D-4. Approve Fireworks Display Permit for Chanhassen High School Storm Chaser Boosters Club D -4
1101
CITY OF
CHANHASSFN MEMORANDUM
7700 Market Boulevard TO: Todd Gerhardt, City Manager
PO Box 147
Chanhassen,MN 55317 FROM: Mark Littfin,Fire Marshal
DATE: September 26,2016 `,
Administration
Phone:952.227.1100 SUBJ: Private Fireworks Display for Chanhassen High School Storm Chasers
Fax:952.227.1110
Boosters Club
Building Inspections
Phone:952.227.1180
Fax:952.227.1190 PROPOSED MOTION:
Engineering "The City Council approves the fireworks display permit from Pyrotechnic
Phone:952.227.1160 Display Inc., on behalf of Chanhassen High School Storm Chasers Boosters
Fax:952.227.1170 Club, to conduct a fireworks show from 2200 Lyman Boulevard, Chanhassen.
Finance
Phone:952.227.1140 Approval of this request requires a simple majority vote of the City Council.
Fax:952.227.1110
Park&Recreation Staff has received a request from Pyrotechnic Display, Inc.,on behalf of the Chanhassen
Phone:952.227.1120 High School Storm Chasers Boosters Club,to conduct a fireworks show from
Fax:952.227.1110 Chanhassen High School.
Recreation Center RECOMMENDATION
2310 Coulter Boulevard
Phone:952.227.1400 Staff recommends approval of the request from Pyrotechnic Display Inc., for a fireworks
Fax:952.227.1404
display permit on October 14,2016 at Chanhassen High School,2200 Lyman Boulevard,
Planning& Chanhassen. Approval requires a simple majority vote of the City Council.
Natural Resources
Phone:952.227.1130 ATTACHMENT
Fax:952.227.1110
1. Application for Display of Fireworks.
Public Works 2. Certificate of Liability Insurance.
7901 Park Place 3. Site Inspection Form.
Phone:952.227.1300 4. Location Map.
Fax:952.227.1310
Senior Center
Phone:952.227.1125
Fax:952.227.1110
Website
www.ci.chanhassen.mn.us
g:\safety\ml\chs fireworks display 09-26-2016.doc
Chanhassen is a Community for Life-Providing for Today and Planning for Tomorrow
APPLICATION FOR OUTDOOR DISPLAY OF FIREWORKS/PYROTECHNIC SPECIAL EFFECTS
Applicant instructions:This application must be completed and returned at least 15 days prior to date of display.
Name of applicant(Sponsoring Organization): Chanhassen High School Storm Chasers Booster Club
Address of applicant: 2200 Lyman Blvd..Chanhassen,Minnesota 55317
Name of authorized agent of applicant: Pyrotechnic Display,Inc.
Address of agent: 9405 River Road SE,Clear Lake,MN 55319
Telephone number of agent: 320-743-6496 Ext. 1
Date of display: October 14,2016 Time of display: about 7pm and 8:30 pm
Location of display:_Chanhassen High School football field Chanhassen,MN - please see attached site map
Manner and place of storage of fireworks/pyrotechnic special effects prior to display:
Delivery and storage in truck on day of display
Type&number of fireworks/pyrotechnic special effects to be discharged:
1.3G product -up to 3 inch aerial shells and Multi-Shot Box Items&Candles
Minnesota State law requires that this display be conducted under the direct supervision of a pyrotechnic operator certified by
the State Fire Marshal.
Name of supervising operator: Tom Olson Certificate No.: 0 0697
Required attachments. The following attachments must be included with this application:
1. Proof of a bond or certificate of insurance in amount of at least$ 5,000,000.00
2. A diagram of the grounds at which the display will be held. This diagram(drawn to scale or with dimensions included)
must show the point at which the fireworks/pyrotechnic special effects are to be discharged;the location of ground
pieces;the location of all buildings,highways,streets,communication lines and other possible overhead obstructions;
and the lines behind which the audience will be restrained
3. Names and ages of all assistants that will be participating in the display. Jud Kilgore,47
The discharge of the listed fireworks on the date and at the location shown on this application is hereby approved,subject to the
following conditions,if any:
I understand and agree to comply with all provisions of this application, MN Statute 624.20 through 624.25, MN State Fire Code,
National Fire Protection Association Standard 1123 (2006 edition), applicable federal law(s) and the requirements of the issuing
authority,and will ensure that the fireworks/pyrotechnic special effects are discharged in a manner that will not endanger persons or
property or constitute a nuisance.
