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HomeMy WebLinkAbout2018 ELIZABETH A.NEVILLE, MMC A�®g�FFOe��® Town Hall, 53095 Main Road TOWN CLERK �� � P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS 0 Fax(631)765-6145 MARRIAGE OFFICER ,ji ®�, Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER V, 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: 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 2,2018 at 7.15 PM (Rain Date: September 3,2018 at 7:15PMI on Peconic Landing's property 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. d Elizabeth k. eville, Town Clerk Town of Southold Suffolk County,New York (TOWN SEAL) Date: August 29,2018 THIS PERMIT IS NOT TRANSFERABLE ���currnrc RESOLUTION 2018-787 ADOPTED DOC ID: 14424 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2018-787 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON AUGUST 28,2018: 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 2,2018 at 7:15PM (Rain Date: September 3,2018 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. 1. Elizabeth A. Neville Southold Town Clerk ti RESULT: ADOPTED [UNANIMOUS] MOVER: James Dinizio Jr, Councilman SECONDER:Louisa P. Evans, Justice AYES: Dinizio Jr, Doherty, Ghosio, Evans, Russell ABSENT: William P. Ruland Neville, Elizabeth From: Neville, Elizabeth Sent: Wednesday,August 01, 2018 2:52 PM n • To: Flatle)/Partin; Fish�bert; Spir elissa; 'gfdfire ononline.o ; Du Bill; Hagan, Damon; Silleck, Mary Cc: Doherty,Jill; Doroski, Bonnie;Ghosio, Bob;James Dinizio; Lauren Standish; Louisa Evans; Neville, Elizabeth; Noncarrow, Denis; Rudder, Lynda (lynda.rudder@town.southold.ny.us); Russell, Scott;Tomaszewski, Michelle;William Ruland Subject: Emailing: Fireworks Applic Peconic_20180801144329 Attachments: Fireworks Applic Peconic_20180801144329.pdf Attached, please find an application for a Fireworks Permit submitted by Peconic Landing for event on 9/2/2018; rain date 9/3/2018. Please review this application and send me your written comments/recommendations/approval. 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: Fireworks Applic Peconic_20180801144329 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: Wednesday,August 01, 2018 2:54 PM To: Greenport Fire Department(gfdfire@optonline.net) Subject: FW: Emailing: Fireworks Applic Peconic_20180801144329 Attachments: Fireworks Applic Peconic_20180801144329.pdf Please review and send me your written approval.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: Neville, Elizabeth Sent:Wednesday,August 01, 2018 2:52 PM To: Flatley, Martin; Fisher, Robert; Spiro, Melissa; 'gfdfire@optononline.org'; Duffy, Bill; Hagan, Damon;Silleck, Mary Cc: Doherty,Jill; Doroski, Bonnie; Ghosio, Bob;James Dinizio; Lauren Standish; Louisa Evans; Neville, Elizabeth; Noncarrow, Denis; Rudder, Lynda (lynda.rudder(@town.southold.nv.us); Russell,Scott;Tomaszewski, Michelle; William Ruland Subject: Emailing: Fireworks Applic Peconic_20180801144329 Attached, please find an application for a Fireworks Permit submitted by Peconic Landing for event on 9/2/2018; rain date 9/3/2018. Please review this application and send me your written comments/recommendations/approval. 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: Fireworks Applic Peconic_20180801144329 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: Fisher, Robert Sent: Thursday, August 02, 2018 9:32 AM To: Neville, Elizabeth; Flatley, Martin; Spiro, Melissa; 'gfdfire@optononline.org'; Duffy, Bill; Hagan, Damon; Silleck, Mary Cc: Doherty,Jill; Doroski, Bonnie;Ghosio, Bob;Jim Dinizio; Standish, Lauren; Louisa Evans; Noncarrow, Denis; Rudder, Lynda; Russell, Scott;Tomaszewski, Michelle;William Ruland Subject: RE: Emailing: Fireworks Applic Peconic_20180801144329 Betty I have no objections to this event taking place as indicated in the application. Bob Robert Fisher Fire Marshal,Town of Southold robe rt.fisher town.southoId.ny.us (W)631-765-1802-(C) 631-786-9180 PRIVILEGED AND CONFIDENTIAL COMMUNICATION CONFIDENTIALITY NOTICE:This electronic mail transmission is intended only for the use of the individual or entity to which it is addressed and may contain confidential information belonging to the sender which is protected by privilege. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution,or the taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this transmission in error, please notify the sender immediately by e-mail and delete the original message. -----Original Message----- From: Neville, Elizabeth Sent:Wednesday,August 01, 2018 2:52 PM To: Flatley, Martin<mflatlev@town.southold.ny.us>; Fisher, Robert<Robert.Fisher@town.southold.nv.us>;Spiro, Melissa<Melissa.Spiro@town.southold.nv.us>; 'gfdfire@optononline.org'<gfdfire@optononline.org>; Duffy, Bill <billd@southoldtownnv.gov>; Hagan, Damon<damonh@southoldtownnv.gov>;Silleck, Mary <marys@town.southold.ny.us> Cc: Doherty,Jill<rill.dohertv@town.southold.nv.us>; Doroski, Bonnie<Bonnie.Doroski@town.southold.nv.us>; Ghosio, Bob<bob.ghosio@town.southold.nv.us>;Jim Dinizio<iim@iamesdinizio.com>;Standish, Lauren <Lauren.Standish@town.southold.nv.us>; Louisa Evans<Ipevans06390@Bmail.com>; Neville, Elizabeth <E.Neville@town.southold.nv.us>; Noncarrow, Denis<denisn@southoldtownny.gov>; Rudder, Lynda <Ivnda.rudder@town.southold.ny.up; Russell,Scott<scottr@southoldtownny.gov>;Tomaszewski, Michelle <michellet@town.southold.ny.us>;William Ruland<rulandfarm@yahoo.com> Subject: Emailing: Fireworks Applic Peconic_20180801144329 Attached, please find an application for a Fireworks Permit submitted by Peconic Landing for event on 9/2/2018; rain date 9/3/2018. Please review this application and send me your written comments/recommendations/approval. Thank you. 1 Neville, Elizabeth From: Spiro, Melissa Sent: Wednesday,August 01, 2018 2:54 PM To: Neville, Elizabeth; Flatley, Martin; Fisher, Robert; 'gfdfire@optononline.org'; Duffy, Bill; Hagan, Damon; Silleck, Mary Cc: Doherty,Jill; Doroski, Bonnie; Ghosio, Bob;Jim Dinizio; Standish, Lauren; Louisa Evans; Noncarrow, Denis; Rudder, Lynda; Russell, Scott;Tomaszewski, Michelle;William Ruland Subject: RE: Emailing: Fireworks Applic Peconic_20180801144329 This is not Town preserved land. Melissa Spiro -----Original Message----- From: Neville, Elizabeth Sent:Wednesday,August 01, 2018 2:52 PM To: Flatley, Martin<mflatley@town.southold.ny.us>; Fisher, Robert<Robert.Fisher@town.southold.nv.us>;Spiro, Melissa <Melissa.Spiro@town.southold.ny.us>; 'gfdfire@optonon line.org'<Bfdfire@optonon Iine.org>; Duffy, Bill <billd@southoldtownny.Rov>; Hagan, Damon<damonh@southoldtownny.Rov>;Silleck, Mary <marvs@town.southold.nv.us> Cc: Doherty,Jill <rill.doherty@town.southold.ny.us>; Doroski, Bonnie<Bonnie.Doroski@town.southold.ny.us>; Ghosio, Bob<bob.ghosio@town.southold.ny.us>;Jim Dinizio<iim@iamesdinizio.com>; Standish, Lauren <Lauren.Standish@town.southold.nv.us>; Louisa Evans<Ipevans06390@Rmai1.com>; Neville, Elizabeth <E.Nevil le@town.southoId.ny.us>; Noncarrow, Denis<denisn@southoldtownny.Rov>; Rudder, Lynda <Ivnda.rudder@town.southold.nv.us>; Russell, Scott<scottr@southoldtownny.Rov>;Tomaszewski, Michelle <michellet@town.southold.ny.us>; William Ruland <rulandfarm@vahoo.com> Subject: Emailing: Fireworks Applic Peconic_20180801144329 Attached, please find an application for a Fireworks Permit submitted by Peconic Landing for event on 9/2/2018; rain date 9/3/2018. Please review this application and send me your written comments/recommendations/approval. 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: Fireworks Applic Peconic_20180801144329 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: Flatley, Martin Sent: Thursday,August 16, 2018 10:38 AM To: Neville, Elizabeth Subject: Re: Emailing: Fireworks Applic Peconic_20180801144329 I have no objections to this being issued Sent from my Verizon,Samsung Galaxy smartphone -------- Original message -------- From: "Neville,Elizabeth" <E.Neville a,town.southold.ny.us> Date: 8/16/18 09:59 (GMT-05:00) To: "Flatley, Martin" <mflatleygtown.southold.ny.us>, "Blasko, Regina" <rblaskogtown.southold.ny.us>, "Duffy, Bill" <billd ,southoldtownn .gov>, "Silleck, Mary" <maiys@town.southold.nyus> Subject: FW: Emailing: Fireworks Applic Peconic 20180801144329 To date,I have not received a response from the Chief of Police or Town Attorney with regard to the Fireworks application of Peconic Landing. Please respond at your earliest convenience so that I may place a resolution on the next Town Board agenda,August 28,2018,for the Town Board too consider. The event is planned for September 2nd.