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Neville, Elizabeth From: Fisher, Robert Sent: Tuesday, May 22, 2018 9:37 AM To: Neville, Elizabeth; Duffy, Bill; Flatley, Martin; Spiro, Melissa; Dinizio,James; Doherty,Jill; Evans, Louisa; Ghosio, Bob; Ruland,William; Russell, Scott Subject: Orient Fireworks Aplic_20180518150905 Betty I have no reservations about this event taking place as planned. Bob Robert Fisher Fire Marshal,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: Friday, May 18, 2018 3:29 PM To: Duffy, Bill<billd@southoldtownny.gov>; Fisher, Robert<Robert.Fisher@town.southold.nv.us>; Flatley, Martin <mflatlev@town.southold.nv.us>; Spiro, Melissa<Melissa.Spiro town.southold.ny.us>; Dinizio,James <iames.dinizio town.southold.ny.us>; Doherty,Jill<iill.doherty town.southold.nv.us>; Evans, Louisa <louisae@southoldtownny.gov>; Ghosio, Bob<bob.ghosio@town.southold.nv.us>; Ruland,William <williamr@southoldtownnv.Rov>; Russell,Scott<scottr@southoldtownnv.Ro_v> Subject: Emailing: Referral Fireworks Aplic_20180518150905 Transmitted herewith is the application of the Orient Harbor July 4th Festivities for a Fireworks Display to be held on June 30,2018 (RainDate:July 1,2018 on a barge in Orient Harbor. Please review and advise of any concerns, questions and/or objections that you may have to the granting of this Fireworks Permit. 823.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: Referral Fireworks Aplic_20180518150905 i ORIENT FIRE DEPARTMENT, INC. 23300 Main Road • Orient NY 11957 (631) 323-2445 • Fax 323-9706 �-UNTEEA D RECEIVED Chief William Wysocki 1st Asst. Chief Michael Prindle JUN 8 2018 2nd Asst. Chief Richard Gillooly southold Town Clerk June 5, 2018 Elizabeth A. Neville, MMC Southold Town Clerk PO Box 1179 Southold, NY 11971 Dear Ms. Neville: The Orient Fire Department is aware of the Orient Yacht Club fireworks application for June 30, 2018 and we currently have no objections of them having this event. Please contact me if you need any additional information or if you have any questions. Sincerely, Bill Wysocki Chief Cell #: 631-603-5731 Email: bi1199x@hotmail.com ELIZABETH A.NEVILLE,MMC ®� � Town Hall,53095 Main Road TOWN CLERK a� �� P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS �.. ® Fax(631)765-6145 MARRIAGE OFFICER �. ®�. Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER ®j �,`� 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 HARBOR JULY 4TH FESTIVITIES,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 Saturday,June 30,2018 at 9:15 PM (Rain Date: Sunday, July 1, 2018 at 9:15 PM on bare off Orient Yacht Club.the time and place set forth in the application therefor. ON CONDITION THAT the bond (indemnity insurance) required shall continue in full force and effect in favor of the Town of 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. /� �n '�,� &. /1 r el_4 Elizabeth A.Neville, Town Clerk Town of Southold Suffolk County,New York Dated: (TOWN SEAL) THIS PERMIT IS NOT TRANSFERABLE Southold Town Board - Letter Board Meeting of May 22, 2018 5°"°`` :,T� RESOLUTION 2018-489 Item# 5.26 °f�a�" ADOPTED DOC ID: 14153 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2018-489 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MAY 227 2018: 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 Harbor Festivities, Inc. for a fireworks display on Saturday, June 30, 2018 at 9:15 PM (Rain Date: Sunday, July 1, 2018 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 and subject to the approval of the Town Attorney. Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: James Dinizio Jr, Councilman SECONDER:William P. Ruland, Councilman AYES: Dinizio Jr, Ruland, Doherty, Ghosio, Russell ABSENT: Louisa P. Evans Generated May 24, 2018 Page 40 RESOLUTION (ID # 14153) � f �® REVIEWED DOC ID: 14153 f' THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. (ID# 14153) WAS REVIEWED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MAY 22,2018: 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 Harbor Festivities, Inc. for a fireworks display on Saturday, June 30, 2018 at 9:15 PM (Rain Date: Sunday, July 1, 2018 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 and subject to the approval of the Town Attorney. tal. Elizabeth A. Neville Southold Town Clerk Town of Southold P0Box 1179 Southold, NY 11971 a * * * RECEIPT * * * Date: 05/21/18 Receipt#: 240035 Quantity Transactions Reference Subtotal 1 Fireworks 6/30/18 $1,0000 Total Paid: $1 Q0.0'0 Notes: Payment Type Amount Paid By CK#1017 $10000 Orient Harbor, July 4th Festivities Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Orient Harbor, July 4th Festivities Po Box 653 Orient, NY 11957 Clerk ID: LYNDAR Internal ID 6/30/18 1 U 0— r i e' Dendence reworks , iL i Ak' f z - ne t X � lbDm■; r+ F . n: ate No_ r v,r � MMMIMMM�—�� 7 n 7d s to A funded by friel.", r ienon- al Fl. . �. 'PhQWbY Jerem Help our communities establish this proud new tradition, funded entirely by friends and neighbors. Please do your part by sending in your donation today! Visit www.orientharborfireworks.com or send your check, payable to Orient Harbor July 4th Festivities P.O. Box 653 Orient New York 11957 Last year's display was amazing ! We need everyone to pitch in to ensure another unforgettable 4th ! Orient Harbor July 4th Festivities is a 501 (c)3 non- profit organization. Your donation is tax deductible. �lj ItieWo -_ o_a: bio " S Alk ap PAV ,_rllrqM= i v ' Help our communities establish this proud new tradition, funded entirely by friends and neighbors. Please do your part by sending in your donation today! Visit www.orientharborfireworks.com or send your check, payable to Orient Harbor July 4th Festivities P.O. Box 653 Orient New York 11957 Last year's display was amazing ! We need everyone to pitch in to ensure another unforgettable 4th ! Orient Harbor July 4th Festivities is a 501 (c)3 non- profit organization. Your donation is tax deductible. J May 14,2018 Theodore Strauel Orient Harbor July 46 Festivities,Inc. / 680 Croton Lake Road Bedford Corners,NY 10549 Cell: 914-523-9289 Email: tstrauel gmail.com Dear Mr. Strauel: Please find attached hereto for the Orient Harbor July 4`''Festivities,Inc. fireworks display scheduled for June 30,2018 with a Rain Date of July 1,2018 at 9:15 PM the following: 1) Letter to Town of Southold Clerk's Office 2) Town of Southold Permit to Display Fireworks Application 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 1 'Please sign the enclosed application and forward to the Town of Southold along check for $100 made out to the Town of Southold with written permission from the Orient Yacht Club's property owner to: Elizabeth Neville,Town Clerk Town of Southold 53095 Route 25 Southold,NY 11971 Thank you for your help in this matter and if you should have any questions please call. Sincerely, Edward Rubio Logistics Manager 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@grucci.com THE FIRST FAMILY OF FIREWORKS May 14,2018 Elizabeth Neville,Town Clerk Town of Southold / 53095 Route 25 Southold,NY 11971 Phone: 631-765-1800 Fax: 631-765-6145 Email: e.neville@town.southold.ny.us CC: lynda.rudder@town.southold.ny.us Dear Ms. Neville: Please find attached hereto for the Orient Harbor July 4"'Festivities,Inc. fireworks display scheduled for June 30,2018 with a Rain Date of July 1,2018 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, 1 J �C, r I _W✓y„f _ Edward Rubio V/ 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-mall: erubio@grucci.com THE FIRST FAMILY OF FIREWORKS i INSTRUCTIONS FOR DISPLAY OF FIREWORKS 1. Name of body sponsoring fireworks display. 2. The date and time of day at which the fireworks display is to be held. 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 kind 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. 8. Such other information as the Southold Town Clerk may deem necessary to protect persons and property. Written permission of the property owner is required. 9. An indemnity insurance policy with liability coverage and indemnity protection of $1,000,000.00 per person for bodily injury; $1,000,000.00 per accident; $1,000,000.00 property damage. 10. The Town Clerk of the Town of Southold must have the insurance policy in her possession before the fireworks permit is issued. The named insured must read: TOWN OF SOUTHOLD. 11. Application for a fireworks permit must be made at least five days in advance of the date of the fireworks displace (The above instructions are in accordance with the Penal Law, Article 405 - Licensing and other provisions relating to fireworks.) 1 1 ELIZABETH A. NEVILLE, MMC �� �� Town Hall,53095 Main Road TOWN CLERK ® P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Fax(631)765-6145 MARRIAGE OFFICERO ®� Telephone(631)765-1800 RECORDS OF MANAGEMENT OFFICER �+ southoldtown.northfork.net FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD APPLICATION 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 HarborJuly4th Festivities, I ri c:- PRINCIPAL PRINCIPAL OFFICE AT PO Box 653, Orient, NY 11957 DATE&TIME OF DISPLAY June 30,2018 0-approx.9:15pm _ EXACT LOCATION OF DISPLAY Barge off Orient Yacht Club SUFFOLK COUNTY TAX MAP NUMBER FOR SITE 1000-24-2-28.1 ; RAINDATE&TIME Ju10 9n-18nannrnx 9'l.rinm The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition Louis M Deleo 57 25 years Excellent 1 - (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: _ i 1n LIN 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 Harbor July 4th Festivities, Inc. FEE: $100 Name 11INanli2ation See policy for additiona 1 information By i t p icant Date of Application 7 ® DATE(MMIDD/YYYY) ACOR>D CERTIFICATE OF LIABILITY INSURANCE 2/15/2018 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). PRODUCERA T NAME: Britton Gallagher PHCNNo Ext 216-658-7100 (FAX No:216-658-7101 One Cleveland Center, Floor 30 E-MAIL 1375 East 9th Street ADDRESS: Cleveland OH 44114 INSURERS AFFORDING COVERAGE NAIC# INSURER Everest National Insurance n 1012 INSURED INSURERB:Continental Indemnity Company Fireworks By Gruccl Inc and/or Pyrotechnlque INSURERC Axis Surplus Ins Company 6620 By Gruccl, Inc and/or Philny Effects, Inc. INSURERD: 20 Pinehurst Drive Bellport NY 11713 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:829568384 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DDIYYYY MMIDDIYYYY LIMITS A GENERAL LIABILITY S18ML00093-181 2/17/2018 2/17/2019 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea o........ce 500,000 CLAIMS-MADE FTI OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 Liability GENERAL AGGREGATE $2,000,000 GEN_'LAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY X 1 PRO- LOC $JEcT A AUTOMOBILE LIABILITY S18CA00044-181 2/17/2018 2/17/2019 Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PPO PERRY DAMAGE $ X HIREDAUTOS Ix AUTOSsociden C UMBRELLA LIAB X OCCUR EAU620937 2/17/2018 2/17/2019 EACH OCCURRENCE $9,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000 DED I I RETENTION$ $ B WORKERS COMPENSATION 73474435-01-04(MASTER) 5/27/2017 5/27/2018 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ORY LI TS ER ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED9 N/A (Mandatory in NH) E L DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 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,June 30,2018, Rain Date.July 1,2018, Location. Orient Yacht Club, Orient, NY, Additional I nsured(s):Orient Harbor July 4th Festivities, Inc, its Directors and Committee Members,Thomas E Foster III; Nathalie&Theodore A Strauel, Orient Yacht Club, its Officers and Board Members, Orient Wharf Company, and its Officers, Greenport Shipyard, Orient Fire Department,Town of Southold, State of New York, Crowley Marine, Costello Marine Construction, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orient Harbor July 4th Festivities, Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O. Box 653 ACCORDANCE WITH THE POLICY PROVISIONS. Orient NY 11957 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD 7 ® DATE(MMIDD/YYYY) ACORY CERTIFICATE OF LIABILITY INSURANCE 2/15/2018 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). PRODUCERTA NAME: Britton Gallagher a"c°N o t•216-658-7100 AIC No:216-658-7101 One Cleveland Center, Floor 30 E-MAIL 1375 East 9th Street ADDRESS Cleveland OH 44114 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Everest National U nce Company 10120 INSURED -INSURER B:Continental Indemnity Company Fireworks By Gruccl Inc and/or Pyrotechnique INSURER -AXIS Surplus Ins Company 6620 By Gruccl, Inc. and/or Philny Effects, Inc INSURER 20 Pinehurst Drive Bellport NY 11713 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:738114432 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DDIYYYY MMIDD/YYYY A GENERAL LIABILITY S18ML00093-181 2/17/2018 2/17/2019 EACH OCCURRENCE $1,000,000 x DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500,000 CLAIMS-MADE 171 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 Liability GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITYS18CA00044-181 2/17/2018 2/17/2019 Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIREDAUTOS X AUTOS Per accident $ C UMBRELLA LIAR X OCCUR EAU620937 2/17/2018 2/17/2019 EACH OCCURRENCE $9,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000 DED RETENTION$ $ B WORKERS COMPENSATION 73-474435-01-04(MASTER) 5/27/2017 5/27/2018 X WC STATU- O R AND EMPLOYERS'LIABILITY Y/N T RY ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA EL EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 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:June 30,2018, Rain Date July 1,2018; Location Orient Yacht Club, Orient, NY, Additional Insured Orient Harbor July 4th Festivities, Inc, Its Directors and Committee Members;Thomas E. Foster III, Nathalie&Theodore A Strauel, Orient Yacht Club, Its Officers and Board Members, Orient Wharf Company, and Its Officers; Greenport Shipyard, Orient Fire Department,Town of Southold, State of New York; Crowley Marine, Costello Marine Construction, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall 53095 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. South Hold NY 1.1971 AUTHORIZED REPRESENTATIVE ©198/8-20010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Orient Yacht Cluh - Orient NY June 30 2018 - Fireworks by Grucci FIREWORKS BY I � � �� s -� C, � 1000' �� - _ '� � •`��' ,� .t�`x 1000' . Y"���� � > - i •,-,. -•:.� �" of�7- �. n d l Barge DisMay Site �b 1000' Max Shell Size 8" . t` 1,000' Fallout Area v Exceeds •_ • 1000' y. Required 11 t� Exceeds - Recommended 1 08' 02Latitude, 01 250' 500' 750' 1000 Longitude. , -. • .. - .6 . • - - - . ••- 6 - • . -• •• 4 6 • 9 4 .8• • 6 -..• 6 E ` 47 -TATE`OF N£ T x° W YC7RK DSA Tip, . pled"PYROTL � yd. - r.t.•� �`{3 =•'P`•t•Yi�'v't�,p _ �.'1%�:r. rt .� - - - - °d"? ti.Rtfr ,y�.'':� �g�a•:•{� :i.^ Pt.t*'i*<+,,rd,�Yd" LU t �✓ t' " ' 0,•5'x:;';=':.•.�'. ''`',:�F'" /i•.-' ;r`f"�-' r..r�, '�. :�'+.