BOROUGH OF HONESDALE, WAYNE COUNTY, PENNSYLVANIA

BOROUGH OF HONESDALE, WAYNE COUNTY, PENNSYLVANIA
APPLICATION AND PERMIT FOR FIREWORKS DISPLAY
Name
Phone No
Cell
Email
example@example.com
Fax
If applicant is an organization a corporation or firm also list the contact persons information Name
Address
Phone No
Cell
Email
example@example.com
Fax
FIREWORKS DISPLAY INFORMATION
Name of the individual or organization that will be responsible for providing the fireworks
Name of the individual that will be responsible for detonating the fireworks Proposed site of the fireworks display
Date and time of fireworks display
date

MonthDayYear
Date
time
Rain Date and Time

MonthDayYear
Date
The manner and place of storage of such fireworks prior to display:
Number and kinds of fireworks to be discharged
The applicant hereby agrees to and has attached the following:

Applicants shall, at the time of the application, provide a certificate of insurance to the Borough with a minimum limit of the insurance of $2,000,000 and naming the Borough as an additional insured. This may be accomplished with $1,000,000 in general liability insurance and $1,000,000 umbrella policy. To hold harmless and indemnify the Borough, its officers, agents and/or employees from anyliability arising from the display for which the permit is issued To comply with National Fire Protection Association standard on Fireworks Display, 2014edition, specifically NFPA 1123 and NFPA1126. Has attached a proposed Fireworks Site Plan Has attached a copy of a valid Fireworks Displays or Exhibition Certificate of Registration from the Commonwealth of Pennsylvania for the individual or organization that will be detonating the fireworks for the date in which the fireworks display is proposed. Applicant has attached a check made payable to Honesdale Borough for the application fee. Applicant agreement to supply fire suppression on site on the date of the fireworks display Applicant will pay, if approved, any applicable Fire Department fee. Any and all holders of the fireworks permits will be required to notify the Fire Chief, or his or her designee, at least 48 hours in advance of the display and further notify the Wayne County Communications Center (911) at least two hours in advance of the display notifying them when and where fireworks will be displayed. Permit holders will be required to notify the Wayne County Communications Center (911) at the conclusion of the display, as well A Post-fireworks site clean-up plan is attached. Applicant has reviewed the violations and Penalties Section of Chapter 110.
Date

MonthDayYear
Date
Signature of Applicant

Clear
Date Sent to Parks and Recreation Commission

MonthDayYear
Date
Attach a separate sheet of paper with a detailed map of the displ lay site showing the following

1.Fall-Out Area: the area over which aerial shells are fired. The shells burst over this area, and unsafe debris and malfunctioning aerial shells fall into this area. The fall-out area is the location where a typical aerial shell dud will fall to the ground considering wind and the angle of mortar placement. 2.Discharge Site: the area immediately surrounding the area where fireworks are ignited for an outdoor display. Include all dimensions of the discharge site. 3.Display Site: the immediate area where a fireworks display is conducted and shall include the discharge site, the fallout area, and the required separation distance from the fireworks discharge site to spectator viewing areas. The display site does not include spectator viewing areas or vehicles parking areas. 4. Distance: from the outside measurement of the discharge site to spectators, overhead obstructions, buildings, highways, and parking areas. Show distances in feet.
Street
If Applicable, mark: Overhead objects 25 feet or higher, within 100 feet of discharge site and fallout area, existing fences, distance to flammable storage; tent or canvas shelter; location and distances for ground display, ready box; direction of prevailing wind; all buildings: structures; highways; streets or other means of travel within 100 feet of discharge site and fallout area; spectator viewing areas and distances from the discharge site and fallout area; parking areas
Approved
Denied
Reason for Denial
Date

MonthDayYear
Date
Parks Recreation Commission
This application has been reviewed and a site inspection has been performed by the Honesdale Fire Department on
Date

MonthDayYear
Date
Fire Chief or designee
Yes
Applicant to supply fire suppression.

YESNO
Approved
Denied
APPLICATION IS: APPROVED:
APPROVED
DENIED
APPROVED
DENIED
APPLICATION IS: APPROVED:
APPROVED
DENIED
Date

MonthDayYear
Date
Borough Secretary
Should be Empty:

BOROUGH OF HONESDALE, WAYNE COUNTY, PENNSYLVANIA

APPLICATION AND PERMIT FOR FIREWORKS DISPLAY

FIREWORKS DISPLAY INFORMATION

APPLICATION IS: APPROVED:

APPLICATION IS: APPROVED: