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2005APPLICATION FIREWORK LICENSE I Calendar Year for Application t 0 2. Name of Applicant -cr 3. Address of Applicant Contact Person J - �e� t W M�WU-e— Phone N o- Y-V q3 4. Is applicant working through a. vendor? Yes No ❑ 5. Name of vendor participating with applicant (if applicable) P14- 6. Address of vendor n 6-t Contact Person L) C r , 1 -'s Phone # � � fi -� �' c �l 'q 7. Is certificate of insurance held by applicant or vendor? Vendor Applicant 8. If held by vendor-, does insurance name applicant and cit as additional insurers? Yes /K No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # 1 ?010�7Lt (Name of Holder) Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the City of Blair, Nebraska and State of Nebraska relative to this applic; ion and the sale and storage of fireworks in the City of Blair, Nebraska. Applicant Date Vend ' (if Date FOR CITY USE ONLY: Date Received 2 12,5 / ® Applicant awarded license: Yes Time Received Iq No F-1 NEBRASKA STATE FIRE MARSHAL . ..... 246 South 14th Street Lincoln, NE 68508 -1804 LICENSE FOR SALE OF FIREWORKS � t Permissible fireworks may be sold at retail commencing 12:01 AM June 25 and ending 11:59 PM July 4 and must be purchased from a licensed distributor or jobber. A jobber may not sell retail. Invoice copies for all fireworks must be kept available for inspection and must show the license number of the distributor or jobber. Fireworks may not be sold outside the city limits of an incorporated town or village. Violations of State Fire Marshal regulations may result in immediate revocation of this license. This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebraska Revised Statute 28 -1246 (1994 Supp.). Such license shall be displayed at licensee's place of business. DATE RECEIVED: 2/3/2005 TYPE OF LICENSE AND FEE; Retailer $125 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: Stand# 2005- E- 24 -RL -76 Vets Field Blair STORAGE LOCATION: Vets Field Blair DISTRIBUTOR(S): B J ALAN COMPANY SALES TAX NUMBER: 17700474 LICENSE HOLDER: Phantom Of Nebraska, Inc 938 N 70th PMB 149 Lincoln NE 68505- COUNTY WASHINGTON WASHINGTON DATE ISSUED: 2/9/2005 STATE FIRE MARSHAL LICENSE NUMBER 7. Is certificate of insurance held by applicant or vendor? Vendor 0 Applicant 8. If held by vendor; does insurance name applicant and city as additional insurers? Yes N No 0 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # a A t l t �� (Name of Holder), Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the City of Blair, Nebraska. and State of Nebraska relative to this applicati and the sale and storage of fireworks in the City of Blair, Nebraska. Applicant Date a Vendor (' applicable) Date FOR CITY USE ONLY: Date Received �" I Z ) O Applicant awarded license: Yes 0 Time Received • NEBRASKA STATE FIRE MARSHAL o 246 South 14th Street rF Lincoln, NE 68508-1804 LICENSE FOR SALE OF FIREWORKS t Permissible fireworks may be sold at retail commencing 12:01 AM June 25 and ending 11:59 PM July 4 and must be purchased from a licensed distributor or jobber. A jobber may not sell retail. Invoice copies for all fireworks must be kept available for inspection and must show the license number of the distributor or jobber. Fireworks may not be sold outside the city limits of an incorporated town or village. Violations of State Fire Marshal regulations may result in immediate revocation of this license. • 1 t' r •' • Aw TAX This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebraska Revised Statute 28 -1246 (1994 Supp.). Such license shall be displayed at licensee's place of business. 