},��i '�?�•r � �' 'sus•':,,.,, '.- �:�r"7;t#s { '`<<x,:'x,'s" rc,;`''-,;ra•.. , v.+'. ", -°Y;••"-..,- c"? �.�k,.. 'z� .zf fly,,^. ,f�p�c n I r p Ox1l, T` moi'yf g4 � r rr r9`"ke,y�,d # s ' ' 3�,Y y----u'-T .w• S - - i 1- FnF ra {+•f ,,� .. ,'it n.r�-:3r�.1�R=^,.��e�'�. �.:,� a€w�.-.:� .�.�t,r -n.�' _ qqq� May 15,2018 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: 1 Orient Harbor July 4th Festivities, Inc. Location and Date of Fireworks Display: Barge off Orient'Yacht Club 2110 Village Lane, Orient,NY 11957 June 30, 2018—Rain Date July 1, 2018 @ Approximately 9:15 PM J� Chief Pyrotechnician: Health: Age: Years Experience: Louis M Deleo Excellent 57 25 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 Cell#: 516 658-4486 -Cell I Fireworks by Grucci,Inc. Office#: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 Bellport,NY 11713 E-mail:erubio(a_auc� ci.com THE FIRST FAMILY OF FIREWORKS r� U.S.Department Eastern Service Center 1701 Columbia Ave. of Transportation Operations Support Group College Park,GA 30337 AN-E2 FIREWORKS DISPLAY NOTIFICATION Company Name: Fireworks by Grucci, Inc. Email Address of Person Submitting Request: ERubio@grucci.com Cell Phone Number for On-Site Technician: 516-658-4486 Event Name: Orient Independence Day Celebration Display Date: June 30,2018 Rain Date:July 1,2018 Display Start Time:9:15 PM Duration of Fireworks Display: 16-17 minutes Max Height of Fireworks:8" with a max height of 700' in altitude Address,City and State:Orient Yacht Club Latitude: 411 8' 2.71" (North) Longitude: 72 18'34.28(West) List the Closest Public Use Airport Within 5 Nautical Miles of the Display if the Fireworks Will Reach or Exceed 500: Rosefield and Klenawicus Airport Special Notes Please email your request to: 9-ATO-ESA-OSG-Fireworks@faa.gov May 14,2018 r DISPLAY: Orient Harbor July 4`h Festivities,Inc. FROM: Edward Rubio Re: June 30,2018 Fireworks Displays / Rain Date:July 1,2018 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 1AG) Thank You, Edward Rubio Logistics Manager 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(g mcci.com THE FIRST FAMILY OF FIREWORKS May 14,2018 TO: Mr. Steve Papa COMPANY: U.S. Fish&Wildlife Service E-MAIL: steve papa&fivs.gov PHONE: 631-776-1404 x 201 FAX: 631-776-1405 FROM: Edward Rubio TOTAL PAGES: 2' Dear Mr. Papa: Attached please find site map for the fireworks display noted below: EVENT: Orient Harbor July 4`i'Festivities,Inc. LOCATION: Barge off Orient Yacht Club 2110 Village Lane, Orient,NY LATITUDE: 41'08'02.71"N LONGITUDE:72° 18'34.28"W DATE: June 30,2018 RAIN DATE: July 1,2018 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, Edward Rubio Logistics Manager 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 15,2018 f , 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.�nningsndec.ny.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 Harbor July e Festivities,Inc. LOCATION: Barge off Orient Yacht Club 2110 Village Lane, Orient,NY LATITUDE: 41'08'02.71"N LONGITUDE:72° 18'34.28"W DATE: June 30,2018 RAIN DATE: July 1,2018 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, -IJy+�•' 1 WYV'�LYF Edward Rubio Logistics Manager 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@=Icci.com THE FIRST FAMILY OF FIREWORKS 1�,hisagreement dated February 15,2018 consisting of two (2) pages is for a 2 Fireworks Performance Contract * * * 3 Between: Fireworks by Grucci, Inc. And: Orient Harbor July 4th Festivities, Inc. * 4 20 Pinehurst Drive P.O. Box 653 5 Bellport,NY 11713 Orient, NY 11957 * 6 Tel: 631-286-0088 * 7 Fax: -9036 * 8 * 9 I.AGREEMENT: * 10 Whereas both Fireworks by Grucci, herein referred to as Grucci and Orient Harbor July 41h Festivities, Inc., herein * 11 referred to as Sponsor,agree that Grucci shall pending receipt of all required permits,signed contract and payment *� * 12 in full, produce and display fireworks fired from a barge off shore from Orient Yacht Club as follows: * 13 * Time of Duration Class of Total Fireworks Date Display (minutes) Fireworks Performance Contract * * 9:15 PM * * June 30,2018 16-17 State $30,000.00 4nitial here �. * 14 * 15 II.SERVICE AGREEMENT: * 16 The Total Fireworks Performance contract cost above is quoted fob destination at site for the fireworks display * 17 and transportation of personnel,equipment and fireworks. Services that need to be provided and paid for by the 18 sponsor are as follows: ** 19 e Section VI. Government Permits and Regulations ** *20 e Security upon arrival until departure at Discharge Sites and Fallout Areas. *21 a Provide direct cell phone or 2-way radio communications and to place the barge in the desired firing location, **22 to authorize performance time. **23 • Marine services to include: tug, barge (2,000 square feet minimum-working area) mobilization, and *24 demobilization;security,dockage,and moorings. *25 • Site access, use and detailed clean-up. *26 *27 III.PAYMENT SCHEDULE: *28 Payment of the Total,Fireworks Performance Contract for$30,000 shall be paid by sponsor as follows: *29 a) A 50% payment of$15,000 is due and payable on or before March 1, 2018 with the return of the Fireworks * 30 Performance Contract * *31 b) The balance of$15,000 is due and payable on or before June 1, 2018 * *32 c) A fee of$200.00, plus 1 Y2 interest will be charged to any unpaid balance per month. 