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20071. Calendar Year for Application 2007 2. Name of Applicant 4 1A & SC6 , 46t—' I A71k6'6S 3. Address of Applicant ,F Y J' �� �' d1 91-,4112, 6 �M? Contact Person _ /ems %�� J 1S 1 , 07 - Phone # 4. Is applicant working through a vendor? Yes 2 No F 5. Name of vendor participating with applicant (if applicable) )/o/ . 6. Address of vendor c�/ �� -��`� (�2 �r��' ��C�cr�/, A�_ Contact Person �C7� Phone # 3 7. Is certificate of insurance held by applicant or vendor? Vendor EO'� Applicant ❑ 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # �/7C� �G, ? (Name of Holder) EZZ,4,-�ca otA :: 1,VC. 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 application and the sale and storage of fireworks in the City of Blair, Nebraska. Vendor (if applicable) Date 3 Date FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes ❑ No 0 DATE (MM/DD/YYY1) rar 3/7/2007 PRODUCER Phone: 440- 248 -4711 Fax: 440- 248 -5406 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Britton - Gallagher and Associates, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6240 SOM Center Rd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Cleveland OH 44139 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIL # INSURED INSURERA: Lexinqton Insurance Co Bellino Fireworks Inc INSURERB: 501 Olson Drive, St 210 Papillion NE 68046 INSURER C: INSURER D: INSURER E: [Kiel ;37f[ei zty 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L NM TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE p POLICY EXPIRATION LIMITS A GENERAL LIABILITY 6990050 5/ 4/ 2 0 0 7 5/4/2008 EACH OCCURRENCE $ 1000000 X COM MERCIAL GENERAL LIABILITY CLAIMS MADE 7 OCCUR DAMAGE TO PREMISES Ea occTurenoe $50000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2000000 POLICY PRO- LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Peraccident) $ ri GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ OTHERTHAN EAACC $ ANYAUTO $ AUTO ONLY: AGG EXCESS/UMBRELLALIABILITY EACHOCCURRENCE $ AGGREGATE $ OCCUR F1 CLAIMS MADE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STAT OTH- ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? If yea, describe under E.L. DISEASE - POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Location: Vets Field Blair,NE Additional Insured: City of Blair Dana College Baseball / Athletics IL" RitIIRL•Y_ >11a Bellino Fireworks Inc 501 Olson Drive Papillion NE 68046 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 -~ w o -~ rl- co Ln IA (13 VIP ifl- 'a CL m N m 41 0 F - LA CL rq cu cn cn CL LU tu fu 0 Oct CL 4 CL rl- 03115'2007 13:54 40233991001 BELLING ENTERPRISES NEBRASKA STATE FIRE MARSHAL 246 South 14th Stroot Lincoln. NE 68608-1804 LICENSE FOR SALE OF FIREWORKS PAGE 02 Permissible fireworks may be sold at retail commencing 12 :01 AM June 26 and ending 11:50 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 chow the license number of the distributor or Jobber. Fireworks may not be sold oul;sidka the city limits of an incorporated town or village. Vlolations of State Fire Marshal regulations may result in Immediate revocation of this license. i • i - , This copy signed, dated and nuMbered by the STATlit FIRE MARSHA. constitutes Issuance of a f- CENSE Pursuant to the pr visfons of Nebraska Revised Statute 28 -1240 (1994 Supp.), Such license shall be displayed at livensels place of business. DATE CEIV : ;x/7/2007 TYPE OF LICENSE AND FEE: RETAILER $25 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: .' i 0 3M i VETS FIELD BLAIR VETS FIELD BLAIR cat t UTOl (S)» B (S ): NUMBER: BELLINO FIREWORKS INC; SALES TAX 470826388 LICENSE HOLDS DANA COLLEGE BASE13ALL / ATHLETICS 501 OLSON [DRIVE 0 M71 f i f COUNTY WASHINGTON DATE ISSUED: 3/12/2007 .d. STATE FIRE MARSHAL. f '` • i II 0 , R • 1. Calendar Year for Application 2007 2. Name of Applicant l f = �ie 1 5 � C) 0 '51 - e t 3. Address of Applicant ` �` to - - b et r n K0900 Contact Person r — rk Phone # _3� - -i 41 -- ✓ j ( 4. Is applicant working through a vendor? Yes No ❑ 5. Name of vendor participating with applicant (if applicable) ' Mcul h m r 06- TV7 C 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) �p 11. Sales Tax Q 6 ` (Name of Holder) ` O 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 application and the sale and storage of fireworks in the City of Blair, Nebraska. _3 -5 -07 Date (:3 5.