2024-0465 Office Use O.nly
Permit#: �0 FIRE MARSHAL FIREWORKS APPLICATION
Permit Fee: • .00
Mt
Invoice • !u'r'r
Reviewed By:
Office of the Fire Marshal E
742 Bay Road, Queensbury,NY 12804
518-761-8206/8205 www.queensbury.net
Project Location: Hiland Park Country Club Tax Map ID#:, 96.' —'
Date of Display: 9/28/2024 Time of Display: 9:30pm
Brief description of scope of project:
Fireworks Display — designated area Highland Golf Course — 1.3G/1.4G 1 %" — 5"
max shell 5" .
Opening- 5-3" salutes &100 multi color finale barrage — Main Body— 55-3", 36-4" -
Finale 50-2" finale barrage, 40-21",40 -3",8-4" color finale shells, and 20-3" salute
finale shells
**PLEASE MAKE SURE TO INCLUDE A SKETCH SHOWING THE
LOCATION OF
THE PROPOSED WORK
OR PROJECT ON THE PARCEL**
FM Fireworks Application Revised 3/10/2023
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Santore's World Famous Fireworks LLC
Mailing Address, C/S/Z: Po Box 687 Stillwater NY 12170
Cell Phone:_(518_)706-7673 Land Line:_(518_)664-9994
Email:
• Property Owner(s):
Name(s): Authorized representative- Dan Flores
Mailing Address, C/S/Z: 195 Haviland Rd Queensbury NY
Cell Phone:_( ) Land Line:_(518_)793-2000
Email:
• Fireworks Contractor(s):
Name(s): Santore's World Famous Fireworks LLC
Mailing Address, C/S/Z: PO Box 687 Stillwater NY 12170
Cell Phone:_( ) Land Line:_(518_)664-9994_
Email:terisa@santorefireworks.com
Please submit Workers' Comp documentation with this application
DECLARATION:
I acknowledge that this is not a permit but only an application for a permit and no work shall
commence prior to approval. All work will be in accordance with the approved plans and in
accordance with the Town of Queensbury and the NYS Fire and Building Codes.
If, for any reason, this application is withdrawn, 30% of the fee is retained by the Town of
Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
I have read and agree to the above:
APPLICANT NAME:Terisa Clothier
APPLICANT SIGNATURE,a74.roackker DATE: 8/29/24
PROPERTY OWNER NAME:Authorized representative—Dan Flores
PROPERTY OWNER SI GNATURE:Daw Flores DATE: 8/29/2024
FM Fireworks Application Revised 3/10/2023
7/14/23,9:49 AM Hiland Park Country Club-Google Maps
ogle NIPps. Highland Park Country Club
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Red Circle = Fallout Zone (280ft) 4 inch max shell "
Blue = launch location El
Yellow =Spectators s
All measurements meet or exceed NFPA 1123
August 29,2024
SANTO R . S
—WORLD FAMOUS—
FIREWORKS
INFORMATION FOR FIREWORKS PERMIT
1. Sponsor Santore's World Famous Fireworks.
2. Date& Time—September 28,2024 - at approximately 9:30 p.m.
3. Location—Designated area of Hiland Golf Course.
4. Matthew Mehan Age: 42 Hair: Brown
263 Hudson Ave. Apt. B Height: 5'7" Eyes: Brown
Mechanicville,NY 12118 Weight: 170 lbs.
Mr. Mehan has over 15 years experience and will be accompanied by one other
SWFF technician with at least five years experience.
5. 1.3 G(Formerly Class B Explosives) ranging from 1 %2"—5". Breakdown as
follows: Opening of Display: 5—3" Salutes & 100— 1 %2"Multi-color finale
barrage. Main Body: 55- 3", 36-4" Color shells. Finale: 50—2"Color finale
barrage, 40-2 %2", 40- 3", 8-4" Color finale shells and 20- 3" Salute finale shells.
6. The explosives will be stored in a licensed magazine at the SWFF facility until the
date of display.At that time the fireworks will be driven to site and loaded into
firing mortars. There will be a SWFF employee with the explosives at all times.
7. Diagram is attached.
7B. Proof of insurance is attached.
7C.Notification of Fire Marshall/Chief for site inspection and approval.A SWFF
employee is willing to view the site with such persons if necessary.