33 ** *34 IV.CREDITING: *35 The sponsor agrees to credit Grucci as "Fireworks by Grucci" in all event programs, invitations, press release, *36 advertising,or promotion copy that is within sponsor's authority. *37 *38 V. RESCHEDULE DATE: *39 In the••event the fireworks performance is rescheduled for any reason, Grucci has reserved July 1, 2018 as an 40 inclement weather date accordingly in consideration for a 15%fee per day of the Fireworks Performance Contract * *41 total plus all out of pocket expenses. These costs shall be paid by the sponsor upon demand. In any event, the *42 sponsor shall be responsible for full contract price and those related costs as stated above. *43 *44 VI.GOVERNMENT PERMITS AND REGULATIONS 45 .Grucci shall file for all necessary permits,licensees and approvals applicable to this contract.However,the sponsor *46 shall be responsible for the payment of all government fees,fire department and police fees,taxes, including but *47 not limited to, sales, use, excise, entertainment, import charges and bonds for such permits, licensees and *48 approvals•for the fireworks performance and the activities undertaken pursuant to this Agreement from the *49 appropriatefederal,state, and local authorities. * * *AMERICAS FIRST FAMILY OF' FIREWORKS * *Fireworks by Grucci,Inc.=20 Pinehurst Drive=Bellport,NY 11713=Tel:631-286-0088=Fax:631-286-9036 7175/5376 ******************************************************************************* J ******************************************************************************* * 56 % �r * 51 This Agreement is subject to all federal, state and municipal laws and regulations now in force or which may be *52 enacted before the completion of this Agreement. Should any municipal, state or federal law or ordinance Ibe *53 passed which prohibits or restricts the performance or operation of the fireworks performance described herein, *54 the same shall automatically restrict or limit the fireworks performances described herein accordingly. * 55 *56 In the event the federal government or other regulatory authorities restricts or prohibits the use of any firework *57 as set forth herein,preventing Grucci from producing a performance as described above,then in such event,Grucci *58 shall substitute a firework of equivalent entertainment value,such substitution shall not constitute a reduction in *59 the contract price. *60 * *61 VII.GENERAL PROVISIONS: *62 a) Neither the Sponsor nor Grucci shall be in default or liable for any type of damages under this Agreement for any ** *63 Force Majeure event. A Force Majeure Event is any such unforeseen act or event this is beyond the reasonable ,*k 64 control of a partythat prevents the Sponsor or Grucci from performing and is not the fault of the Sponsor or Grucci; *65 and in addition a Force,Majeure Event is also defined as war, government intervention, un-navigable waters or * 66 waterways,strikes, inclement weather,fire,explosions,civil disturbance,act of God or the public enemy, military *67 action,terrorist act, unforeseeable or unpreventable lack of materials or equipment. *68 b) Once the contract is signed and the performance is then cancelled by the sponsor for any reason, Grucci shall *69 be paid one hundred percent(100%)of the total contract price. *70 c) Grucci shall not be responsible for any weather or atmospheric conditions that may interfere with the *71 performance or aesthetic quality of the fireworks or the performance. *72 d) This agreement constitutes the entire Agreement between the parties relating to the subject matter hereof, * 73 and may not be changed, modified, renewed,or extended except by a written agreement,signed by the party *74 against whom enforcement of change, modification, renewal or extension is sought. 75 e) Fireworks by Grucci agrees to procure general liability insurance in the amount of five million dollars and to * 76 issue form attached hereto,evidencing such insurance and covering the persons and entities named therein as *77 additional insureds against any claims arising out of the sole negligence of Fireworks by Grucci, Inc. in excess of ** *78 $2,500.00 per event. 