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2012t � To: Firework Vendors From: Brenda Wheeler Subject: Fireworks License Date: February 6, 2012 Enclosed please find an application form for a license in the City of Blair to sell Fireworks for the 2012 season. At the January 24, 2012 City, Council meeting, the Council passed Ordinance No. 2216 updating our firework regulations. Attached is a copy of the amended code. The City will issue up to three (3) licenses within the City limits to be located at Vet's Field (13 and Butler). The applicant /license holder must be a non - profit entity located in the City of Blair and each individual non- profit entity shall be allowed to submit up to three (3) applications for a license. A Vendor (Fireworks Wholesaler) may be listed on any number of applications with any number of non - profit entities (See attached list of non - profit organizations). All applications for licenses must be submitted using the enclosed form. The application must include a copy of insurance certificate and bank draft or certified check made payable to the City of Blair in the amount of $5,000 for the license fee. Any applications not successful shall have the bank draft or certified check returned within seven (7) days of the lottery drawing. As required by Section 7 -405 of the Blair Municipal Code, if there are more applications than licenses available, each eligible application will have its application submitted to a lottery wherein the license holders for that year shall be drawn by the City Clerk. No non - profit entity shall be awarded a second license until all other eligible non - profit entities have been selected. Each licensee will have a total area 75' x 100' to erect their storage and sales outlet. All tents will need to be no larger than 60 x 40 to allow for setup of the tent along with storage of all trailers and trash containers. You will be required to meet the minimum State Fire Marshal standards on setback requirements. State Fire Marshal standards will be distributed to successful bidders. Each successful bidder will be required to furnish trash service providing am le trash containers to handle their own trash accumulation. All trash related to firework business is required to be cleaned up daily. The City will provide one 110 volt, 15 amp outlet for each of the spaces. Please submit your application to the City Clerk by 4:30 p.m. on Thursday, March 1, 2012 If you have any questions, feel free to contact me at (402) 426 6694 or by email at brwheeler@ci.blair.ne,us Sinc 1 , Brenda Wheeler City Clerk Enc 0"O" OPPOflTUf11TT 218 South 16th Street ® Blair, Nebraska 68008 ® 402 -426 -4191 ® Fax 402 - 426 -4195 E -mail cityofblair @cl,blalr,ne,us m C) • r+ (D co fD 0 mv Cl) - 0 0 �raw � 3 �z /�z 0. Zo d+ �� o W W phaR- m G ra n �tiil�t 1�/Jh�S i�tob cnrrrcs 1 7M ri se o f av March 2, 2011 Bellino Fireworks, Inc. 501 Olson Drive, Suite 210 Papillion, NE 68046 RE: Firework License in Blair Dear Mr. Dooley, We regret to inform you that Teammates of Blair was not awarded a license for fireworks in Blair for 2012. Enclosed please find the three (3) cashier's checks submitted with your applications. Thank you for your interest in the City of Blair. We hope you will continue to make application for a firework's license in the future. Sincerely, Brenda Wheeler City Clerk Enc EOVAL NOUSINO OPPOPTUNITV 218 South 16th Street • Blair, Nebraska 68008 • 402 -426 -4191 • Fax 402 -426 -4195 • E -mail cityofblair @ci,blair,ne.us N a I N EI ri of d►� March 2, 2012 Roger Burris Phantom Fireworks 2840 S. 70 Street, Ste -7, PMB -149 Lincoln, Nebraska 68506 RE: Firework License in Blair Dear Mr. Burris, The Blair Eagles Aerie #3215 has been awarded one (1) license for fireworks in Blair for 2012. We have received your Certificate of Insurance but will need to receive your Nebraska State Fireworks Permit License