- Date FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes ❑ No 11 DATE (MM /DDNYYY) ACORD 2/27/2007 PRODUCER Phone: 440 - 248 -4711 Fax: 440 - 248 -5406 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Britton - Gallagher and Associates, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6240 SOM Center Rd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Cleveland OH 44139 INSURED B.J. ALAN COMPANY BIG BEAR FIREWORKS, INC. PHANTOM FIREWORKS, 555 MARTIN LUTHER KING JR BLVD. YOUNGSTOWN OH 44502 INSURERS AFFORDING COVERAGE NAIC # INSURERA: Lexington Insurance Co INSURERB: Arch Specialty Ins Co INC INSURERC: Axis Surplus Ins Company INSURER D: INSURER E: CnVFRnnFR 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM /DDNY POLICY EXPIRATION DATE MM /DD/YY LIMITS A GENERAL LIABILITY 6990129 10/30/2006 10/30/2007 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurence 50,000 $ CLAIMS MADE [K] OCCUR MED EXP (Anyone person) $ PERSONAL &ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY PRO X LOC JECT AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHERTHAN EAACC $ ANYAUTO $ AUTO ONLY: AGG B EXCESS /UMBRELLA LIABILITY ULP 0 0 0 2 4 8 5 10/30/2006 10/30/2007 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 X OCCUR EI CLAIMS MADE $ DEDUCTIBLE $ X RETENTION $ 10,000 WORKERS COMPENSATION AND WC STATU- OTH- TORY LIMITS I I ER E.L. EACH ACCIDENT $ EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ OFFICER /MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ C OTHER EXCESS LIAB (OVER ARCH EAU704353 10/30/2006 10/30/2007 $5,000,000 EACH OCCURRENCE $5,000,000 AGGREGATE SPECIALTY) DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS PRODUCT LIABILITY EXTENDS ONLY TO PRODUCTS PURCHASED FROM B.J. ALAN COMPANY OR DIAMOND SPARKLER CO. LOCATION: Vet's Field Blair, NE 68008 PROPERTY OWNER: City of Blair 218 South 16th Street Blair, NE 68008 ADDITIONAL INSURED: Blair high School Fine Arts Boosters MUNICIPALITY: Blair, NE 68008 Group Code: Lincoln, NE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER City of Blair WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE Vet's Field Blair, NE 68008 CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO Blair NE 68008 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) © ACORD CORPORATION 1988 �_ \ _ If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) ° ~y NEBRASKA STATE FIRE MARSHAL 246 South 14th Street \j Lincoln, NE 68508 -1804 5 LICENSE FOR SALE OF FIREWORKS 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. LICENSE GOOD ONLY FOR JUNE 25 - JULY 4 OF YEAR LICENSE ISSUED 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: 1/23/2007 TYPE OF LICENSE AND FEE: RETAILER $250 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: Stand# 1 1301 BUTLER STREET B LAI R STORAGE LOCATION: 1301 BUTLER STREET B LAI R DISTRIBUTORS) /JOBBER(S): B.J. ALAN COMPANY SALES TAX NUMBER: 17700474 LICENSE HOLDER: PHANTOM OF NEBRASKA 2840 S. 70TH ST., SUITE #7; PMB 149 [ee1I1 i11 VA WASHINGTON WASHINGTON DATE ISSUED: 2/2/2007 1 G STATE FIRE MARSHAL LICENSE NUMBER LINCOLN .: 1 1; APPLICATION FIREWORK LICENSE 1. Calendar Year for Application 2007 2. Naane of Applicant Trinity Luthern Church 3. Address of Applicant 141 South 20th Blair, NE 68008 Contact Person John Ems l i e Phone # 402-426-2851 4. Is applicant working through a vendor? Yes ® No ❑ 5. Name of vendor participating with applicant (if applicable) Ka- Boomer's Inc. PO Box 86 Wahoo, NE 68066 6. Address of vendor PO Box 86 Wahoo, NE 68066 Highway T7 Wa oo, NE 8 6 Contact Person Rich Ludvik Phone # 402 - 443 -4593 7. Is certificate of insurance held by applicant or vendor? Vendor P Applicant ❑ 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes R1 No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # 1-5 (Name of Holder) Ka- Bo omer's Enterprises, Inc. 