7D. Cleanup has to be provided by sponsoring organization. Immediately following
display, SWFF technicians will go over site to look for any unexploded debris. SWFF
crew will clean up all materials that are used in the display such as firing mortars and
bring them back to our own facility.
Main Office:PO Box 687, Stillwater,NY 12170(P)518-664-9994
Email:jwardna,santorefireworks.com
Visit Our Website at:www.santorefireworks.com
NEW YORK STATE 5.E
DV COERCIAL DRIVER LICENSE , .
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MEHAN_ . ea C i
MATTHEW;LAWRENCE •
263 HUDSON'AVE APT es.bs
MECHANICVILLE,NY 12118
HAZMAT Erx c 65/10/2024 I
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JUL 83 es:ee11/06/2020
STATE OF NEW YORK-DEPARTMENT OF LABOR
PYROTECHNICIAN CERTIFICATE OF COMPETENCE I N' S
MATTHEW L MEHAN
CLASS:B,
NON PROXIMATE AUDIENCE ONLY_
THIS CARD MUST BE CARRIED
WHEN USING PYROT CERT#PPr 256
EXPIRES 03/25
NYC&NYS CERTIFICATIONS REQUIRED IN NYC
• 1111111IIt®IIl[IOIIII n
Federal Explosives License/Permit
U.S.Department of Justice (18 U.S.C. Chapter 40)
Bureau of Alcohol,Tobacco,Firearms and Explosives nuauam;tagerun nounntrrmnarnin
In accordance with the provisions of Title XI,Organized Crime Control Act of 1970,and the regulations issued thereunder(27 CFR Part 555),you may engage in
the activity specified in this license or permit within the limitations of Chapter4O,.Title 18,United States Code and the regulations issued thereunder,until the
expiration date shown. THIS LICENSE IS NOT TR&NSFERABLE.UNDER•27 CFR 555.533. .See"WARNINGS"and"NOTICES"on reverse.
Direct ATF ATF-Chief,FELC LiceuseePennit;.
•
Correspondence To 244 Needy Road . . Number• 6—NY-083-23-7C-01081
Martinsburg,WV 25405-9431' _ _ ..
Chief,Federal Explosives Licensing Ccntc.(FELC) Expiration. March 1 2027
r i i .1' / Date 7
Name
SANTORES WORLD FAMOUS FIREWORKS LLC
Premises Address(Changes?Notify the•FELC.at least 10 days before the move.) . '
846 STILLWATER BRIDGE`ROAD
SCHAGHTICOKE, NY 121.54- • •
Type ofLicense or Permit . , •• - •
23-IMPORTER OF EXPLOSIVES . "
Purchasing Certification Statement. • - ' Mailing Address(Changes? Notify the FELC of any changes.)
The licensee or permittee named above shall use a copy of this license,or'.Penmit to assist a_ ,
transfcvor of explosives to verify the identity and the lionised status of the licensee or - . ,
permittee as provided by 27 CFR Part 555. The sienattire on each copy must be an-original: ' SANTORES WORLD FAMOUS FIREWORKS LLC
sic nannre. A faxed scanned or e-mailed copy of the license.or.pennit with a signature
intended to be an original signature is acceptable. The signature must be that of the Federal 143 SUMMIT AVE'
Explosives Licensee(FEL)or a responsible person of the FEL, I certify:that this is atrue BERKELEY HEIGHTS, NJ 07922-
copy of a license or permit issued to the licensee or pennittee named above to engage in the--
business or operations specified above under"Type of License or Permit:": -
Licensee/Pennittee Responsible Person Signature Position/Title
• — —Printed-Name Date— XIFI u`nri 5-10e:1-F:Sicn0.15TCuut7'---
PreviousEditionisObsolete WHIM eioswO FsssUs FsewoftMS IIGECssTnasMER BROM11BPB:1I154 1.s .23.7C-01G1Atia 1,rs La-WORM OF EtPeOB1ri3 Revised September 2011
Federal Explosives License(FEL)Customer Service Information
Federal Explosives Licensing Center(FELC) Toll-free Telephone Number: (877)283-3352 ATF Homepage:www.atfgov
244 Needy Road Fax Number: (304)616-4401
Martinsburg,WV 25405-9431 E-mail: FELCeatt:gov
Change of Address (27 CFR 555.54(a)(I)). Licensees or permittees may during the term of their current-license or permit remove their business or operations to a
new location at which they intend regularly to-carry on such business or operations. The licensee or permittee is required to give notification of the new location.of the
business or operations not less than 10 days prior to such removal with the Chief,Federal Explosives Licensing Center: The license or penuit will be valid for the
remainder of the term of the original license or permit. (The Chief,FELC,shall,if the licensee or permittee is not qualified,refer the request for amended license
or permit to the Director of Industry Operations for denial in accordance with§555.5,1.)