79 f) This agreement shall be interpreted in accordance with and the rights of the parties hereto and shall be * 80 determined by,the laws of the State of New York. * 81 g) Any and all disputes, controversies, actions, claims, or proceedings arising under, out of, in connection, or * 82 relating to the terms of this contract,and amendment thereof,commenced by, between or against any of the ** * 83 parties to this contract shall be commenced and maintained solely in the courts of the State New York, and by ,*t 84 the signing of this contract all parties hereby submit to this same jurisdiction. * 85 h) By signing this contract the Sponsor agrees to reimburse Grucci for any and all costs including but not limited * 86 to administrative and attorney fees related to any and all disputes, controversies, actions, claims, and/or 878 proceedings arising under, out of, in connection,or relating to the terms of this contract. 8 * 89 To validate this contract, it must be signed and returned *90 to Grucci on or before March 1, 2018 *91 * *9293 �_X *I / * * heodore sitau4 Abate Felix James Grucci(Phil) Date * * President/CEO *94 *95 Congratulations, you have just purchased thefinest fireworks performance available in the world. * * * * * * * * * * * * * *AMERICAS FIRST FAMILY OF FIREWORKS * *Fireworks by Grucci,Inc.=20 Pinehurst Drive=Bellport,NY 11713=Tel:631-286-0088=Fax:631-286-9036 7175/5376 ******************************************************************************* r Neville, Elizabeth From: Neville, Elizabeth Sent: Friday, May 18, 2018 3:29 PM To: Duffy, Bill; Fisher, Robert; Flatley, Martin; Spiro, Melissa; Dinizio,James; Doherty,Jill; Evans, Louisa; Ghosio, Bob; Ruland,William; Russell, Scott Subject: Emailing: Referral Fireworks Aplic 20180518150905 Attachments: Referral Fireworks Aplic_20180518150905.pdf Transmitted herewith is the application of the Orient Harbor July 4th Festivities for a Fireworks Display to be held on June 30;-2018-(RainDate:-July 1,2018 on a barge in Orient Harbor. Please review and advise of any concerns,questions and/or objections that you may have to the granting of this Fireworks Permit. 823.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: Referral Fireworks Aplic_20180518150905 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 Neville, Elizabeth From: Neville, Elizabeth Sent: Friday, May 18, 2018 3:20 PM To: 'orientfd@optonline.net' Subject: Emailing: Referral Fireworks Aplic_20180518150905 Attachments: Referral Fireworks Aplic_20180518150905.pdf Attention: Chief Bill Wysocki I have attached for your review the application of the "Orient Harbor July 4th Festivities".for a Fireworks Permit for an event on June 30,2018 on a barge in Orient Harbor. I need a letter from you as the Chief of the Orient Fire Department stating that you are aware of the event and have reviewed the application and approve of it and will stand ready to assist at the event, if needed. Please direct the letter to the address below. Thank you. r Elizabeth A. Neville, MMC Southold Town Clerk 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: Referral Fireworks Aplic_20180518150905 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 - 4 RECEIVED Rudder, Lynda From: Leslie Fernandez <Ifernandez@grucci corn> SAY 16 2011 Sent: Tuesday, May 15, 2018 5:57 PM To: Neville, Elizabeth; Rudder, Lynda Southold Town aerk Cc: Edward Rubio; Corey-Grucci; Christopher Grucci;Ashley Colichio Subject: Application to Clerks - Orient Harbor- 180630 Attachments: Application to Clerk's Office - Orient Yacht club - 180630.pdf Dear Ms. Neville: Please find attached hereto for the Orient Harbor July 4th Festivities, Inc.'fireworks display scheduled for June 30, 2018 with a Rain Date of July 1, 2018 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 (Filed on-line) 12) Letter to Sponsor The Originals are to follow by the sponsor with the check for the permit. Thank you for your help in this matter and if you should have any questions please call. FIREWORKS RV Lr/sUe/M. FewvLGtndzk Logistics Assistant Fireworks by Grucci,Inc. Grucci Middle East Event Organizer,LLC p: +1.631.286.0088 ext.114 a: 20 Pinehurst Drive Bellport,NY 11713 w: www.grucci.com e.lfernandez@arucci.com - w � fi y 1 ELIZABETH A. NEVILLE, MMC ��� G, Town Hall, 53095 Main Road TOWN CLERK P.O Box 1179 Ze Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Fax (631)765-6145 ' MARRIAGE OFFICERD Telephone,(631)765-1800 RECORDS OF MANAGEMENT OFFICER d `� southoldtown.northfork.net FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD APPLICATION 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 OrientHarborJuly4th Festivities, I "C---- PRINCIPAL c_PRINCIPAL OFFICE AT PO Box 653, Orient, NY 11957 DATE&TIME OF DISPLAY June 30 2018 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 JuIu1 7nlAa,annrr)Y Q 1-c;nm The following persons are to be in charge of the actual shooting of the fireworks: Name Age Experience Physical Condition Louis M Deleo 57 25 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 Harbor July 4th Festivities, Inc. FEE: $100 Name of Organization See pol icy for additional information By Signature of Applicant Date of Application ® DATE(MMIDDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 2/15/2018 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 CONTACT NAME Britton Gallagher Alco"N Ext•216-658-7100 ivc No 216-658-7101 One - 8- One Cleveland