no later than June 15, 2012. Enclosed you will find a map indicating the location of the space that has been designated for your sales outlet at Vet's Field. Please remember that your tent will need to be sized accordingly to allow for setup of the tent along with storage of all trailers and trash containers to meet the minimum State Fire Marshal standards on setback requirements (Please see attached map for layout options and maximum tent size).You are also required to furnish trash service providing am le trash containers to handle your own trash accumulation. All trash related to firework business is required to be cleaned �da ily. The City will provide one 110 volt, 15 amp outlet for each of the spaces. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, 4 renda eeler City Clerk Enc — (2) Cashier's Checks 270102818/270102819 Cc: Blair Eagles Aerie #3215, Pa Box 242, Blair, NE 68008 OPI NOUSINY OVVOflTUNITY 218 South 16th Street - Blair, Nebraska 68008 - 402 - 426 -4191 - Fax 402 - 426 -4195 - E -mail dtyofblair @d.blair,ne,us February 17, 2012 City of Blair Attn: Brenda Wheeler 218S 16 Street Blair, NE 68008 Dear Brenda, Enclosed you will find our 3 applications with the appropriate fees attached to be entered into the 2012 lottery drawing for the license to sell consumer Fireworks in the City of Blair. If you need anything else or have any questions or concerns please let me know. Thank you. Sincerely Linda Dicks Phantom Fireworks 2840 S 70 St., Ste 7, PMB 149 Lincoln, NE 68506 402 - 944 -2118 ldicks fireworks . com 2840 S. 70th Street, Suite 7 - PMB 149 - Lincoln, NE 68506 - Phone: 402.944.2118 - Fax: 402.944.2628 800 www.fireworks.com / ) / 1. 2. 3. 4. 5. M Calendar Year for Application 2012 Name of vendor participating with applicant (if applicable) Address of vendor - 2� 'q � - PryL B j 4q U ncr -;ice , El t- . Contact Person x � &)urr1 Phone # L- b (- O ° 2l l 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 No � 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # . - tp - 1( (Name of Holder) =: - . t&j r 4 �- . l 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. Fwe 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. FOR CITY USE ONLY: Date Received Time Received Applicant awarded license Yes El No EJ 1 0 C DATE (MM /DD /YYYY) 02/09/2012 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 ALTERTHE COVERAGE AFFORDED BYTHE 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 MCGRIFF, SEIBELS & WILLIAMS, INC. P.O. Box 10265 CONTACT NAME: (A/C N No Ext :800- 476 -2211 FAX No): E -MAIL ADDRESS: Birmingham, AL 35202 INSURER(S) AFFORDING COVERAGE NAIC # EGLB01888933 INSURER A :Liberty Surplus Insurance Corporation 10725 EACH OCCURRENCE INSURED B J Alan Company INSURER B :Ironshore Specialty Insurance Company 25445 Big Bear Fireworks, Inc. INSURER C: Phantom Fireworks, Inc. 555 Martin Luther King, Jr. Blvd INSURER D INSURER E: Youngstown, OH 44502 INSURER F: COVERAGES CERTIFICATE NUMBER:4P5A8LMA 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS A GENERAL LIABILITY EGLB01888933 10/30/2011 10/30/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 CLAIMS -MADE Fx_1 OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 $ POLICY PRO F X7 LOC JECT A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS B UMBRELLA LIAB X OCCUR 000770202 10/3012011 10/30/2012 EACH OCCURRENCE $ 9,000,000 X AGGREGATE $ 9,000,000 EXCESS LIAB CLAIMS -MADE DED I J RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE WC STATU- I OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) This certificate relates to the operations of Phantom, of Nebraska, Inc. at 2840 S 70th St., Ste 7, PMB 149 Lincoln, NE. 68506; City of Blair and its duly elected and appointed officers; Blair Vets Field 1301 Butler Street Blair NE 68008; F.O.E. Blair Aerie #3215 / Blair Eagles PO Box 242 Blair NE 68008; Dale Miller 1829 Lincoln Street Blair NE 