via the U.S. Postal Service, and (iii)delete the message and any material attached thereto from any computer, disk drive,diskette, or other storage device or media. -----Original Message----- From: Neville, Elizabeth Sent:Thursday,August 17, 2017 11:53 AM To: Duffy, Bill; Fisher, Robert; Flatley, Martin;Spiro, Melissa Subject: Emailing:Applic Fireworks PecLndg_20170808141657 2nd reeust Importance: High Please respond at your earliest convenience with your comments/recommendations. Thank you. 1 Elizabeth A. Neville, MMC Southold Town Clerk, Registrar of Vital Statistics Records Management Officer; FOIL Officer Marriage 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: Applic Fireworks PecLndg_20170808141657 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. z ELIZARETH A.NE'VILLE,MMC y® Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 sQ Southold,Ni civ York 11371 REGISTRAR OF Vrl'AL STATISTICS +' Fax(631)765-6145 MARRIAGE OFFICER 4 ' Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER ��' �+� ww%v.soudioldtowany.gov FREEDOM OF INFORMATION OFFICER OF'F'ICE OF THE TOWN CLERK TOWN OF SOUTHOLD INS'ITRUC"lC>(ONS FOR D SI"LAY OF FIREWORKS 1. lame of body sponsoring fireworks display. 2. The date and tune of day at which the fireworks display is to be held. 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. 5. The number and bind of fireworks to be discharged. 6. The manner and place of storage of such Fireworks prior to the display. 7= A diagram of the grounds on which the display is to be held,showing the point at which the fireworks are to be discharged, the location of all buildings, highways and other lines of communication, the lines behind which the audience will be restrained and location of all nearby trees, telegraph or telephone lines or other overhead obstructions: o. Such culler information as the Southold Town Cleric may deem necessary to protect persons and property. Written perrrrission of the property owner is required. 9. An indemnity insurance policy with liability coverage and indemnity protection of$1,400,000.00 per person for bodily injury; $1,000,000.00 per accident;$1,000,000,00 property damage. 10. The Town.Cleric of the Town of Southold must have the insurance policy in her possession before the fireworks penuit is issued. The named insured must read:TOWN OF SOUTHOLI). Thirty f30)To%vn of Southold POLICY 11. Application for a fireworks permit must be made at least f days in advance of the elate of the fireworks d_ isplat_ (The above instructions are in accordanco with the Penal Law, Article 405 - Licensing and Coker provisions relating to fireworks.) 1i F01,V-4a ELIZABETHA.NEWLLE,INMC �+� �� Town Hail,53095 Dalai Road TOWN CLE1{ll P.O.Box 137$ to M Southold,New York 13971 RE,GISTRAR OF VITAL STATISTICS $ flax(631)765-6145 MARRIAGE O);MCYR Tblaghone(691)766-1800 RECORDS OF MANAGEMENT OFFICER 1 `�+� uoutho7dtown.northfork,net FREEDOM Or-]NFOReViAUON OFFICER AUG j OMCE OF THE TOWN CLERIC TOINN OESOUTHOLD APPLICATION PEMIT TO DISPLAY FIREWORKS APPLICATION IS HEREBY MADE, pursuant to the provisl6tis of Section 405.00 of the Penal Late of the State of New York,for a permit to display fireworks as hereinafter specified: DISPLAY IS