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:Neville,Elizabeth Sent: Wednesday,August 01,2018 2:52 PM To:Flatley,Martin;Fisher, Robert; Spiro,Melissa;'gfdfire@optononline.org;Duffy,Bill;Hagan,Damon; Silleck,Mary Cc:Doherty,Jill;Doroski, Bonnie; Ghosio,Bob;James Dinizio;Lauren Standish;Louisa Evans;Neville,Elizabeth;Noncarrow, Denis;Rudder,Lynda(lynda.rudder@town.soutliold.ny.us);Russell, Scott;Tomaszewski,Michelle; William Ruland Subject: Emailing:Fireworks Applic Peconic 20180801144329 Attached,please find an application for a Fireworks Permit submitted by Peconic Landing for event on 9/2/2018;rain date 9/3/2018. Please review this application and send me your written comments/recommendations/approval. 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.631 765-1800,Ext.228 Fax 631 765-6145 Cell 631466-6064 1 Neville, Elizabeth From: Duffy, Bill Sent: Tuesday, August 21, 2018 11.56 AM To: Neville, Elizabeth Subject: RE: Emailing: Fireworks Applic Peconic_20180801144329 No objection William M. Duffy, Esq. Town Attorney Town of Southold Southold Town Annex 54375 Route 25 (Main Road) P.O. Box 1179 Southold, New York 11971-0959 Office: 631.765-1939 Fax: 631.765.6639 Email: billd@southoldtownny.gov 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: Monday,August 20,2018 1:49 PM To: Duffy, Bill Subject: FW: Emailing: Fireworks Applic Peconic_20180801144329 Bill, Everyone has responded positively on this fireworks permit except you. Would you just send me an e-mail,so I can put a resolution on to approve at next week's Town Board meeting? The event is scheduled for September 2nd. -----Original Message----- From: Neville, Elizabeth Sent:Wednesday,August 01, 2018 2:52 PM To: Flatley, Martin; Fisher, Robert; Spiro, Melissa; 'gfdfire@optononline.org'; Duffy, Bill; Hagan, Damon;Silleck, Mary 1 Cc: Doherty,Jill; Doroski, Bonnie; Ghosio, Bob;James Dinizio; Lauren Standish; Louisa Evans; Neville, Elizabeth; Noncarrow, Denis; Rudder, Lynda (lynda.rudder@town.southold ny.us); Russell,Scott;Tomaszewski, Michelle;William Ruland Subject: Emailing: Fireworks Applic Peconic_20180801144329 Attached, please find an application for a Fireworks Permit submitted by Peconic Landing for event on 9/2/2018; rain date 9/3/2018. Please review this application and send me your written comments/recommendations/approval. 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: Fireworks Applic Peconic_20180801144329 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 CHIEF JEFFREY WEINGART (631)477-9801 -STATION 1 1STASST CHIEF SUSANO JIMENEZ (631)477-8261 -STATION 2 isr (631)477-1943-CHIEFS OFFICE 2ND ASST.CHIEF JAMES KALIN (631)477-4012-FAX CHAPLAIN CLAUDE KUMJIAN a 311 THIRD STREET•P.O.BOX 58 ASST CHAPLAIN THOMAS MURRAY GREENPORT,NY 11944�� k�" Email:gfdfire@optonline.net SECRETARY/TREASURER JAMES KALIN _ _ _ _ _ www.greenpoWd.org Organized 1845 RECEIVE[ August 14th, 2018 AUG 1 5 2018 e . Southold Town Clerk To Whom It.May Concern, The Greenport Fire Dept has no issue with the fireworks display at Peconic Landing on September 2nd, 2018. 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 plea_ se.feel,free to contact me at the number below. Firemati ally, Jeffrey L Weingart Chief Engineer RECEIVED AUG 1 2018 Southold'Town Clerk ELIZADETH A.NEVILLEI MMC ��y down Hall,53095 Main Road TOWN CLERK a P.O.Bog 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p MARRIAGE OFFICER Fsx(631)765-6145 '�' O`' Telephone(631)766-18b0 RECORDS OF,MANAGEMENT OFFICER dl '1►� so ephone(63 )765 1800 FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLEII,K TOWN OF-8OUTHOLD 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 Peconic Landing at Southold Inc. PRINCIPAL OFFICE AT 1500 Brecknock Road, Greenport, NY 11944 DATE&TIME OF DISPLAY 9/2/18 at 7:15 pm RXACT•LOCATION•OF DISPLAY Peconic Landing property near Brecknock Hall SUFFOLK COUNTY TAX MAP'NUMBRR FOR SITE RAIN DATE&TIME ._9/3/18 at 7:15pm The following persons are to be in charge of the actual shooting`of the fireworks: Name Age Experience Physical Condition Peter Marshall 67 yrs 18 yrs. Health: Good (Additional names and information may be submitted on an attached sheet Number and type of fireworks is as follows: UG Fireworks: 2.5"=672. Cakes=18: Manner and place of storage of fireworks prior to display: Delivery will be day of display. 