2/3/2005 TYPE OF LICENSE AND FEE; Retailer $125 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: Stand# 2005- E- 24 -RL -76 Vets Field COUNTY Blair WASHINGTON STORAGE LOCATION: Vets Field Blair WASHINGTON DISTRIBUTOR(S): B J ALAN COMPANY SALES TAX NUMBER: DATE ISSUED: 17700474 2/9/2005 STATE FIRE MARSHAL LICENSE HOLDER: Phantom Of Nebraska, Inc LICENSE NUMBER 938 N 70th PMB 149 Lincoln NE 68505- 03/08/2005 10:08 4024845879 PAGE 02 - I RTIFICATE'D LIABILITY INSURANCE OATF (MM/rONY) Aritton-Gallagher & - AAslftc &tftRi T%if:!_ 6240 soar Center Road gclQn, OH 44139 THIS CUIRTIFIC:ATE 1$ ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORbED BY THE POLICIES BELOW, INSURERS AFFORDING COVERAGE IYOURS0, 1.q ATAN COMPANY, P�TO14 Q0 NBUR49KA,, WC, 5$5 ' MA IN LUT$W KING BjjVD Y0EWGST-qWN, GH 44502-'jj INSQRF=RA!AXcib U*cj&,jty Igmur4 C INSURER 13 Lexington lunruance Co. !NOURERO�Axiff SReciftlC Z, l•ourance Co. jN INSL)Rek f, THE POLICIE$ OF 1NSURMA W' )W HA.VFt',BEEN I$$OE0 TO THE INSURED NAMED A130VE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ' L /-\NY Rf.QUIREMENT, TERM OR CONDITION QF ANY 'CONTRAPT OR OTHER DOC TERT09CAT8 MAY BE ISSUED OR OVIENT WITH ReSPF-CT TO VMJCII HI$ C MAY PERTAIN, THE IN SURANC A E F FOROF OY THEVOL11018S 00CRIK6 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDiTibNS OF SUCH - POLICIES. AGGREGATE LIMITS SHOWN MAY HAViL- REDUCED SY PA10 CLAIMS, TYPE OF INUVRAN E POLICY NU�RBER • POLICY EFFE m POLMY EXPIRATION 016=1101wo. D='M=Dmy) �qAl. f_IAPTLr(Y 10/$0/04 10/30/05 EACN MOURRENcr=' $1000000 x COMME-RCIAL G.FNERAw_jAQi0TY CLAIMS MADE OCCUR FIRE DAMAGE & rjrb) $50000 meo Exp An one Eer $ - PERSONAL &ADV INJURY 1000000 ORNERAL AGGREGATS 2 $ '1000000 _"E 'L AGGREGATE QMIT APPLIES NEER: PRODUCTS - COMP /OP AGG s 20.00000 POLICY Ll 2 X LOC' AUTOMOOILE LI[AWILMY COMBINED SINGLE LIMIT $ ANY' AUTO Irza accident) ALL OWNED AUT05 9CHDLIL7;0 AUTOS BODILY INJURY (Per pewri) $ HIRED AUT05 BODILY INJURY NON•PWNr;D AUT08, (Pet atciderit) PROPERTY DAMAGE $ (P& accident) LIABILITY AUTO ONLY � GA ACCIORNT JQIE S ANY AUTO OTHER THAN EA ACC S AVf0 ONLY; AGO A EXtgaS I-IARIUTY tLFOPJ 4815 10/30/D4 10/30/65 _C 4000000 OCCU FICLAWS MADE AO QF�FOATE $ 4000000 DEQUCTIRLE $ RETENTION $ 1.0000 $ WORRERS COMPENSATION AND IOTH, I FIR I , �MPLQYERS' LIABILITY E.L. EACH ACCIDENT E•1- D15EASE - EA EMPLOYEE $ E.L. DISEASE', POLICY LIMIT $ 5,000,000 DESCRIPIIQH OF A00.0 MY VNUORR 106TIOPFCIAk PRO{/1510N$ SHOULD ANY Cf THE AAOVF_ bi%CRjI3r PoLjc;E Be CANCELLED BEFORE THE EXPIRATION CTTY, OF ZT.AIR PATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 oAys wRrr-rEN NOTICE TO TI4I!4F_ft7lFJC;AT9 HOLDrIll NAMED TO THE LEFT, BUT FAILURE TO DD so SH ALL 218 50• 16TH STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER., ITS AgENTe OR IB•AIR, NE 68008 Avl ROkESE'N TATIVE ACORD -25r8 (7/97) NUBRAS 2526989 POW080 Ilycertificatesmawfm kv %� r%u %Aur%rVr%A I IUN l5idlb I 03/08/ 10:08 4024845879 PAGE 09 K IMPORTANT If ' the certificate holder (.t an ADDITIONAL, INSURrED, the pollcy(ies) must be endorsed, A statement on this certificatp does', not parifer to the certificate holder in lieu of such endorsement(s)- If $UBROQATION I$ WAIVE -b, subject to the terms and conditions of the policy, certain: policies may regglre an endor'sernent, A .staWrn, on this certificate does not c onfer rights to the certificate holder in Jifou Qf wch enripi'se . DISCLAIMER The Certificate