Signature of applicant(or agent): z,. Date of application: Sept. 15,2016
Signature of Fire chief: X ✓ r;,_ (1E7z, - Date: ___971/s.24_,...p,
Printed name of above official: ,� 1,45 )
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hone: / (s Z 1 _lI f
Signature of issuing authority: Date:
Printed name of above official: Phone:
ACr> DATE(MM/DDIYYYY)
4..... .0 EP CERTIFICATE OF LIABILITY INSURANCE 19!1512016
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).
PRODUCER CONTACT 1
NAME:
Britton Gallagher PHONE --
One Cleveland Center, Floor 30 MA,Nie E 00 —_ ( ,No
A/C >
1375 East 9th Street ADDRESS:
Cleveland OH 44114 INSURERIS)AFFORDING COVERAGE : NA€CX i
-- INSURER A:Axis Surplus Ins Company ---
INSURED INSURER B:Everest Indemnity Insurance Co ; _ -1
Pyrotechnic Display Inc. INSURER c Everest N tio_n_aIInsurance Company 10120
8450 W.St. Francis Road INSURER D:MN WC Assigned Risk Plan
Frankfort IL 60423 ( -'
INSURER E:
INSURER F: ,
COVERAGES CERTIFICATE NUMBER:1556688639 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 I -------- ;AODL SUER) POLICY EFF I POLICY EXP - -------------
LTR TYPE OF INSURANCE I INSR I WVD I POLICY NUMBER -IMMIODIYYYYI I(MM/DDIYYVY)I LIMITS
B GENERAL LIABILITY i !SIoML00006-161 9/30;2056 1 9130/2017EACH OCCURRENCE $1,000,000
X— € € 1 DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES iEa occurrenceJi$500.000
L....... i CLAIMS-MAOE X OCCUR I ~MED EXP(Any one person) S
1 I PERSONAL B ADV INJURY I$1,000,000
GENERAL AGGREGATE 152,000,000
GENt AGGREGATE LIMIT APPLIES PER l i PRODUCTS-COMP/OP AGG 152.000.000
I POLICY'X !JEd { -
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I COMBINED SINGLE AUTOMOBILE LIABILITY Sl8CA00006-tri i 9/30/20169/30/201r
� 1,_.ac.ctie,II, St A00,000
IX ?ANY AUTO _ i 1 BODILY INJURY s Per person) S ------'--..
1 ALL OWNED SCHEDULED i BODILY INJURY(Pe.:accidents j
AUTOS t__- I AUTOS .�.NON-OWNED - I PROPERTY DAMAGE _
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A UMBRELLA LIAB i X `OCCUR I 'EAU733983 9130/2016 913012017 'EACH OCCURRENCE .4,000.000
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!X EXCESS LIAR ! CLAIMS-MADE AGGREGATE $4.000.000
I 1i ,
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DEDI 'RETENTIONS i _ ,S
D I WORKERS COMPENSATION I i 'MNAR0000019718-7(MN) 9/30/2016 j 9/30/2017 X i] VWC STATU- I ;0TH---- - -- -
AND EMPLOYERS'LIABILITY Y/N I ( i L___1SORY L€MR's_l__._Lig..._-.-
ANY PROPRIETOR/PARTNER/EXECUTIVE I I I €E.L.EACH ACC€DENT $1,000,000
OFFICER/MEMBER EXCLUDED'I IN/AI ------ ------_,.-._-.
(Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE/$1,000,000
If yes.describe under I )" --------------
DESCRIPTION OF OPERATIONS t.,e!''+a, 1 E L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS I 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.
DISPLAY DATE: October 14, 2016
LOCATION: Chanhassen High School - 2200 Lyman Blvd, Chanhassen, Minnesota
ADDITIONAL INSURED: Chaska School District; City of Chanhassen, Minnesota; Storm Chasers Booster Club,
Chanhassen High School, Chanhassen, Minnesota
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Chanhassen High School Storm Chasers Booster Club THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: Ms.Terre Kemble ACCORDANCE WITH THE POLICY PROVISIONS.
2200 Lyman Blvd
Chanhassen MN 55317
AUTHORIZED REPRESENTATIVE
CO 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
Site Inspection Form
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Site contact person (day of display) wee NJ o- E ,� (--,<..: ;-c.
Site Diagram: (See Example below). When diagramming the shooting location,mark area where low level products shall
be placed. Make sure your measurements include the following distances:
A. Spectators
B. Parking
C. Residences Maximum size shell based on
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