TORE SPONSOJW�'ID BY Peconic Landing at Southold Inc, PRINCIPAL OFFICE AT 1500 Brecknock Road,Greenport, NY 11944 DATE&TME OF DISPLAY September 3, 2017 @ 7:15 pm EXACT LOCATION OF DISPLAY Peconic Lending property SUp"p"O IC COUNTY TAX MAP Nl lNffiER FOR SITE RAID DATE&Ttl" September �+, 2017 crit 7;15 pm The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition Edward Metz dob: 2/26/58 10 years + Health; Excellent (Additional names and'srrformation may be submitted on an attached sheet Number and type of fireworks is as follows: 1,3G FireworVs;.: 2.5 inch=695. Cakes=1S. Manner and place of storage of fireworks prior to display: Delivery will to day of display Attached hereto and made a part of hereof is a diagram of the grounds on which the display-L's to be held. Also attached is a certificate or policy of insurance coverage. NOTICE: Written permission,with signature of thi3.proper ,4?Ivner,Aust be submitted with the Application, fl-) �( ! _ (—o-! Cb\nz >l `3vL<_i��(^pCl _�tC FEE: $100 Mai-no of Orgaruzation See policy-tae additional information By YLI /I col� Signature:of Applicant Date of Application t'. .f1��s is tmcnt i)f 3s1 tic4 Federal Expl{3.r Ives License/Po2`1uit i3vwu of Akohol 1 obnco.Finarrns mid Izxptosst'ea (I8 U.S.C Chapter 41) F �hf =i�r#sb in atrrrt,$^rist��rlh t he Ixos'fs;^ttms of"'tile}CI,l}�Rnaer}ititrn�Gttlttt�IrlEt aF 1 Yt1,at:d rl;t regttEatferts i3strul tGtttwndtr�2?t;.FTi Pstt 553 }�,r raas'�ngagc ht w • tt�`JCtr1?ii,I�cti:h',I sa 3he5',""ae�»ac s;r t?tg7sisl w g;sin tl;e Tltatais�jt;,sisaFCltstptc=f+tO.'F'tt�15,iJnitr:d�tsft iv'edgttnd iitC tv' i�r35 is5u-,ti tSaeressn'i.er.titttrt Qtt .rsstisuriaic$hrm11 it?15 LgCg'!jk_4.'L!t? Y} f 4E €i � T {-a 'F ; a"t�'tslr �v'Ii 'Sa�"ard•�1oIlCts^as.r . 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'v - }^u� e'"'�a '�wy, '?f . `aRM/ < `.9.ffi.S,OJ S ,�'�r}.=-5•�x`w y'QN'^”"=.��. .;r rmY-ar;.y T�-�:.%:r7'�`#;`!��.'3�^w`';i>�F,9"'{+n;ji`>�, .�. z i+' ,°{' ./3✓r ✓��`� ,,t..'R•,.41aS�y�.,, �'r-r�,�<�y, A •`T�E'�^%'•$ 35f'a';b.ir��Q 4>i _ - r - L,5'r .nlyr` "$r�'t�..s':• n�"A`:. - �.d^"�K: t � !'�<'' �.,a. lg'&`s`>t y+,:- 7},�'Y" :� X� �Q'°► ,R.:r, � °�3t��"�'L`'�_e�. '�„ ^`:�' ,ey'" `��- ?r,-., e`,,3'r�,.. ,"` i,q:".:3y�cs., <t }f_ �., .� v:'.>.,2. .r^�»r�!.'M�d-".`'nY•e. - "*' ,� ��,T:'<c C"L s��',�4 I`..o.Wx ,rrn< u4'JA,•�'.^.^A,ez-� S.`,F,.,'r',>,d,K^^.. �+b`�3.'�6�.-��-.��u,•.-ate � ; _ S�",��.:',��`v��'.ID s - , �da t, 1 »�'r ;.rt x' y .: 3,1,, .t� •�'� :rte,.. rr�.�•'.,:'��ry, �^�,.,'� "'`�"..ti".tom v SY" � . � � r.'� r.,^: ,,`.,`,�'t+ y"'�i'�•• �d;�. N G�LJ...333�� _ r.%tt4.� �i ;`� ��. c •yy;;�� Sn �+ y, Y" a} '^'r:==:§-�"L. - ;x:•,�it<µ s ,k'fa. _ y ::f`{ ..,z' t. g$ Pit rL v.'" Y <->S.'ss- <y yM. „.'�'. '�,"..a.t(, t�5'�,v `+vi,�� •, L1 - _ 71A, EF ryygp_ ,■yg; kN< � >v. 'rB�' �`,?�� °'��y�, � r•i.'�` i,�` "tit;K",,.Y� x� ,µJP^ � - � y '✓ •w� `;i�! 3+">� w��•'��.Y '.<LT.;9y�it r..ais:r �'" Z¢t�,'t +�h ai+' 'X„rtr,'i"a4a,�.j!�'�s��t _..r MR R KS ,rI 4.p4�`(� .w:'xS...�..Y.. ,;%4,'`r'jv- ss,�'ha%;�°�a."._� �.".�',. "`�.'