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D-4. Chanhassen High School – 2200 Lyman Boulevard: Approve Fireworks Display Permit for the Chanhassen High School Storm Chasers Booster Club for October 13, 2017
QT \ Y • CITY OF CHANIIASSEN Chanhassen is a Community for Life-Providing for Today and Planning for Tomorrow # IIA MEMORANDUM TO: Todd Gerhardt, City Manager FROM: Mark Littfin, Fire Marshal DATE: September 25, 2017 01441 SUBJ: Private Fireworks Display for Chanhassen High School Storm Chasers Boosters Club—October 13, 2017 PROPOSED MOTION: "The City Council approves the fireworks display permit from Pyrotechnic Display Inc., on behalf of Chanhassen High School Storm Chasers Boosters Club, to conduct a fireworks show from 2200 Lyman Boulevard, Chanhassen, on October 13, 2017. Approval of this request requires a simple majority vote of the City Council. Staff has received a request from Pyrotechnic Display, Inc., on behalf of the Chanhassen High School Storm Chasers Boosters Club,to conduct a fireworks show from Chanhassen High School on Friday, October 13, 2017. RECOMMENDATION Staff recommends approval of the request from Pyrotechnic Display Inc., for a fireworks display permit on October 13,2017 at Chanhassen High School, 2200 Lyman Boulevard, Chanhassen. Approval requires a simple majority vote of the City Council. ATTACHMENTS 1. Application for Display of Fireworks. 2. Certificate of Liability Insurance. 3. Location Map. g:\safety\inl\chs fireworks display 09-25-2017.docx PH 952.227.1100• www.ci.chanhassen.mn.us • FX 952.227.1110 7700 MARKET BOULEVARD • PO BOX 147 • CHANHASSEN • MINNESOTA 55317 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 13, 2017 Time of display: about 7 pm and 8:30pm Location of display: Chanhassen High School football field Chanhassen,MN - please see attached 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& Large Roman 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: Keith Kutzke Certificate No.: 0 0282 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. Brett Wojack, 18 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): 1 -� v \v(h,yDate of application: Sept. 9,2017 *(Signature of Fire chief: ( 3Date: Printed name of above official: r'1 - \Thr1sGrl Phone:95�- a7 - 11-3)— (1;Signature of issuing authority: N • - Date: /8A7 Printed name of aboveofficial: 1e Phone:6159' 7 cS PLEASE FORWARD THIS APPLICATION TO THE CORRECT PARTIES, HAVE IT SIGNED AND MAIL THE SIGNED FORM BACK TO US AT: PYROTECHNIC DISPLAY, INC. 9405 RIVER ROAD SE CLEAR LAKE, MN 55319 F r ® DATE(MMIDD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 9/7/2317 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). CONTACT PRODUCER NAME: Britton Gallagher PHONEFAX (Arc.No.E.0.216-658-7100 i_ (AJC,No). One Cleveland Center, Floor 30 E-MAIL 1375 East 9th Street ADDRESS: Cleveland OH 44114 INSURER(S)AFFORDING COVERAGE I NAL_ INSURER A:Axis Surplus Ins Company INSURED INSURER B:Everest Indemnity Insurance Co Pyrotechnic Display Inc. INSURER c:Everest National Insurance Company 10120 8450 W. St. Francis Road INSURER D:MN WC Assigned Risk Plan _ Frankfort IL 60423 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:2122273919 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 `HIS 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 EXPIDLIMITS LTR INSR WVD POLICY NUMBER (MMDIYYYY) (MM/DDIYYYY) B GENERAL LIABILITY SI8ML00006-161 9/30/2016 9/3012017 EACH OCCURRENCE $1,000.000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea ry.currence) S500.000 CLAIMS-MADE X OCCUR MED EXP(Any one person) S PERSONAL&ADV INJURY S1,000,000 GENERAL AGGREGATE $2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S2.000.000 POLICY© PST LOC $ C AUTOMOBILE UABILITY I SI8CA00006-161 9/30/2016 9/30/2017 IEalaccidenINWt)INUL6 t 1f r S1,000,000 X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ,* AUTOS NON-OWNED5 X HIRED AUTOS X AUTOS (Per PROPERTYitDAMAGE $ A UMBRELLA LIAB X OCCUR EAU733983 9/30/2016 9/30/2017 EACH OCCURRENCE $4,000,000 X EXCESS UAB CLAIMS-MADE AGGREGATE 54,000,000 DEO RETENTIONS S • D WORKERS COMPENSATION MNAR0000019718-8(MN) 9/30/2016 9/30/2017 X WC STATU- OTH. AND EMPLOYERS'LIABILITYTORY LIMITS ER ANY PROPRIETOR PARTNER/EXECUTIVE Y 1 N E.L.EACH ACCIDENT 51,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 51.000.000 If yesdescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 51.000.000 DESCRIPTION OF OPERATIONS/LOCATIONS I 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 13,2017 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD j! ,�` f -•I - -, ,,rte„-. S t y �`-.t;• # . I , 1 .~ N C 7 Lilit.'...'-;,;.:-.• PI ry c ,, -�x7 s .: }i6hs o ri. s0 'yY �_ y it- -i .14,- -' Cr) 0 , I' ,e-;„ '.7:s?:,',Ilv .,, . Q rpt, 1- -rt,: A.fr: ,, ,-.....,k �° r _'� ',,i ,tea"- r, /'. too - •.• . :, �`, r: CE+• nj •1 _ ir� am, %. __. t. 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