Center, Floor 30 E-MAIL 1375 East 9th Street ADDRESS. Cleveland OH 44114 INSURERS AFFORDING COVERAGE NAIC# INSURERA Everest National Insurance Company 1 120 INSURED INSURERB Continental Indemnity Company Fireworks By Grucci Inc and/or Pyrotechnique INSURERC AXIS Surplus Ins Company 6620 By Gruccl, Inc and/or Philny Effects, Inc INSURER D: 20 Pinehurst Drive Bellport NY 11713 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:738114432 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSRBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY) [MMIDDIYYYY1 LIMITS A GENERAL LIABILITY SIBML00093-181 2/17/2018 2/17/2019 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 Liability GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO _LOC COMBINED SINGLE LIMI 1 $ A AUTOMOBILE LIABILITY S18CA00044-181 2/17/2018 2/17/2019 Ea accident $1,000,000 _ X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS OOWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident C UMBRELLA LIAB X OCCUR EAU620937 2/17/2018 2/17/2019 EACH OCCURRENCE $9,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000 DED RETENTION$ $ B WORKERS COMPENSATION 73-474435-01-04(MASTER) 5/27/2017 5/27/2018 X WRY LATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA E L EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 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. June 30, 2018, Rain Date July 1, 2018, Location Orient Yacht Club, Orient, NY, Additional Insured Orient Harbor July 4th Festivities, Inc, Its Directors and Committee Members,Thomas E Foster III, Nathalie&Theodore A Strauel, Orient Yacht Club, Its Officers and Board Members, Orient Wharf Company, and its Officers, Greenport Shipyard, Orient Fire Department, Town of Southold, State of New York, Crowley Marine, Costello Marine Construction, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Hall 53095 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. South Hold NY 11971 AUTHORIZED REPRESENTATIVE ©198/8-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ® DATE(MMIDDIYYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 2/15/2018 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 teems 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: FAX Britton Gallaher PHONE g AIC No Exti 216-658-7100 (A/C,No:216-6 -71 01 One Cleveland Center, Floor 30 E-MAIL 1375 East 9th Street ADDRESS Cleveland OH 44114 INSURERS AFFORDING COVERAGE NAIC# INSURERA Everest National InsUrance Company012 INSURED INSURERB-Continental Indemnity Company Fireworks By Gruccl Inc. and/or Pyrotechnique INSURERC-Axis Surplus Ins Company 26620 By Gruccl, Inc and/or Phllny Effects, IncINSURERD 20 Pinehurst Drive Bellport NY 11713 INSURER E: INSURER F. COVERAGES CERTIFICATE NUMBER:829568384 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DDIYYYY MMIDDIYYYY A GENERAL LIABILITY S18ML00093-181 2/17/2018 2/17/2019 EACH OCCURRENCE $1,000,000 X 'PREMISES(Ea occurrence) $500,000 COMMERCIAL GENERAL LIABILITY CLAIMS-MADE 15F]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 Liability GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO JECT LOC $ A AUTOMOBILE LIABILITY SI8CA00044-181 2/17/2018 2/17/2019 COMBINED SINGLE Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS x AUTOS Per acad.nt C UMBRELLA LIARX OCCUR EAU620937 2/17/2018 2/17/2019 EACH OCCURRENCE $9,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000 DED RETENTION$ _ $ g WORKERS COMPENSATION 73-474435-01-04(MASTER) 5/27/2017 5/27/2018 X roRSLATU ITS1 I OER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A EL EACH ACCIDENT $1,000,000 _ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E L DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS 1 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 June 30, 2018, Rain Date July 1, 2018, Location- Orient Yacht Club, Orient, NY, Additional Insured(s)Orient Harbor July 4th Festivities, Inc, Its Directors and Committee Members,Thomas E Foster III, Nathalie&Theodore A Strauel, Orient Yacht Club, Its Officers and Board Members, Orient Wharf Company, and its Officers, Greenport Shipyard, Orient Fire Department, Town of Southold, State of New York, Crowley Marine, Costello Marine Construction, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orient Harbor July 4th Festivities, Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P 0 Box 653 ACCORDANCE WITH THE POLICY PROVISIONS. Orient NY 11957 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD Orient Yacht Club — NY Orient, June 9 o FIREWORKS 8Y � nt 'S Barge Display Site a Max Shell Size 8" 1,000'Fallout Area c *Exceeds Coast Guard, ;R s Required 100'/1" **Exceeds NFPA 1123 g•s, Recommended 70'/1" Latitude 41°08'0271"N 0' 250' 500' 750' 1000' Longitude. I I I I 1 *• 72° 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 3115/18 F- ' f . fi t ! i i i i a OF NSW'YORK..: L SPAR `LA =11:C?1'(.:.CHNI('IAN'CERTIFICAT�'COP COPwit��SfP1C� - f LU1 DE;o ' 1'9.:M�i?