! �fy�+s^• ��' n,�' 4 � .. �ct��fi'l�,(� ELIZABETH A.NEVILLE,MMC �� Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Southold,Now Yolk 11971 REGIS'T'RAR OF VI'T'AL$TATI$TiCS � � a Fax(631)765-6145 MARRIAGE OFFICER , Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.southoldtotionny.gov FREEDOM OF INFORMATION OFHCER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD POLICY for the Issuance of Fireworks Permits I. The Town may grant a permit for the display of fireworks by municipalities, fair associations,amusement parks, erp sons 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 rn,if held Sunday4hursday, 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 fireivarks must be received by the Town Clerk a n-d ni:mum 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) Certificato of insurance naming the Town of Southold as additional insured with coverage Iimits of$2,000,000 for public liability and$2,000,000 for property damage, (0) Detailed diagram showing location of fireworks discharge and rninirntun 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 lacing 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$100.00,together with a processing fee in an amount to be determined by the Town Board to cover the Town's costs for monitoring and enforcing compliance with the Penal Law. (The above histructions are in accordance with the Penal.Lair,Article 405-Licensing and other provisions relating to fireworks.) CERTIFICATE 4F L ABILIW INSURANCE �A ci s 7�i THIS CERTIRCATE IS iSSUM AS A MATTER OF INFORMATION ONLY AND COKFEIRS NO RIG14TS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMPMATtVMY OR WCOATIVELY AMEND. EXTEND OR ALTER THE CCVC AGC AFFORDED BY THE POUa)E5 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CO WRAGT BETWEEN THE ISSUMO INSURER(&). AUTHORt790 REPRF-815NTA'tIVr=OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. It the cerCflesto Itoldar is an ADrDMO14AL INSUMD,the galtcy(its)must have ADDITIONAL INSUREtf pmvislons or be endo-sad. If SUBROGAVON IS INAW813,subject to the terve artd coridffions of ft policy,ccrtatn paltelbs may requim an endorsm6nt A St418rrietit an this certificate dues riot aoiifor rIghts to tho corfiflcato holder In Rau of aueh Sndorseme Sl. PRODUCER ° A Fitldtee K T A1IwdSp6mdtytnmhance,Inc. NAbt _ ,_.ichell _ _.-__._ - ----_--___ 10451 Gus 8tvd pimp 727347,3070___ _-_ Ilam.ti4Y 727-347 5B�S Twaure(gland,FL 339t11i-404 1 - - --` A!3j-� F ie�sp=i2aty.rtzr:t_. Il9utiEeZaaJccet=�tioJt - ta�tca -- Iltsti"i;Am T.H.E.Insurancetarnpitriy P-RO ENG3NF�ERING,IP#G, u}suaea iR"S'JRERB: _..__.___-- .•. .._ ------•----..-_.___._.__..-.. �; qBA:SAY FIR6W ORKS AND INTERNATIONAL FYROTEC!-(#141CtMPOR-FEM9 9It4 SOUTH OYSTER BAY ROAD,SUITE 111 BETHPAGE NY 1-1114 COVERAGES CERTIFICATE INUM13ER: 11MRSION NUMBER: 1'Ht$I$T4i Cr:RT3i<Y iriAT THEPOLICIES OF IraSURANU I.ISTED 6n13W KkArS BEEN ISSUED TO THE INSURED NAMED A!I0M FOR THE POLICY I ER16- tNsDICATED. I•IOTVdri1-ISTANDING ANY RmUiREMENT.TERM OR CONDI'PION OF ANY COW-RACT OR OT14M DOCtEt-.+.ENT WITH RESPMY TO Y n.4 THIS CERTIFICATE MAY BE r3,3`UED OR MAY PERTAIN,TIE INSURANCE AFFORDED BY THE POLEC39S DESCRIBE}HERON IS SUBJECT TO ALL THE TERUS, EXCLUSIONS AND t:ANOrTIONS Of SUCH POLICIES LMT$SPtc vVN MAY I-OWE BEEN REDUCED BY PAID CLAIMS, LTR TR TtPEtTFtN$URAttCEDL (SRI TV�T• F 1 i - � •,,,f I r FoUcyN+-MBER A !ti ecr�Lrl rra GJctk at UABILITY ! a 1w^HSXxU1 E}JCE S 1,0121!,1100 Li At052rS4.47 i 0.115/2017 j 0?I15120-,8 F } 0 J I EF'ra;r>?SE5.E =rx enpL_1 s 100 00 - i l i I i}„�sO IXP�eirr�4rm P4spr� 1 3 t`IIA `F•ERS>;t•JrtiLaA°VINdUiy W=rQ $- 1,00D,OtI9 Ji.'