68008. The above listed are Additional Insureds respects to General Liability policy as required by written contract subject to policy terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Blair Brenda Wheeler AUTHORIZED REPRESENTATIVE 218 S 16th Street Blair, NE 68008 Page 1 of 1 ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD NEBRASKA STATE FIRE MARSHAL 246 South 1 Street Linc 68508-180 LICENSE F OR SALE OF FIREWORKS JULY 201S 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. Rules and regulations can be viewed and printed from our website: www.sfm.ne.gov. 14 L01:4 i &73 ZIL00 I • • • 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. e X61 a y" 3/13/2012 TYPE OF LICENSE AND FEE: RETAILER $79.88 �- -- 1 2 1 RI Stand #: 2012 -RP- 2449146- 1628 -RL -001 1301 BUTLER ST COUNTY BLAIR WASHINGTON STORAGE LOCATION: 1301 BUTLER ST BLAIR WASHINGTON DISTRIBUTORS) /JOBBER(S): B.J. ALAN COMPANY SALES TAX NUMBER: DATE ISSUED: 17700474 3/13/2012 1 � WORD rise 01 av March 2, 2012 Dan Williams Wild Willy's Fireworks, LLC 7913 Hidden Valley Drive Papillion, NE 68046 RE: Firework License in Blair Dear Mr. Williams, The Josephs Coat Thrift Store & Food Pantry has been awarded one (1) license for fireworks in Blair for 2012. We have received your Certificate of Insurance but will need to receive your Nebraska State Fireworks Permit Licenses no later than June 15, 2012. Enclosed you will find a map indicating the location of the space that has been designated for your sales outlet at Vet's Field. Please remember that your tent will need to be sized accordingly to allow for setup of the tent along with storage of all trailers and trash containers to meet the minimum State Fire Marshal standards on setback requirements (Please see attached map for layout options and maximum tent size).You are also required to furnish trash service providing am le trash containers to handle your own trash accumulation. All trash related to firework business is required to be cleaned up daily. The City will provide one 110 volt, 15 amp outlet for each of the spaces. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, Brenda Wheeler City Clerk Enc - (2) Cashier's Checks 70016093/70016092 Cc: Josephs Coat Thrift Store & Food Pantry, 1737 Washington St., Blair, NE 68008 -121- EOUALHOU6 NO 218 South 16th Street • Blair, Nebraska 68008 • 402 - 426 -4191 • Fax 402 -426 -4195 • E -mail cityofblair @ci,blair.ne.us 1. Calendar Year for Application 2012 6. Address of vendor , ` w� r Contact Person M W'%'W%0V1^S Phone # - ° 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 No 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # o l - _olot3 %7 ` (Name of Holder) %re,\-jo ' s , L.L 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. a/ m/ are i a— Date I , Date FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes D No R Vendor (if applicable) May 25 2012 10:29AM Wild Willys Fireworks 4022533190 DRANTON IN SURANCE , INC. cEPJ TER POMT ROAD, S nT£ M R r POST OFFICE BOX 94467 BIRMNGRA.M, ALABAMA 35M BMUNGHAN, ALABAMA. 352o TEI..I PHOND (205) 854,W6 PA, ( �� • �Si►�fc3 We =46, �t inwrance is afforded as stated below. This Certificate does not affmru ti.vely or negat ively amend, extend or alter the coverage afforded by the insurance policy and the ice afforded is subject to all the terms exclusions and;conditions of the policy. INSURE Admiral Insurance Company POLICY NO. CAOp0003209 -22 -1091 WAINIED INSURED Wild Willy's, Fireworks 7913 flidden'Valley Drive Papillion, NE 6$016 P L]ICY TERM March. 