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 application and the sale and storage of fireworks in the City of Blair, Nebraska. Applicant Date 71- Af Vendor (if applicable) Date'. FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes 1 : 1 No F-1 ALLIED SPECIALTY INSURANCE oF TMU 2-5 HE LOOP 419p SUITE fift sAN AMNIG,, TEXAS 7a216 210-341-1321 Certificate Number: ool8 D 01. This certificate neither affirmatively nor negativel amends, extends or alters the oovera e afforded by the pol ic y(ies) cribed hereon and is issued as a matter of inyormation and Confers no right upo the holder.- The olic identified below by a�olic number is in force on the date of certificate issuance. Insurance is a f orde onl with respect to those coverars for which a specific limit Of liability has been entered and is Subjec to all terms of the policy having reference thereto, nothing herein contained shall modify any provision of said poli In the event of cancellation of the policy, the Compan issuing said p will make all reasonable effort to send UOtice of Cancellatio to the Certl Holder at the address shown herein, but the Company assume no res s ponihilifi,es fo any mistake or failure to give such notice. Any insurance made a part of the policy includea ae a erson insured with respect to an occurrence taking place at a Fireworks Stand site: (1) the Fair or exhibition association, sponsoring organization or committee (2) the owner or lessee thereof (3) a municigality granting the Named Insured Permission to operate a(n) Fireworks Stand ut only as r ects bodily ingur or damage caused by e or contributed property to by the negligence of Khe ed Insured am y while acting in the course and scope of their mployment. NANE & ADDRESS OF INSURED- Ka-Boomers Enterprises, Inc. ADDITIONAL INSURED-. P.0, Box 86 City of Blair & Emplo y Wahoo Trinity Luthern Church ME 68066 XAME & ADDRESS OF MTETCATE HOLDER Citv of Blair . STAND LWATION-4 2 South 16tl 1 Vet's Field Blair, NE 68008 13th & Butter Blair, NE 68008 PRIMARY COVERAGE EXCESS COVERAGE Company-* T.H.E. Insurance Company Policy Number; M5MT7137 'Ury LIABI ITY LIMITS Bodily In & BI/PD.- acc $1,000,000 Propert y gamage, AGG ss 1 $500,000 Products: $1,000,000 Policy Period: From- 03,101107 To 03,101108 COMBINED TM L. LIMIT Bodily In jury & Property amage $500,000 Coverage shown herein applies only to those items scheduled on or endorsed to the pai t Is not valid unless an orIgInal signature appears below. This cert (Copies Not Valid)* Coverage under the policy is conditioned upon full compliance by all insureds with a applicable National Fire Protection Association (NFPA) codes and standards in effect at the time the stand Is open. March 1, 2007 &J a_)UU J&XqC1P1,/ 'DW (W CERTIMATE Ts5UWffCT' CAUTHUNIZED Z�AUXATMW NEBRASKA STATE FIRE MARSHAIII �.••` -sy`rr • • South 14th Street Lincoln. NE 68508-1804 LICENSE FOR SALE OF FIREWORKS V I 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. F +� r • • • r This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebraska Revised Statute 2 8-1246 (1994 Supp.). Such license shall be displayed at licensee's place of business. . r ; • r; 3/20/2007 TYPE OF i RETAILER $250 Stan :1 1 10 13TH AND BUTLER 131 13TH AND BUTLER BLAI R DISTRIBUTOR(S)/JOBB KA- BOOMERS ENTERPRISES INC SA LES TAX NUMBER: 15671981 �u WASHINGTON WASHINGTON .• r STATE FIRE MARSHAL LICENSE H 1/2 PRICE FIREWORKS PO B OX .• LICENSE NU MBER WAHOO NE 68066- PM 80187=0 5i