-tYLRWAIELILiiTAFPLIc'SPE2 I , ,-----_-..._..,...._ 1 I � �S;I=rvERr+.��.rcrE�t,T€_ I s I0,O09,OBtl aeLICY rJIM,. 1 PnoQalcr -40Jt5X AGG l s 2,Gtf[I,{ OTHER i I PJr te:tlon itlt�i tttity I s f,000,iI1 ,y ;AiTTaasalr Luu3lLmr i I i CPPb101284 Q7 (( COISP017 OJ1512046 i y : t)A W I S f,t2Q0,No AW Mir,o 1 I OWLYa'YJ1,R_tPari> t s t atvlr�'° s�JEnuLo i i - AUTCSOtILY :}{l�`3Ti+ AUSMED j ; s ` i B�ILYuvJItRYiJ raatC<nq`5 i At'=ONLY `-�AUTOS Y C � ! [Fh2U?M•fYL�.4f�E - ! S- Fl IM-ELLAIJAE Keco stELP00i0292.07K) 0P,1512017 0211$12so18�Fr+L1i9 Jlif?"ch E s 4;600,091 , EX, LtaB AGI A1F,i*��19c; 5 J :AsGR--GATE S 4 0G44J0_.. i Ire , -- i 'r A ,WORM Ru t: iP€tti.ATJGIi 1 ii1$:67-p03 j 0%1151 17 10211512010 ..t1.:.3F,�T�:R'.�JE�.f�_ !AKPJ;lx?44t-sR5•LIAVfI.UY YF}J i J ' 'rJYJ'ROTOiLS�isRIT.-L•R�93fEC1978S!£ , 4FF':c%ailrF-rdBEAExGLUr�E•J4 �;tJ 1Am I OGYAr2ge it;aftded to[lie 51~t=_fs�of:OT,ISE,FL,GA_It_,L4_.......- S�uIOERi - - i S 1,0012,= lL to:f ra uirl i MA MD NC,NJ.NV,NY.P.A.RI,SC,TX&VA; THIS i t�Is�ts_,�J rel c`r�i s 1 A40�tX10 a gl"aricHa �nA v j POLICY DOES NOT PROVVI 01SABILI cr�BE.'IEFITS IN NY, � B�.AIEcfL=,E-=UL'GYLIIarT 5 S 1,6�f3,�QU •Ex> ss t lahilllyl it EI 1'0-'010$89.07 VG,L f ':0211W017 + am5rA'718'EACH OCCURRENCE S9,4it0,3a>1 l i AGGR 7GATE 4%0,10,M1 ! I ' °"�-',.isralP`.laj�Cf-^P�7tI�K'afLU`G1T'.QNBfVEf;tFL•-S fAGt R03Qt.,vda+^llv,gi Rat�rkF�chep!AF,R1B}9u el13td:ifl It r,�ro mut:rv4'�:iic�} -�~K�, ••.,,.• Display D99:93103 Rain Dale:0103 Loearion: Pe--caws LaMd V at Sbu:t`,aid,Greenport;NY RE•General t iAifty,the k11cF%*g We riarwtad ao a-diZonal"snsured In respect to the nogli wito bf the nemsd F.-sured; Pem:ork L',IM6iy at Southold Inc;Bry-kM6 FP39 Fowridalion L1c,PaCo6c I.-Jltts r.g Hcuaing A�-a5Gn Cj,-jp•:ratvs Lw,T Itu Stearal at Pewn:c La Ass 15te-d LMn9 33csirance Inc,Pecornr L,noirig H 000 I'.balth Services luc,Tann of Southold Hord Hirm13is5 Aareement pIr,`Gritraci bahvaan the named irrvimo--�d the additiwai Irisilr€l appras_ Forthar this Imurar,5 S:slf be desmed to be 0nl a-y 81'4 r0--contributory:vitti ms ped to the Inaweaoe of such additpmal Msumd iF y c,j aid to wJc;t a cund ban in the wrden.OGtitract viith.sucA ad(ifioritr kzt}rtd. CI RT lfIGAYE Hu i GER OAK-t;LLATION _ Peconlc Land!-.;at S'--uIhQkI Im.. `Nrly(3Q)Days Katice of Cana-Ia€lon Applies 750)Sre.-V xk qd SHOULD ANY r0F•THa A80 f VESCRME0 POLICIES BE e-ANCEI.LED R E.FORE Greenport NY 11944 THE EXPIRAMON ELATE; ;NE4E4r, NOTICE 'FALL BE BEL VEftIlD r.LJ ACCORDANCE W3TH THE POLICY PPO`lIMNS, AUT It;?R M�PRf;SOM,TJL'E Cert K31313 L T 4 =• atti.. rel 1338-2015 ACORD CORPORATION. All rights reser ed. At-0-RD 25(2016t03) "Th$ACORD name and logo are rbelistered mai cls of ACORD PGt.I,Y NUMBER:GPP010128"7 COMMERCIAL GENERAL LIABILITY CG 20 26 0104 THIS ENDORSEMENT CHANCES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement mortifies insurance provided under tt:e following: COMMERCIAL GENERAL LIABILITY COVERAGE PART St;I•II~DULI; Name Of Additional Insured