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 theeProyerty Owner,;must,be submitted with,.the -Application. P_ L . � yi- CA—i FEB: 10o Name-of n See policy%fox additional information By Printed ame o pp ican Sig tune of-Ap ' arit e-mail 'address: Telephone Number-63 f— 7-7- � S t5 '� Date-of Application o�oSUFFot��o ELIZABETH A.NEVILLE,MMC ,may. Town Hall,,53095 Main Road TOWN CLERK o P.O.Box 11'79 ce Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p • Fax(631)765-6145 MARRIAGE-OFFICERy ' RECORDS MANAGEMENT OFFICER Telephone(631)765-J 800 FREEDOM OF INFORMATION OFFICER www.southoldLownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD POLICY for the Issuance of Fireworks Permits, 1. 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, I Fireworks permits shall indicate that-the display must be concluded by 10:00 p.m.if held Sunday-Thursday, 11:00 p.m.if held Friday or Saturday, and there shall be no time restriction if held on July 4. 4. No person shall engage in or allow the manufacture,assembly, storage or display of any fireworks or pyrotechnics display without first obtaining a permit issued by the Town Clerk. A completed application for display of fireworks must be received by the Town Clerk a minimum of 30 days prior to the date of display. The permit application for any fireworks or pyrotechnics display shall"be accompanied by the following: (a) a copy of a valid certificate of competency as a pyrotechnician for the individual supervising the firing of the display; (b) Certificate of Insurance naming the Town of Southold as additional insured with coverage limits of$2,000,000 for public liability and$2,000,000 for property damage; (c) Detailed diagram showing location of fireworks discharge and minimum separation distances in accordance with the applicable requirements of Penal Law Section 405(2); (d) A"copy of.th6 contract with fireworks display,company;and- (e) All applications shall require the-approval of the Fire Chief of the District in which the displaywill take place and the Fire Marshal before being presented fora approval by the Town Board. - �,aSUFF�t,��0 ELIZABETH A.NEVILLE,MMC �y0 Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 COD Southold,New York 11971 REGISTRAR OF VITAL STATISTICS & ® .'� Fax(631)765-6145 ' MARRIAGE OFFICER ! RECORDS MANAGEMENT OFFICER �Q( � Telephone(63 765-3 800 FREEDOM OF INFORMATION OFFICER www.southo[dtowimy.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD INSTRUCTIONS FOR DISPLAY OF FIREWORKS 1. Name of body sponsoring fireworks display. 2. The date and time of day at which the fireworks display is to be held. 3. The exact location planned for the fireworks display,including TAX MAP NUN(BER. 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. 16. 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. Thirty (30)Town of Southold POLICY 11. Application for a fireworks permit must be made at least fv�.-days in advance of the date of the fireworks dxsnlav .. (The above instructions are in accordance with the Penal Law, Article 405 - Licensing and other provisions relating to fireworks.) t 5. All applications for a fireworks permit shall be subject to an application fee in an amount of$100.00,together with a processing fee in an amount to be determined by the Town Board to cover the Town's costs for monitoring and enforcing compliance with the Penal Law. (The above instructions are in accordance with the Penal Law,Article 405 -Licensing and other provisions relating to fireworks.) NO ADMITTANCE = �` PECONIC LANDING 10TH ANNIVERSARY � 5 1yw 3" MAX SIZE SHELLS 210 RAIDUS N0 4 j 41 07 06.71 N y ` 72 21 47.03 W r. BAY FIREWORKS SPONSOR: Peconic Landing at Southold Inc. Fireworks Company Pyro Engineering, Inc. dba Bay Fireworks 999 S. Oyster Bay Rd., Suite I 1 I Bethpage,NY 11714 P: 516-597-5500/F: 516-597-5507 Show Date(s): 9/2/18 Rain Date(s): 9/3/18 Location: Peconic Landing,Brecknock Hall, 1500 Brecknock Rd.,Greenport Time: 7:15 pm' 1. Total number of Class B shells being used: 2.5"=672. Cakes=18. Maximum shell size: 2.5 inches in diameter. 2. All shells are DOT approved. 