•J,�J, Pro: � �'Si r �\_tl- g{ { � ? .P,,.ft y IA SS ROXIM @nom °'4 . lM, [q^ `/.1 RD �t1UST :CAS , ,t .1..�, Ni.re•''�L,I A,H � , m,„ w A. t i j �1 U.S.Department Eastern Service Center 1701 Columbia Ave. of Transportation Operations Support Group College Park,GA 30337 AJV-E2 FIREWORKS DISPLAY NOTIFICATION Company Name: Fireworks by Grucci, Inc. Email Address of Person Submitting Request: ERubio@grucci.com Cell Phone Number for On-Site Technician: 516-658-4486 Event Name: Orient Independence Day Celebration Display Date: June 30,2018 Rain Date:July 1, 2018 Display Start Time: 9:15 PM Duration of Fireworks Display: 16-17 minutes Max Height of Fireworks:8" with a max height of 700' in altitude Address,City and State:Orient Yacht Club Latitude: 411 8' 2.71" (North) Longitude: 72 18' 34.28(West) List the Closest Public Use Airport Within 5 Nautical Miles of the Display if the Fireworks Will Reach or Exceed 500: Rosefield and Klenawicus Airport Special Notes Please email your request to: 9-ATO-ESA-OSG-Fireworks@faa.eov May 14,2018 DISPLAY: Orient Harbor July 4`h Festivities, Inc. FROM: Edward Rubio Re: June 30,2018 Fireworks Displays / Rain Date:July 1,2018 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, �-OcLoj Edward Rubio Logistics Manager Cell#: 516-658-4486 Fireworks by Grucci, Inc. Office #: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 Bellport,NY 11713 E-mail: erubioQgmcci com THE FIRST FAMILY OF FIREWORKS May 14,2018 , TO: Mr. Steve Papa COMPANY: U.S. Fish&Wildlife Service E-MAIL: steve papa&ws.gov PHONE: 631-776-1404 x 201 FAX: 631-776-1405 FROM: Edward Rubio TOTAL PAGES: 2 Dear Mr. Papa: Attached please find site map for the fireworks display noted below: EVENT: Orient Harbor July 4`h Festivities,Inc. LOCATION: Barge off Orient Yacht Club 2110 Village Lane, Orient,NY LATITUDE: 41'08'02.71"N LONGITUDE: 72° 18' 34.28"W DATE: June 30,2018 RAIN DATE: July 1, 2018 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, J Edward Rubio Logistics Manager 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 14,2018 01 Elizabeth Neville,Town Clerk Town of Southold / 53095 Route 25 Southold,NY 11971 Phone: 631-765-1800 Fax: 631-765-6145 Email: e.neville@town.southold.ny.us CC: lynda.rudder@town-southold.ny.us Dear Ms. Neville: Please find attached hereto for the Orient Harbor July 4`h Festivities, Inc. fireworks display scheduled for June 30,2018 with a Rain Date of July 1, 2018 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, ) j �C�Ut.r-�t� l'�-tvL-€�•. 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@grucci.com THE FIRST FAMILY OF FIREWORKS May 14,2018 Theodore Strauel Orient Harbor July 4"'Festivities, Inc. 680 Croton Lake Road Bedford Corners,NY 10549 Cell: 914-523-9289 Email: tstrauel&gmail.com Dear Mr. Strauel: Please find attached hereto for the Orient Harbor July 4`h Festivities, Inc. fireworks display scheduled for June 30, 2018 with a Rain Date of July 1,2018 at 9:15 PM the following: 1) Letter to Town of Southold Clerk's Office 2) Town of Southold Permit to Display Fireworks Application 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 Please sign the enclosed application and forward to the Town of Southold along check for $100 made out to the Town of Southold with written permission from the Orient Yacht Club's property owner to: Elizabeth Neville,Town Clerk Town of Southold 53095 Route 25 Southold, NY 11971 Thank you for your help in this matter and if you should have any questions please call. Sincerely, �, �'C�ts' A" tom. Edward Rubio Logistics Manager 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@grucci.com THE FIRST FAMILY OF FIREWORKS May 15,2018 , r 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.Jennings(a dec ny.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 Harbor July 4`h Festivities,Inc. LOCATION: Barge off Orient Yacht Club 2110 Village Lane, Orient,NY LATITUDE: 41'08'02.71"'N LONGITUDE:72° 18'34.28"W DATE: June 30,2018 RAIN DATE: July 1, 2018 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, r .[) G�+�'Pt^,�` Edward Rubio Logistics Manager Cell#: 516-658-4486 Fireworks by Grucci, Inc. Office#: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 BcUport,NY 11713 E-mail:erubio _grgcci.com THE FIRST FAMILY OF FIREWORKS May 15,2018 / As per the document N.F.P.A. 1123-2000 Code for Fireworks f Display and the Town of Southold regulations, the following information is provided. Sponsor/Client Name: Orient Harbor July 4th Festivities, Inc. Location and Date of Fireworks Display: Barge off Orient Yacht Club 2110 Village Lane, Orient,NY 11957 June 30, 2018—Rain Date July 1, 2018 @ Approximately 9:15 PM Chief Pyrotechnician: Health: Age: Years Experience: Louis M Deleo Excellent 57 25 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: CC41-a t� RU . Edward Rubio Logistics Manager Cell#: 516 658-4486 -Cell Fireworks by Grucci,Inc. Office#: (631) 286-0088 20 Pinehurst Drive Fax#: (631) 286-9036 Bellport,NY 11713 E-mail erubionae cocci com THE FIRST FAMILY OF FIREWORKS