Person(s)Or Organization(s) Peconic Landing at Southold Inc;Brecknock Hall Foundation Inc;Peconic Landing Housing Association Cooperative Inc;The Shores at Peconic Landing Assisted Living Reeltlence Inc;Peconic Landing Horne Health Services Inc;Town of Southold but as respects the negligence of the named insured only, Display Date.09/03 Rain Date: 09144 Location of Display: Peconic Landing at Southold,Greenport NY NO COVERAGE APPLIES TO LIABILITY RESULTING FROM THE,50LE NEOLIGENGE OF THE ADDITIONAL.INSURED- Information required to complete this Sohedula,if not shown above,will be shown in the Declarations. Section 4 — Who Is An Inswed is amended to in- clude as an additional insured the person(s)ar orpni- zatton(s)shown its the Schedule.but only vAth respect to liability for "bodily injury", "property dsPiagen or "personal and advertising injury" caused, in whale or in part, by your acts or omissions or the acts or omr s- sions of those acting on your behalf: A. In the performance of your ongoing operations;ar B, In ccmnection wdth your premises ovinad by or rented to you. CG 20 28 07 04 0 ISG Properties,Inc.,2004 Page'I of 1 [� * * * RECEIPT Date: 08/08/17 Receipt#: 227175 Quantity Transactions Reference Subtotal 1 Fireworks 09032017 $100.00 Total Paid: $10000 Notes: Payment Type Amount Paid By CK#83445 $10000 Peconic, Landing Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Peconic, Landing P O Box 430 1500 Brecknock Rd Greenport, NY 11944 Clerk ID: BONNIED Internal ID 09032017 enc Workers' CERTIFICATE OF INSURANCE COVERAGE sTATI =nsationUNDEF THE NYS DISAI ILlTY BENEFITS LAW PART�. 7Q be completed by Disability Senehts Carrier or Licehsod Insurance Agent of that Carrier la_Legal fame&Add ads of insured(use street aodmg 40 ) - `1b.Business Telephone NurnDar&I {51 ti)597�D0 � PYRO ENGINEERING ING D8A 8AYFi3T£010AK$ lo,NYS Unemployment insurance E=mployer R.et}iz traiiPn Number of 999 SOUTH OYSTER BAY RD STE 111 Insured 91E7HPAGe,NY 11714 Fr S 'Mork Lccatlw of Insured{Dnty raqurred0owarnVe is efaacdricafJy&vffed to t 10,Federal Emptaper!dent icai cn Number of insured nr Sarei$ecyrtty certain tcrcaimru rrr,°YesvYork Slate.lo.a 3�Y,a}�-ftp PoflM itil+.anber • r 763-At-$947 2.U me and Address of EMity Reciclesting Pto of of Coverage 3a.Nam of Inswance C@rrS21 t {Emily Bung t els d as Itta Gerd to How} New York State Insurance Aird(NYatF) i 315.¢o�Nwilber of Entity Lsta.3 In Sme'1 a" PIP-COMIC LANDING AT SG!JTHOLD,INC. DOL 5213 59-1 1500 BRECKNOCK RQA'D f GREENPORT.NY 11344 3c,PONCYaftacth-o pwicid ¢ 01I04121�d3 to 01104CI1.}18 �] A_Af!4f the errLplpyer`s errsployeea ef6gr"trle+srv.d$r Tho Et®w Yank LlisebiCtiy�neftts Law 8.Only the following mss or classes of srrp$oyar's errsylopess; { I I LInder penaila of,parury,r certify lhst I ern an aurhofRed reprasertabWe or I'xi�rsed int pf the irsatance carrier Wersncad tkbave and thet the named insured has NYS Disability Sena ft, 3nsurafire covsraq�i as descebed above. Date SPgmd 4117/2417 BY �-- JO$nph J.Masi E5r�sah+�c u��nsr,n�:_ctrm�r's auertanard rcyrer^cwmra er YY3 Licit tseur�a flgr^rti�f��c mEummr corsr�r} Te"hons Number(866)69713332 Title Director of NY Illsablaty fleriefits Insurance w Ifr1FTORTANT, If Sox"4a"':s