3. Display will be fired electrically and/or manually. 4. Delivery to site will be approximately 12:00 noon. Set up will take approximately 4-5 hours. 5. All displays will comply with all requirements as set forth in NYS Penal Code 405 and NFPA 1123, 1124. 6. Pyro Engineering,Inc. has complete understanding of all rules and regulations governing public fireworks displays and this display will be in accordance with those rules and regulations. 7. Personnel representing fireworks display company: Lead: Peter Marshal (NYS DOL license PR-36) Cell: 516-554-7463 8. Technician(s): tbd i Signed JFire ks ompany epresentatrve i r �5 4 J S 067A 7C ZZE xtZYm Za t w� • Sf1�F1Y0 aJI3d0 SJ•ftSS u�• • uX2 S SCJ$ 6: ZL SmicaIf18 Y9i YloD2i 0218 ur4g ;g=. shin Mss Na � - zoasxs aa$ sax$ off' 01 2i27urd 8=noa 8I 6L6Lnsel. #Ana I�INIII�lIIINII��ll�sllllll�• 71 . s;=�J�N�Nt�Cl3�Ifs1-._�-y_vvt,�"t�Y '- , .,J--__.._.-_._-••-•----_ • bNiSR-N3WA--• 1 k,• 63ia' 36 ISAW aati3 si t t 'a{ '• = .-. i' FAL: ..�:�• A7146-3,4"3ranv3sdwixoaa •y/:YS�•Y I7i�03L7Q v Y�°i ,;�•���� : �r��i�i�,;a�jo•���a�ia���ra�rJ�irr;�:so�,,G VO Yl. U.S.AcparirrtentrrfJustice Federal Explosives License/Permit Durcau ol`Alcohol,Tobacco,F"trrarms mid Explosives 08 U.S.C. Chapter 40) r tttzr�ta� tirtr��xaatt 5n aceordanc a with the provisions of Titic}FI,Orgartocd Crime Control Act of 1970,and ilio regulations issued thereunder(27 CIER Part 555).you inky engage in die activity gxvified an this lir erisc Kir ivrinh within the limilntionb of Chapter 44.Title IS.United States Codd and the regalazroris issued tttereundes,autGl titc expirntion dato shown. `f'9i15 LICE.N%F.1- £3 '"t`'i ;S r fr:E i '-1.tk3�l�t,?�?d l2� s. Sec'��rARtii]NGS"and"NtY1iCE5"au aver . Direct ATF ATT-Chief.FELL LtCerrsC�T'srtrtil �� !� s t, is t Cormspondalce,ro 244 Needy Road Number I all Martinsburg,WV:5.905-9431 _ Chief.Fcdcral r. loswts Licensing Center 0-'1 I, " Expin,tion&41V / _ hate ?tame F� BAY FIREWORKS & 1NTL PYRO IMPORTERS Preinises Address xlraagpo Notify itse Fax at feats la dayirbl;9ilre thettu+t•e) 999 SOUTH OYSTER SAY RD SHITE 111 BETHPAGE NY 11714- Typc of License or Permit 51-IMPORTER OF EXPLOSIVES Purchasing Ccrtification Staterawl Mailing Addrebs(C:hanWO Notin'the 1,FJC of any change. Th,>lictu,�c or pc'stt hi&,named above shall use a copy of ilm ljom.,4 or perntl io&ub-'t a trmi4cr Lv of explQSwo to vtrify te,f`R identity.land the licdtmcad rdutux ed'tltc liiaisix or pmninceanprovided by7-7(:iRPart555. 'rho siptattirgi tea.ltti-ov tw 'hr.mtimciwd PYRO E�iGItVEEt3lhIG INC t a A rwtetf,s:wet I w c-mailzd ccgry of the Inoenac or pern»t with a signature mtrndedtoUc:aloe;tstlalxi tarurcltaatiltr�te lttesig tSrrereaistfictlmtafthcFccterai BAY FIREWORKS a WTI.PYRO IMPORTERS I cnlosaFcs Licrnsrc{Ft?},v s respatta iblc p��uta ei'the l°£L I e.~di Ata[this i;:ntttte 999 SOUTH OYSTER BAY FID SUITE 111 "-j'y Air a li"'114.ur tenni issued to the licavicc ar painit:ee namtd WhoVt t�+l�r}w in the B THPA4E, NY 11714- tw e cr ttparmaats slreeifiai abava u»U`;r"<i1 Flr t�f'lac4ur:rx}'rrtnir L.icenseeF'ennitteelicxptxistbkPerstynSigitattera Political--'Title PritttcdNamc Bate All.I-Mtn part i PrOVIPt.t;wllt4V'.;:4Dbb.-.ictc %gJlbttrtaatlLa4 yl te`3Lt Ott'43M p7 itttl i,:Mh.r,wo.141 macltttq t,mut 4smt?Itti(Immtt li:¢Ised C1;.-}:Cf:lilt Federal Explosives Uceww(Fl:I)OtxtuntrrSersicelnfamantion Federal Fsptri,*let,Ucensing Ccnter(1`ELC) roll-frce'relephane Number: (877)283-3332 ATF Homepage;w%,%%atf:uov 2.4-1 Neat •Road I=00%,utnbcr: (3(A)6164401 tvtartinaburg,WV 25405-9431 F-mait. I1L.Cixatf.got (Stange of Address (27 M SS3.S,lin)r1{). Licensee-,or permittees mac during the toren of their curretit license or permit m--snore their busir e.