of Ihs it ti e t?n the 'reverse side of this form does not constitute a contract between the Issuing insurer(s), aw'tMarf� ri riapresentativq or producer, and the certificate holder,' nor does it aifirmatiyely or negatively.., armand, extand or alter the coverage afforded by the policies listed thereon. acnan.11..4:� 171071 J 03/ 08f' 2005 10:08 4024845879 PAGE 04 PTON-OWM D STANDS LIMITATION P10mg= is added to Sectj III -VIR0.1 IS Al Vsunr) as ru'lliows: -5. Any p=61% or-'0'r9u4=fi0li,wkq hands m s;ettifitat o r i n=aqc: f *, n0a . Qw;jQd AAM*Mtv( iovilh vai4Sur ag l y . f I. j with m5pec HOWOV.Pc ry. - �W,466 * Of (OUrancr priQr to Ille "accumo- lqr;)kTWX% w3d Wixauro is 0XI file with uv. b, Coverap p Sri 44d u. 114 PUASrOph ix . to the designs tbd o f P'= 0 r% e, M US'6dit ttu'�. p rMl l ses . s 01 lacatiqlt wb is i piad by, Olt mntM or tca m a cortifinta OF 044 teMporary str=viran, wfti f(w th& mmil . o f t he AA OhtT tm- a, CO&dlfioas srid f OtWOr0romlia uw,4uged AudwrWd kopratritatille 03/08/2005 10:08 4024845879 PAGE 05 Additional 10sur LL-- V� dohs Paragraph 5. is added to 5e 00 , . .11 -N- WHO IS AN INSURED as follows: .Any or orga ' i ftior�, acting as a vendor, but only wide respects to "bodily bijaary" or 4 `property damage' arising t��.ft of "your products" which are distributed or sold in the course of the vendor' bu:5 n,e however, the imurance afforded to a vendor does not apply to: a. `fBodily iljuzy�' or i� roporty damage" for which the v endor is obligated to p ay d aaaages b reason of the a' ssiiiblat►on of. liability ill the contract or agreement. This subparagraph does not apply to liability. - for "da . magos that the vendor would have in the absence of the' .contmct or agreement b. may express Warrtfuty unautlaoriz0 by Yot c. Any physical. or , o#ie*mical change in the product made intentionally by the vendor; d. Repackaging uttles� - u apa.clred solely for the purpose of inspection, demonstration.,, testing, or the subatitutior , : parts under instructions from. the manufacturer, and then repackaged. in the original, confaii l6r; e. Any fail,iire to nnake such • inspections, adjustments, tests or servicing as the vendor has agreed to zraake or poally undertakes to make in the usa . course of business, iii connection with ; thc - di:strihution or sale of the products; Detn.on.stration, .iiist4llatiDn, servicing or repair operations, except such operations performed at the Veohdo* f" s premises in, connection with the sale of the product; g. Products whicb., .after.- disiribvtion or sale by you, have been labeled or relabeled or used as a cozatainer; or 4ny :rather thing ar substance by or for the vendor. This insurance does ziof- pply , to ,ally insured person oar organization, from whom, you have acclu3red such products,, or .any ingredients, part or container, entering into, acconjpamyiz).g or containing such ; pr 'Qducts. Addition..al Jxt.su.red'-- Bla' a Zet Paragraph 6, is added to LSectiOat 11 — WHO IS AN INSURED as follows: Notwith standing - any . tean or condition, Of this policy to the contrary, any peT5ou, or organization regm ed by wntt liability coverage for operations peeorrned by the'Nained Insured - on behalf•of such G or organization will qualify as an additional insured for such. coverage as is provide'd, under Coverage ,A. In addition, a 16ssor.Wivho leases a location to the Named Insured and is required bywritten contract to have liab ility. cove.Tage for operations performed by tli.e Named Insured on behalf of such lessor wi.l1 qualify .as aii.additional, insured for such coverage as is provided under Coverage ,A.. 03/08/2005 . 