tweaked,and 11r'ss fairs re signed by the Insurancs ea,doeA autha&ed representative or NYS licensed 41iwan4e Agent of!hat carrier,this cert#Icale is COMPLETE-(fail R tlisafp to the certificate-holder. i if Sax"41'Is checked.ti1!s certiticaw"t5 NOT COMPLETE.for purposes cif SacWn 220,Surd.8 of tho Disability Stmeiits Law,tt mu5l be made;t ' for caomplawn to the 8aard.!38 Pians Acceptorxe Univ.328 Stat*81raet,Schenectady,NY M05 PAS RT Z To be completed by the NYS Workers'Compensation Board(Only if 0ox^4b"of Part I has baen checked) State of New York Workers' Compensation Board i According to infarrnaton maintoined by ti-*WS'Ja'orker 'Cenrponsaiion Board,llle abov--named employer has complied with the NYS Usability€3enefits 4aw with respect to ail of hiilher employee's 1 a Gate Signed By igrrahrr.of.'IYS F. rsm per;a� �rd vra`doyxl '" i Tetephoneilumber " M Tina Planse Note:4niy insuranco carnets titmsed to write SAYS disability bm&-,9t1:in urarica prolicies and NYS liconsed Irnsurance anenta a those insuran e canierr are eufhodzed to issuo Fwn DB-IK 1. trisurance brokers arm NOT authorized to issue this form. ns-120.1 -is; Certificate Number 426027 POLICY NUMBER: CPP0101284-07 COMMERCIAL GENERAL LIABILt"l'Y CO 24040'5 09 WAIVER OF TRANSFER OF FIGHTS OF RECOVERY AGAINST OTHERS TO U This endorsement modifies insurance provided ussiderthe following: CCMMERGIAL GFNERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization, Peconic t nndiag at Soulimid Inc;Brecknock Hall t=oundaffan Inc;Pawniic Landing Housing Aossc&--flan Cmaeperauve Inc, Thu�3horas of Peconic Landing Assisted Living Resldence Inc:Pewnic Landing Home Heatlh Services Inc,T own of Southold as respects to the nop igenoe of the Named insured wN19 at Peconic t.artding at Southold,Graennarl NY for the riod of 09143 ram date W04 a.w. Inforn-olion recigired to oom lets this Schedu e,if not shown above,will be stmwn in the Declarations_ The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section IV--Conditions; We.waive any right of recovery we niay have against the person or organization shown in the Schedule above becatwe of payments we make for injury or damage arising out of your ongoing opmtinns or your worn"done under a cantraat with,that person or organization and Included In the "products- cornpleted operations hazard", This vraiver apprses only to the person or organization shown its the Schedule abD,.,--. CG 24 04 05 09 0.lnsuranca Se vices Office, Inc-,,2008 Pages of 9 � SPONSOR: Peconic Landing at Southold Inc. Fireworks Company Pyro f-Ingineering,Inc. dba Bay Fireworks 999 S. Oyster Bay Rd.,Suite 111 Bethpage,NY 11714 P: 515-597-5500/F: 516-597-5507 Show Date(s): 9/3117 Rain Date(s). 914/17 Location: Brecknock Hall., 1500 Brecknock Rd.,Greenport,NY Time: 7:15 pm 1.Total number of Class.B shells being used:2.5"=695. Cakes—'1$. Maximum shell size:2.5 inches in diameter. 2. Al shells are DOT approved. 3. Display will be fired electrically and/or manually. 4. Delivery to site will be appro-a mately 12:00 noon. Set up will take approximately 4-5 hours. 5. All displays will comply with all requirements as set forth in NYS Penal Code 405 and NEPA 1123, 1124. 