%or operations to a new location at which they intend r,gulady tet carry on such business ar operations rate t.cer?sec or parmitKc is rt quftr3 tta)ism nt diticatiart trf the new location cif t ht business or operations not less than 10 day's prior to such r emrn-4l with the Chief;Federal INplosives Licensing Center. Tate license or p+mnil gill Ix valid rar the r6'timinder of the lettra of the original license or permit. (Tbc(Ftief,F EI)C,shall,if the licerisft or peraditee is not qualified,refer die request for amended Neese or perndt to the rArector of Industry Operations for denial In accordance with§F55.54.) Pightr of 5ucct.ion (2 i GM?553.59). W Certain parsons other than the licensx or permittee may secures the tight to carsw nn tine same c%ptasi%V materials business or operations at the settle address shown on,and for the remainder of the[crit Of it cti ten(Heenso ear ivrrtllt. Suah pcmw!;arc: (I)'Cite surviving spottnY or child.at execifier.adminiamlor,or other leenl r:prMlitativo of a decmscil Iicenwe or permittee;and(3)A receiver or ensue in lsnnknipley,or an assignee for benefit of creditors. (b)In order to seethe the ryrt It provided by this txclion,the person or pcssons continuing the business or opt.-radom;shall furniqa the license or pertitii Jnr fbr that business or opertatlons for endorwrliclit of tarsal succession to the chief.lq:I.C.within 30 days fiorn the bate oil which the succemr begins to cam,on tate:business or operstiom, Cut Hem l Federal Expluaises LfcetrseiPermit(FEL)(nfurrttadon Card t t r I Liec-rns6,Pcnrh Nagle:PYRO ENGINEERING INC t t t I 1 1 Busim-ssNamc: SAY FIREWORKS al INTL PYRO IMPORTERS t 4 I j LicensrrWrtnitNumber:6-NY-059 51.0E-OD129 t I i L iccubePcrtnit Ty-pc:51-IMPORTER OF EXPLOSIVES 1 i - 1 1 { L xpiratirm: May 1,2020 1 I 1 l 1 PFras.ldeae;\�x[`slid ror ft:Sale or Oahe.,Aisp�jtiw of E.Vlobives. 1 __- ------------------ --- Client#:535 PECOLAN ACORDTM CERTIFICATE OF LIABILITY INSURANCE DAT8/001/201120D/YYYY) 18 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 COVERAGEAFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). CONTACT Cook Maran PRODUCER NAME Cook Maran&Associates (PAH NNE o Ext):631 324-1440 A/c,No): 461 Pantigo Rd ADDRESS: certificates@cookmaran.com East Hampton,NY 11937-2647 INSURER(S)AFFORDING COVERAGE NAIC# 631 324-1440 INSURERA:Steadfast Insurance Company 26387 INSURED INSURER B:Ironshore Specialty Insurance Company 25445 Peconic Landing At Southold,Inc. INSURERC:MEMIC Indemnity Company 11030 1500 Brecknock Road INSURER D:American Guarantee&Liability Ins Co 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 /NSR ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDDIYYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY Y GL0980820704 04/02/2018 04/0212019 EACH OCCURRENCE $110001000 X CLAIMS-MADE �OCCUR PREMISES Ea occurrence $100 000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $3,000,000 X POLICY El ECT LOC PRODUCTS-COMP/OPAGG $3,000,000 OTHER PRO- F D AUTOMOBILE LIABILITY BAP980820604 04/02/2018 04/02/201 COMBINED SINGLE LIMIT Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ IER AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED Per accident $ X AUTOS ONLY X AUTOS ONLY B UMBRELLA LIAB OCCUR 003113301 04/02/2018 04/02/201 EACH OCCURRENCE $10,000,000 tED XCESS LIAB X CLAIMS-MADE AGGREGATE $10 000 000 X RETENTION$1000 $ C WORKERS COMPENSATION 3102804785 04/02/2018 04/02/201 X PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E L EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED N 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 I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Fireworks Display Sunday,September 2,2018(Rain Date September 3,2018). The Town of Southold is included as Additional Insured with respect to General Liability as required by a written contract. 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 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1628745/M1434755 SWOOD FIREWORKS DISPLAY HOLD HARMLESS AGREEMENT Between Peconic Landing at Southold Inc. and PYRO ENGINEERING, INC. (Contractor) WITNESSETH: 1. PYRO ENGINEERING, INC. (Contractor)agrees to indemnify and hold harmless Peconic Landing at Southold Inc. from and against any loss, damage or liability, including reasonable attorney's fees and expenses incurred by the latter entities and their respective employees,agents,volunteers or other representatives arising out of the installation,firing or disassembly of pyrotechnic equipment or device and/or the supervision and presentation thereof. ' 2. The applicant has furnished the Certificate of Insurance with limits of liability described below: Workers Compensation/Employers Liability: $1,000.000 per occurrence. General Liability: $1,000,000 per occurrence Automobile Liability: $1,000,000 , Umbrella/Excess Liability: $9,000,000 per occurrence A true copy of the Certificate of Insurance is attached indicating the member entity and applicable associations,recreations or committees formed by the member entity to organize the"event"must be named as additional insured on all liability policies. _ r- 3. The facilities will be used for the following purpose and no other: EVENT: Fireworks Display SHOW DATE: 9/2/18 RAIN DATE. 9/3/18 Dated 7� ��/� Signed �- (Contractor) Witness: DATE ACo® CERTIFICATE OF LIABILITY INSURANCE 04119/2018 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER NONE c Shaunna Marquis Clark Insurance AICN o E . : (860)430-3700 AAX IC No): (860)430-3730 180 Glastonbury Boulevard ADDRESS: smarquis@mayboneedark.cwm Suite 401 INSURER($)AFFORDING COVERAGE NAIL ti Glastonbury CT 06033 INSURERA: Lexington Insurance Company 19437 INSURED INSURER 6: Liberty Mutual Insurance Company 23043 Pyro Engineering Inc.,DSA.Bay Fireworks INSURER C: Chesapeake Employers'Insurance Company 11039 999 S.Oyster Bay Rd. INSURER D: Suite 111 INSURER E Bethpage NY 11714 INSURER F: COVERAGES CERTIFICATE NUMBER: 18-19 Master 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. 1 SR TYPE OF INSURANCE POLICY F POL CY EXP LTR NSD YWD POLICYNUMBER MWD MIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 AMAGE TO RED CLAIMS-MADE ®OCCUR PREMISES E-.occurrence $ 100,000 MED EXP(Any one person) $ A 023627358 02/15/2018 02/16/2019 PERSONAL BADV INJURY $ 1,000,000 GEFI'LAGGREGATE LIMITAPPLIES PER- GENERALAGGREGATE $ 2.000,000 POLICY [:]PiCT LOC PRODUCTS-COMPIOPAGG $ 2,490,000 OTHER, 1 1$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea,cadent _ ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILYINdURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 9,000,000 A EXCESS Lim HCLAIMS-MADE 023627359 02/15/2018 02/15/2019 AGGREGATE $ 9,000,000 DED I I RETENTION S - $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNEMEXECUTIVE E.L EACH $ 1,000,000 B OFFICER/MEMBEREXCLUDED? NIA WC5-39S 387471-Oi6 02/15/2018 02/15/2019 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $ 1,000,000 Ryes, eunder EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,AddHional Remarke Schedule,may he attached If more space is required) Liberty Mutual Workers'Compensation States:CT,GA,NC,NV,SC,VA Date of Display:September 2,2018 LOCATION OF DISPLAY:Peconic Landing at Southold,Greenport,NY RAIN DATE:September 3,2018 Peconic Landing at Southold,Inc.;Brecknock Hail Foundation,Inc.;Peconic Landing Housing Association Cooperative,Inc.;The Shores at Peconic Landing Assisted Living Residence,Inc.;Peconic Landing Home Health Services,Inc.;Town of Southold are included as additional insured as respect to the General Liability policy per written agreement/contract, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Peconic Landing at Southold Inc. ACCORDANCE WITH THE POLICY PROVISIONS.- 1500 Brecknock Road AUTHORIZED REPRESENTATIVE Greenport NY 11944 0 1988 2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD ® DATEY)AC LCERTIFICATE OF LIABILITY INSURANCE 04/1912018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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(iss)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Decker Agency NAME: The OeckerAgency Inc PHONE Nv Ext: (716)883-1455 FAX Arc No: (716)883-6210 37 Elmwood Avenue E-MAIL ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# Buffalo NY 14201-2018 INSURER A: National Continental Ins Cc 10243 INSURED INSURERS: Pyro Engineering Inc,DBA:Bay Fireworks INSURER C: 999 S Oyster Rd Suite 111 INSURER D: INSURER E: Bethpage NY 11714 INSURER F: COVERAGES CERTIFICATE NUMBER: 18.19 Master 5 million 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, INSRPOLICY E F POLICY LTR TYPE OF INSURANCE INSD WvD POLICYNUMBER IMMIDR= (Mwop= LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S. CLAIMS-MADE OCCUR PREMISES Ea accurrence, $ MED EXP(Any one person) 5 PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECT LOC PRODUCTS-COMPIOPAGO S OTHER S AUTOMOBILE LIABILITY CEOMBBIINdED SINGLE LIMIT $ 5,000,000 ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED CNY0004909233-8 02/1512018 02115/2019 BODILY INJURY(Per accident) $ ALTOS ONLY AUTOS HIRED MON-OWNED PROPERTY i DAMAGE AUTOS ONLY ALTOS ONLY (par aadZ $ Additional Personal Injury $ 100,000 UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTWE - OFFICER/MEMBER EXCLUDED? NIA E.L EACHACCIDENT S (Mandatory In NH) If yes,describe under E.L.DISEASE•EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT IS I DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Operations of the named insured 'CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL.BE DELIVERED IN Peconic Landing ACCORDANCE WITH THE POLICY PROVISIONS. 