1, 2012 to March 1, 2013; Bath Trays 12:01 A.M. Standard Time COVERAGE Pfoducts Liability, including broad form vendors liability: fJccturence Basis [l Claiins Made Basis $2,000,000 each occurrence, $5,000,000 products aggreg The limit of liability shall not be increased 'by the inclusion of more th= one insured -or additional Ww INSURED OPE ONS The inan ufacture, sale or distribution of consumer fireworks (1.4G) and related products It is if nawd below, this policy iinchtdes as AddWonal Insnds 1) the distributor Of the Named Insur ed's p# oduets and/or 2) the own& ofproperty on which the Named Tnsured's products are sold and/or 3) the licensiag authority issuing a pertrut or license for the sae of the gamed l'm�s product =d/or 4) as entity for which cov *erage is rewired by written conhwt. N (8;) OP D . � ONAL " Eo(S) City of Plaif. 21$ South I ;0 Street Blair, Nebr ka 68008 Voice (402)!..4264191 Josepws:co� Thrift Stbre & Food. Pantry 1.737 Wasl itgton St. Blair, NE 6840$ It is c&tified,';tW thispglicy requires a 30 day tnutual notice of canmllation bebm= the Insurer and the Named Insured, hi the event of mach cancellat ion eve will:endeavor to mail 10 days written notice to the Additional hmzed(s), whose name and address is shown hereon, but failure to mail such 4atice slxall no obligation or liability of any kind upon the insurer and/or the undetsigned. t'• N we 116 1 g 0 ; Z KI ! t ,..4;4 I r E�buraiy 21 2012 F � TRIVNGFRk o PROSIODE INSURER Admiral Insurance Company PO LICY NO. CA060003209 - 22 - 1091 NAMED INSURED Wild Willy's Fireworks 7913 Hidden Valley Drive Papillion, NE 68046 PO LICY TERM March 1, 2012 to March 1, 2013; Both Days 12:01 A.M. Standard Time COQ' QE Premises-Operations Liability: Occurrence Basis ❑ Claims Made Basis LIMIT OF LIABILITY $1,000,000 each occwrenm $5,040,000 gener4t aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. 1NS D !'i ! OPERATIONS The sale of consumer fireworks (1.4.G) and related products at the insOred location, during the period of operation. It is certirl6d that, if named bellow, this policy includes as Additional Insureds 1) the operator of the insured lwation used principally for the retail sa a of the Named Insured's consumer fireworks and/or 2) the owner of the property on whicl_i the Insured location is situated and/or 3) the licensing authority issuing a permit or license for the insured location and/or 4) an entity for which coverage is required by written contract. NAME(S) OF ADDITIONAL INS/ S) City of ala�r 218 South .l6' Street Blair, Ncbr' 68008 Voice: (402 426 -4191 losepb's Crud Thrift Store & Food Pantry 1737 l h jgton St, Blair, NE 6008 ADDRESS:OF INSURED-LOCATI Veterans Memorial Ball Field Blair, NE 6$008 PERIOD OF OPEPATION June 23r 20 12 —Judy e, 2012 It is certified that tfiis policy requzres a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation tive will endeavor 0 mai110 days written notice to the Additional Insured(s), whose name and address is shown herein, but failure 6 mail such ;notice shall impose nv obligation or liability of any kind upon the insurer and/or the undersigned. Febgoa 2 .2412 • D.kTE OF 1 1SSUE TRWINGER, P S P NEBRASKA STATE FIRE MARSHAL 2 South 4 Lincoln, NE 685 08 1 FIREWORKS LICENSE FOR SALE OF 9 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. Rules and regulations can be viewed and printed from our website: www.sfm.ne.gov. This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebrasl Revised Statute 28 -1246 (1994 Supp.). Such license shall be displayed at licensee's place of business. DATE RECEIVED: 3/17/2012 TYPE OF LICENSE AND FEE: RETAILER $159.75 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: Stand: 2012 -RP- 2475578 - 1634 -RL -006 1301 BUTLER ST COUNTY BLAIR WASHINGTON STORAGE LOCATION: 1301 BUTLER ST BLAIR WASHINGTON DISTRIBUTORS) /JOBER(S): WILD WILLYS FIREWORKS SALES TAX NUMBER: DATE ISSUED: 001 - 010138714 3/19/2012 PAPILLION NE 68046- Eb ����'� ? se of a March 2, 2012 Ka- Boomer's Enterprises, Inc. PO Box 86 Wahoo, NE 68066 RE: Firework License in Blair Dear Mr. Ludvik, The Trinity Lutheran Youth Group has been awarded one (1) license for fireworks in Blair for 2012. We have received your Certificate of Insurance but will need to receive your Nebraska