10: 08 4024845879 PAGE 06 1. 2. Calendar Year for Application 2005 Name of Applicant Trinity Lutheran Church & JOY Preschool 3. Address of Applicant 141 South 20th St. Blair, NE 68008 -1884 Contact Person John Emslie Phone# 402 - 426 -2851 4. Is applicant working through a vendor? Yes C1 No ❑ 5. Name of vendor participating with applicant (if applicable) Ka- Boomer's Ent., Inc. PO Box 86 Wahoo, NE 68066 Phone 402 -443 -4586 6. Address of vendor Mail - Po Box 86 Wahoo, NE 68066 Warehouse - 1 258 County Road 18, Wahoo, N Contact Person Rich Ludvik Phone# 402 - 443 -4593 Cell 402-443- 7. Is certificate of insurance held by applicant or vendor? Vendor ® Applicant 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes 0 No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # 1567981 (Name of Holder) Ka- Boomer's Enterpr Inc -. FOR CITY USE ONLY: Date Received Applicant awarded license: Yes ❑ Time Received / ��— N ❑ Z .� FRX NO. : 4029649499 Jun. 22 2005 11:47RM P1 ALL190 SPECIALTY INSURANCE OF TEXAS 0.5 ME LOOP 410 SU3:TE GiMax SAN ANTONIO#, TEXA5 79216 210-341-1:2�21 Numb 00040 a CERTIFICATE OP INSURANCE FIREWORKS STANDS Thio certificate neither affirmatively nor negativel e- alters the anv6 Mormaation e'alforded by the P a , 11ftO , 07 rUes) uPon Qmndsp ehxtends or a matt�L-.- o f and cp%fe 0 " df---ucribed h d l er and ja issued r the ho, The.policy(ies) identified below by a. numbe is in f on th of cp-;rtlfioa e izou ance. coverages for Vhiah a InaWr&naw im a OrdeU n th oly with reop to ose OPeci-110 1i it Qf liabilj,t has been entered and i sun j to all terms 01 the PaIiQy- having rafe-refire e tho-', ha*rei eto, nothin . taned sha.1.1 Modify any proul of sas palilzy. g n In the event of canoollati of the Policy, the Company i0suing said polifl y will mRke all reasonable pffor, - Send Notice Of Cancellation to the CarttfiOate Holder at thc% acfdretao hawn herein, �Ut the CbMt;� ny a8oumes no respon U n, vibitie for any in* u jat & t TQ or fQil'u"e to give such no Ice, Any InaurenTze made a part ol. 011uy inc ludo rs ct t® n occ r s, a.r- insured. Ifith epe aurr ence t ing ak p. 4 jfk4 ce at. a Firevorks _ A or exhibition assooffLation, and oitel (1) the Fair spon2ori Qrganization or committ (2) the owner or nerd he -e thereof (3) mun Ieose _ty grartt�.ng the Mav I noure d perm to operate a(n) Fireworko Stand bit only ax reo Mto dads wry or propert igenc o f damage r-ftaused by or contribut to by t % in egamp.d Intured while, acting In the cotkrse and ocope of their employme NAND & ADDRESS OF INSUR ADLIXTI09AL 13mRED Ka-Boomera Entarpriar�as, P of 81 air e-. all employees Wahoo Trinity Lut1jerri, Church HE 68066 KANE & ADDRESS OF CERTIFICATE HOLDER. CitY Of S-2-air STAND LWATION 218 Soath 16th 13th Butl Bla. Nt 5$008 PRIMARY CnVEMAgg_ Company: T. H. 9. Insura.1-1co Company Police NUMber3 LIABI ITT LIMITS DI/M Opp ti peg z see A001 Producto-, _0 J,. P 0 0, 0.0 0 PDIiay Period; From " 05/15/03 To 05/15/06 Bodily lr�'Ury & Exa-eegs 61' $0 * - COMBINED SINGLE LIMIT Pry art I n ury D amage Covera shown hlVrOin aPPIies OnlY tO thoSe items sch e, d th policy. on or L;: to This aert1fjcatL-, Lz not v u oak Qr S � j gxature app r I (Copleo Hot valld). na z ea . b OV . COV'*,raqe under thL-. P-Olicy is cpndi+-�,aped upon fu.19 compl±an by all ±nsureds with all a�pllqqhla Nat-iona-1, Fire Prateoti?n open. atiGn (NPPA) codes and standards n eff a t t..h t.i th atand IS 4W 4 'i