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HomeMy WebLinkAboutFIR2024-00017 Fireworks - FIR Inspections - 7/1/2024 A�® CERTIFICATE OF LIABILITY INSURANCE DAIS/Zs/2o24YY> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Brown&Brown-Daytona Beach NAME: Courtney Crown [FAXPHONE 300 North Beach Street •386-239-7237 A/c No):386-323-9147 Daytona Beach FL 32114 nooeles : Courtney.Crown bbrown.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Gemini Insurance Company INSURED 69860 INSURER a:AXIS Surplus Insurance Company 26620 American Eagle Superstore, Inc. Big Fireworks INsuRERc:Arch Insurance Company 6601 W Grand River Ave INSURER0: Lansing MI 48906 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:390509638 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 SUER POLICPOLICY NUMBER MM/DDY EFF/YYYY MM/DY EXP LTR LIMITS A X COMMERCIAL GENERAL LIABILITY VNGPOO1835 9/15/2023 9/15/2024 EACH OCCURRENCE $1,000,000 CLAIMS-MADE FkI OCCUR PREM SES Ea 000u ence $300,000 MED EXP(Any one person $ PERSONAL&ADV INJURY $1,000,000 7.L AGGREGATE LIM IT APPLIES PER GENERALAGGREGATE $2,000,000 JECT POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINEDaccident SINGLE LIMIT $ Ea ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident) r $ B UMBRELLA LIAB X OCCUR P-001-000183506-05 9/15/2023 9/15/2024 EACH OCCURRENCE $4,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000.000 DED I I RETENTION $ WORKERS COMPENSATION SPER OTH- AND EMPLOYERS'LIABILITY Y/N TATUTEI ER ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C EXCESS LIABILITY UXP0059088-08 9/15/2023 9/15/2024 EACH OCCURRENCE 5,000,000 AGGREGATE 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) NON OWNED FIREWORKS VENDORS COVERAGE PER WRITTEN CONTRACT PER FORM CG20151219 FOR GENERAL LIABILITY.GENERAL LIABILITY AND EXCESS LIABILITY COVERAGES TOTAL$11,000,000 PRODUCTS AND COMPLETED OPERATIONS AGGREGATE DURING PERIODS WHEN CONSUMER FIREWORKS ARE SOLD. Additional Insured: Hood Canal Temple Association,Mason County and North Mason Fire Rescue Authority and their Agents 23341 WA-3 Belfair,WA 98528 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Boomtown Productions LLC, DBA Boomtown Fireworks 23341 WA-3 Belfair WA 98528 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE d'S V� FIREWORKS LEASE AGREEMENT ti This agreement is made between Hood Canal Temple Assn,Inc,as licensor and Boomtown 7 Productions,LLC as licensee for the said purpose of allowing retail sales of Consumer Fireworks Rom the following location: 23341 WA-3, Belfair, WA 98528 Parcel tax ID#1233250000014 The licensor represents that it owns or controls the use of the lot as listed above and agrees to grant licensee the right to operate a retail firework stand on the premises for the period of June 20,2024 through July 8,2024 for a license fee of$1,500.00 due no later than July 8, 2024. Sales date are June 28-July 5,2024. Should fireworks sales be banned due to dry weather conditions If prior to sales:no charge If sales occur but banned during normal sales time: pay 10",of sales The licensee shall pay all cost involved in the erection,operatior;and maintenance of the stand, and shall guarantee that the premises shall be returned to the original condition after removal of the stand. The licensee will provide liability insurance coverage and provide to the licensor,before occupancy.The insurance shall name the licensor as an additional insured,and licensee will hold the licensor harmless from any claims arising from the maintenance or operation of the structure. The licensee shall pay for and obtain licenses and permits required by law and post any performance bonds which might be required. The licensee shall guarantee that the stand is operated in a business like manner and adhere to all local state regulations. If the property is sold,ingress/egress changed,or location impacted due to construction or the like,then this license is subject to revocation and refund of any payments made. LICENSOR: LICENSEE: 4/15/2024 Hood Canal Temple Association J61nathan Miller,Boomtown Productions plk Gy Gr-vf 40h1MGTON"{, F Washington State Patrol Fire Protection Bureau G24168 Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE 11*11, RJMAt'40 4� Stand Number: SN-15911 Licensee Data 6J LA Operational Data Boomtown Productions, LZASHINGT4. N O Wholesaler: [MULTIPLE SUPPLIERS] 13507 79th Avenue Court Northwest County of Operation: Mason Gig Harbor, WA 98329 0 Operated For: Licensee License Number: WSPFL-02027 Stand Operated By: Johnathan Miller Phone Number:(360) 620-1732 Date of Issue:April 24, 2024 Date of Expiration:January 31, 2025 Consumer Fireworks Retailer Licenses issued after May are ONLY valid for New Years Sales This license is NOT valid without a permit from a local fire code official/authority having jurisdiction This license allows for operation of a single location/stand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. 3000-420-041(10/18) SURRENDER THIS PORTION OF THE LICENSE TO THE FIREWORKS WHOLESALER •�"`T'""'re Washington State Patrol Fire Protection Bureau G24168 Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE 9 �RlMAC �t`F� Stand Number: SN-15911 Licensee Data A� Operational Datir Boomtown Productions, LLC'A gwlNI-Tf)l Wholesaler: [MULTIPLE SUPPLIERS] 13507 79th Avenue Court Northwest County of Operation:Mason Gig Harbor, WA 98329 Operated For:Licensee License Number: WSPFL-02027 Stand Operated By:Johnathan Miller Phone Number:(360) 620-1732 Date of Issue:April 24, 2024 Date of Expiration:January 31, 2025 Consumer Fireworks Retailer Licenses issued after May are ONLY valid for New Years Sales This license is NOT valid without a permit from a local fire code official/authority having jurisdiction. This license allows for operation of a single location/stand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. THIS LICENSE PORTION ACCOMPANIES YOUR LOCAL PERMIT APPLICATION 300-0-420 041(10/18) Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal G24168 CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE Stand Number: SN-15911 Licensee Data ,v Operational Data Boomtown Productions, LLINACOP SHINGTO64 %- Wholesaler: [MULTIPLE SUPPLIERS] 13507 79th Avenue Court Northwest County of Operation: Mason Gig Harbor, WA 98329 Operated For: Licensee License Number: WSPFL 2027 Stand Operated By: Johnathan Miller Phone Number-(360) 620-1732. Date of Issue:April 24, 2024 Date of Expiration:January 31, 2025 Consumer Fireworks Retailer Licenses issued after May are ONLY valid for New Years Sales This license is NOT valid without a permit from a local fire code official/authority having jurisdiction. This license allows for operation of a single location/stand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. 3000-420-041(10118) THIS PORTION OF THE LICENSE MUST BE POSTED AT THE STAND AT ALL TIMES