Right of Succession (27 CFR 555.59). (a)Certain persons other than the licensee or pennittee may secure the right to carry on the same explosive materials
business or operations at the same address shown otn,and for the remainder of the term of,a current license or permit. Such persons arc: (1)The surviving spouse
or child,,or executor,administrator,or other legal representative of a deceased licensee or pennittec;and(2)A receiver or trustee in bankruptcy,or an assignee:for
benefit of creditors. (b)In order to secure the right provided by this section,the person or persons continuing the business or operations shall furnish the license or
permit for for that business or operations for endorsement of such succession to the Chief.FELC,within 30 days front the date on which the successor begins to
carry on the business or operations.
(Continued on reverse side)
Cut Here X.
1
I Federal Explosives License/Permit(FEL)Infotmation Curd
t
1 License/Permit Name:SANTORES WORLD FAMOUS FIREWORKS LLC
1
1 -
I Business Name: -
1 - -
1 License/Permit Number:64NY-083-23-7C-01081
1
I LicenseiPernit Type:23-IMPORTER OF EXPLOSIVES
t
1
Expiration: March 1,2027
1
I Please Note: Not Valid for the Sale or Other Disposition of Explosives.
•
sH 862(3i22) Expires: 1/31/2025
WE RER
DIVISION OF SAFETY HEALTH `� ® � ® O L THIS LICENSE MUST BE
LICENSE AND CERTIFICATE UNIT . TATE of La as I Deppaharrtment POSTED IN YOUR PLACE OF
STATE OFFICE CAMPUS,BLDG. 1 BUSINESS
ALBANY,NY 12226 License No. D_5796
LICENSE TO DEAL IN OR MANUFACTURE EXPLOSIVES
Santore's World Famous Fireworks, LLC
846 Stillwater Bridge Rd
Schaghticoke, NY 12154 •
August N. Santore, Jr.
Is hereby licensed to deal in or manufacture explosives in compliance with the requirements of the Labor Law and Industrial
Code Rules.Any change in the conditions under which this license is granted may cause it to be revoked.
Every person selling,delivering or giving away any explosives must keep at the principal place of business within the state,
a record of each transaction,including:
1) the NAME or TYPE and QUANTITY of explosives SOLD,DELIVERED or GIVEN.Note;No license is needed to
purchase smokeless powder,or black powder and quantity is not exceeding five pounds for use in firing antique •
firearms or artifacts or replicas thereof.However,dealers MUST post all such transactions on the"Dealer-
Manufacturer Report of Explosives Transactions".
2) the DATE OF EACH SALE,DELIVERY or GIFT.
3) the NAME,LICENSE NUMBER,and BUSINESS ADDRESS of the purchaser,donee,or person to whom the
explosives were delivered and the firm,if any,represented by such person.
4) the NAME,ADDRESS,and LICENSE NUMBER of the person TAKING THE EXPLOSIVES AWAY
from the seller or donor.
)71/4
Amy Phillips,Director
FOR THE COMMISSIONER OF LABOR
SH-862(5-98)
Commercial General Liability
Policy Number: S18ML00235-231 Policy Effective : 2/9/24
Company: Everest National Insurance Company
Named Insured: Santore's World Famous Fireworks LLC
HOLD HARMLESS INSURANCE
It is agreed that within the Limits,Terms and Conditions set forth in the policy,the
Company will defend,indemnify and hold harmless:
Town of Queensbury and the Highland Golf Club
from any claim, demand,suit,loss, cost of expense, or any damage which may be
asserted,claimed against or from:
Aerial firework display taking place at Highland Park Golf Course,_September 28,2024.
by reason of any damage to property or bodily injury, including death, sustained by any
person whomsoever and which damage,injury or death arises by the negligence of:
Santore's World Famous Fireworks LLC
or by their agents, servants, and employees while acting in the course and scope of their
employment.
/4/14.1.A.'
Authorized Representative Signature