6. Pyro Engineering,Inc.has complete understanding of all rules and regulations governing public fireworks displays and this display will be in accordance with those rules and regulations. 7. Personnel representing fireworks display company: Lead: Edward Mets(NYS DOL license PR-2) 8. Techs ician(s): tbd Signed Fim 's Coinpanyepresentative FIREWORKS DISPLAY HOLD HARMLESS AGREEMENT Between Peconic Landing at Southold,Inc. and PYRO ENGIN ERT G,LNC. (Contractor) WITNESSETH; 1. P'YRO ENGINEERING,INC. (Contractor)agrees to indemnify and bald harmless Poc or�k,Landing at Southold,Inc. from and against any loss;damage ar liability, including reasonable attorney's fee's and expe,.nses incurred by the latter entities and their respective employees,agems,volunteers or other representatives arising out of the,installation,firing,or disassembly of pyrotechnic equipment or device and/or the supeii ision and presentation thereof. 2. TIie applicant has furnished the Certificate of Ir mace vtfith limits of liability described below- Workers Compensatioa/l�tnployers Liability: $1,000.000 per occurrence, General Liability:$1,000,000 per occurrence Automobile Liability: $1,000,000 Umbrella/Excess Liability: $9,000,000 per occurrence A true copra of the Certificate of Insurance is attached indicating the meniber entity and applicable association&recreations or committees famed by the member entity to organize the:'event-unust be named as additional iasured on all liability policies, The facilities will be used for the following purpose and no other: E4'ENT: if irewocks Display_�_ SHOW DATE: 913/17 PAIN DATE: 9/4/17 Dated Sued _ (Contractor) Witness,-,. f � � 17- IIMv# 442513396 IF FOUND, RETURN TO: 1EUWARD�J,METZ- s " ® NySDOL - L&C UNIT EYES BRO . CLASS:A ROOM 161 BUILDING 12 unrR BLN ,, "AW DISPLAY o HGT 6 2 " STATE OFFICE CAMPUS ALHANy NY 12240 ;:THiS'CARD MUST BE CARRfED` -N a "`lWHEW'USING.PYROT -DII NYC wS Neville, Elizabeth From: Jo-Anne Triolo <joanne@bayfireworks.com> Sent: Tuesday,August 08, 2017 2:24 PM To: Neville, Elizabeth Subject: Re Peconic Landing Certificate of Insurance Attachments: NYS DOL LIcense Edward Metz.pdf I downloaded a copy. This is the best I can do. When I scan the copy, it comes out blurred. License#PR-2. Expires 08/18. On Tue, AuQ 8, 2017 at 2:03 PM,Neville, Elizabeth <l".Neville(�i)town.soutllold.ny.us>wrote: Joanne, No, nCYt E " -rt:i Kate Of 111surance. i need the Pyrotechnics' Competency Certific.,-2�.� Yhe copy sen'(. is so small and blurred that all of the information cannot h,— =-.i ? cin iL. Please enlarge it and send it again. Thank you. From: Jo-Anne Triolo [mailto:'o� anne ba fireworks.com] Sent:Tuesday, August 08, 2017 1:59 PM To: Neville, Elizabeth Subject: Peconic Landing Certificate of Insurance Good afternoon L lizabeth. Attached is a cop), of the Certificate of Insurance for the Peconic Landing display in Greenport. Let me know if you need anything Further. Sincerely. 10-Anne i Jo-Anne Trio 1 o Pyro Engineering Inc. dba Bay Fireworks 999 South Oyster Bay Road, Suite 111 Bethpage,NY 11714 516-597-5500 Phone/ 516-597-5507 Fax Jo-Anne Triolo Pyro Engineering Inc dba Bay Fireworks 999 South Oyster 13ay Road, Suite 1 I 1 Bethpage,N)' 11714 516-597-5500 Phone/ 516-597-5507 Fax 2