1500 Brecknock Road AUTHORIZED REPRESENTATIVE /q1 Greenport NY 11944 + -+ . .+ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2018103) The ACORD name and logo are registered marks of ACORD New YorkState Insurance Fund Workers'Compensation&Disability Benefits Specialists Since 1914 8 CORPORATE CENTER DR,2ND.FLR,MELVILLE,NEW YORK 11747-3166 CERTIFICATE OF WORKERS' COMPENSATION'INSURANCE 1 A A A A'A A 753044987 BOSTON INSURANCE BROKERAGE 24 FEDERAL ST FL 4 "M11110 BOSTON MA 02110 SCAN TO,VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER EPECONIC LANDING PYRO ENGINEERING INC PECONIC LANDING AT SOUTHOLD DBA BAY FIREWORKS 1500 BRECKNOCK ROAD 999 S.'OYSTER BAY RD, STE 111 GREENPORT NY_ 11944 BETHPAGE NY 11714 POLICY NUMBER CERTIFICATENUMBER POLICY PERIOD DATE H2437 559-4 615389 02/27/2018 TO 02/15/2019 .4/19/2018 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 2437 559-4, COVERING THE ENTIRE, OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE$TATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR,WEBSITE AT HTTPS:/NWWW.NYSIF.COWCERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/0j2 MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER:321195883 U-26.3 YORK Compensation CERTIFICATE OF INSURANCE COVERAGE srArlr Compensation Board UNDER THE NYS DISABILITY BENEFITS LAW PART 1. To be completed by Disability Benefits Carrier or Licensed Insurance Agent of that Carrier 1 a.Legal Name&Address of Insured(use street address only) i b.Business Telephone Number of Insured (516)597-5500 PYRO ENGINEERING INC DBA BAYFIREWORKS 1c.NYS Unemployment Insurance Employer Registration Number of 999 SOUTH OYSTER BAY RD STE 111 Insured BETHPAGE,NY 11714 Work Location of Insured(Only required if coverage is specifically limited to 1d.Federal Employer Identification Number of Insured or Social Security certain locations in New York State,i.e.,a Wrap-Up Policy) Number 753.04-4987 2.Name and Address of Entity Requesting Proof of Coverage $a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) New York State Insurance Fund:(NYSIF) 3b.Policy Number of Entity Listed in Box"1 a" PECONIC LANDING AT SOUTHOLD,INC. DBL 5213 59-1 1500 BRECKNOCK ROAD GREENPORT,NY 11944 3c.Policy effective period 01/04/2003 to 01/04/2019 4.Policy covers: N A.All of the employer's employees eligible under the New York Disability Benefits Law S.Only the following class or classes of employer's employees: Under penalty of perjury,l certify that 1 am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability Benefits insurance coverage as described above. Date Signed 21112018 Byw Joseph J.Masi (Signature of insurance career's authorized representative or NYS Licenwil Insurance Agent of that insurance carrier) Telephone Number (866)697-4332 Title Director of NYSIF Disability Benefits insurance IMPORTANT: If Box"4a"is checked,and this form is signed by the insurance carriers authorized representative or NYS Licensed insurance Agent of that carrier,this certificate is COMPLETE.Mail it directly to the certificate holder. If Box"4b"is checked,this certificate is NOT COMPLETE for purposes of Section 220,Subd.8 of the Disability Benefits Law.It must be mailed for completion to the Workers'Compensation Board,DB Plans Acceptance Unit,328 State Street,Schenectady,NY 12305 PART 2.To be completed by the NYS Workers'Compensation Board(Only if Box"4b"of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability Benefits Law with respect to all of his/her employees. Date Signed By Signature of NYS Workers'Compensation Board Employee) Telephone Number Title Please Note; Only insurance carriers licensed to write NYS disability benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (9.15) Certificate Number 473134