State Fireworks Permit Licenses no later than June 15, 2012. Enclosed you will find a map indicating the location of the space that has been designated for your sales outlet at Vet's Field. Please remember that your tent will need to be sized accordine1v to allow for setup of the tent along with storage of all trailers and trash containers to meet the minimum State Fire Marshal standards on setback requirements (Please see attached map for layout options and maximum tent size).You are also required to furnish trash service providing #pple trash containers to handle your own trash accumulation. All trash related to firework business is required to be cleaned up daily. The City will provide one 110 volt, 15 amp outlet for each of the spaces. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, Brenda Wheeler City Clerk Enc - (2) Cashier's Checks 51894/51890 Cc: Trinity Lutheran Youth Group, 141 S. 2e St, Blair, NE 68008 218 South 16th Street - Blair, Nebraska 68008 - 402 - 426 -4191 - Fax 402 - 426 -4195 - E -mail cityofblair @cLblair,ne.us 1 � � /Se Of 7\� March 2, 2012 Ka- Boomer's Enterprises, Inc. PO Box 86 Wahoo, NE 68066 RE: Firework License in Blair Dear Mr. Ludvik, The Trinity Lutheran Youth Group has been awarded one (1) license for fireworks in Blair for 2012. We have received your Certificate of Insurance but will need to receive your Nebraska State Fireworks Permit Licenses no later than June 15, 2012. Enclosed you will find a map indicating the location of the space that has been designated for your sales outlet at Vet's Field. Please remember that your tent will need to be sized accordingly to allow for setup of the tent along with storage of all trailers and trash containers to meet the minimum State Fire Marshal standards on setback requirements (Please see attached map for layout options and maximum tent size).You are also required to furnish trash service providing am le trash containers to handle your own trash accumulation. All trash related to firework business is required to be cleaned up daily. The City will provide one 110 volt, 15 amp outlet for each of the spaces. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, Ad__� Brenda Wheeler City Clerk Enc - (2) Cashier's Checks 51894/51890 Cc: Trinity Lutheran Youth Group, 141 S. 20 St, Blair, NE 68008 218 South 16th Street - Blair, Nebraska 68008 - 402 -426 -4191 - Fax 402 -426 -4195 - E -mail cityofblair @ci,blair.ne,us L ,;, j M IM I W I I 1. 3. Calendar Year for Application 2012 Name of Applicant Address of Applicant Trinity Luther Youth Group 141 S 20t Blair, NE 68008 Contact Person Tim Svendgard Phone # 402 - 426 -2066 Home 4. Is applicant working through a vendor? Yes [� No ❑ 5 - . Name of vendor participating with applicant (if applicable) K a- B oomer's Enterprises, Inc. 6. Address of vendor P O Box 86 Wahoo, NE 68066 847 Highway 77 Wahoo, NE 68066 Contact Person Rich Ludvi k Phone # 402-4 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 E y� No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # 15671981 (Name of Holder) Ka- Boomer's Enterprises, Inc FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes ❑ No ❑ NEBRASKA STATE F�RE MARSHAL tK 246 South 14th Street Lincoln, NE 68508-1804 F OR SA' i (� H S E I [ t- J 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. Rules and regulations can be viewed and printed from our website: www.sfm.ne.gov. R U "C' E [1,1� a �-3� E � ,,7� � 3, �L?' D J31 d 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: 3110/2012 T. OF LICERSE AND FEE: RETAILER $106.50 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: Shand: 2012-RP-2413660-1617-RL-001 13TH AND BUTLER COUNTY BLAIR WASHINGTON STORAGE LOCATION: 13TH AND BUTLER BLAIR WASHINGTON z 0 SALES TAX NUMBER: DATE ISSUED: 15671981 3/12/2012 LICENSE HOLDER: STATE FIRE MARSHAL LICENSE NUMBER KA-BOOMER'S ENTERPRISES, INC. PO BOX 86 WAHO• NE •80•• -