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Home My WebLink AboutItem 09 - Fireworks DisplayPermit Request Event: XO Marriage Conference Location: Fellowship Church — 2450 TX-121 - Grapevine, TX Show Date / Time: Friday, February 11, 2022— 9:20 PM Load In time — Friday, February 11, 2022— 6:00 PM Pyrotechnics Supplier: Pyrotex, Inc. Lead Pyrotechnician: Jessica Amspoker 214-646-7878 Offices: 4368 FM 1553, Leonard, TX 75452 Contact Phones: 903 587 8000; 903 587 8001 fax; 214 384 7655 mbl Contact email: ATF Licenses: 5-TX-147-33-3D-11659 State Licenses: see attached Show DescriLition This is a ground effects display fired from the walking path on the southeast edge of the lake. The display is eight minutes in length and is electronically fired. All aerial shells are 2.5" in diameter or less, which requires a minimum safety distance of 175 feet; we plan on 200 feet from the closest person or structure in all directions. This display complies with NFPA-1126 and 1123. The lead pyrotechnician will have full visual access of all effects prior to and during firing. The assistant pyrotechnicians will have 2.5 gallon water extinguishers on site and will provide a fire watch. The pyrotechnician will not fire if the area is not secure. City of Grapevine Special Event Permit Application �T1.1 X A_sy Date Completed Application Submitted: (At least 60 days prior to event date) OFFICE USE ONLY PERMIT NUMBER: Thank you for considering Grapevine for your event. By providing the information below, you will help us to determine how to assist in making your event safe and pleasant for all involved. Your application will be approved with conditions or denied based on this information. Should certain parts of this application require additional information, you will be responsible for supplying that before the application can be approved. There is a $100 non-refundable administrative fee for submittal of all applications. This application must be signed, notarized, include a site map, insurance, and submitted to Parks and Recreation Administration at least 60 days prior to the event. Parks and Recreation will forward it to the other City departments involved for approval. Applications received less than 60 days prior to event date are subject to being denied. Event Title: XO Marriage ❑ Race/RunNValk ❑ Parade ❑ Lake Park Event (non-race/run/walk) o Fireworks Display ❑ City Park Event Event Date: 2/11/2022 Event Start Time: 9:20 am / pm Event End Time: 9:30 am / pm Setup Date: 2/11/2022 Setup Time: 6:00 am / pm Tear Down Time: 10:00 am / pm Event Location / Park / Street: Fellowship Church - 2450 N Hwy 121 - Eastern edge of lake Organization Hosting Event: Pyrotex, Inc. Tax Exempt: ❑ Yes * No I Tax ID #75-1979109 Address: 4368 FM 1553 Contact Person: Derek Willingham Address: same Email: derek@pyrotex. yes, proof to be furnished) City: Leonard Phone: 903-587-8000 Zip: 75452 In 100 words or less, please give us a short summary describing your event. Include all activities that will be conducted as part of this event. This is an 8 minute fireworks display fired from the east side of the lake. All effects are loaded day of show. The show is fired remotely from approximately 100' away. It is all electronically fired. Persons Expected: Number of Participants: N/A Number of Vehicles: 3 Number of Event Staff/Volunteers: 3 Description of Vehicles and/or Comments: crew vehicles *Depending on size of event, a parking plan may be requested with the application* Required Documents based on event type: CoE Liability CoE Special Special Event Route & Communication/Emergency Insurance Lake Activity Event Permit Event Map Plan Policy Permit Permit Race/Run/Walk • • • • *• Parade • • • • Lake Park Event • • • *• **• **• (non-race/run/walk) Fireworks Display • • • • *• City -ark Event • • • *• * City will advise as to whether or not this cocument is required. ** Only one permit required, see criteria for which is applicable. FW Initial here if I have included a route and/or site map with my completed application. A detailed aerial map of the route your event will follow and any planned use of public space, including tent/vendor placement, temporary restroom placement, participant parking and any other planned activity that will have a designated location on the property. F W Initial here if I have included Certificate of Insurance with my completed application. Please furnish the City of Grapevine with a certificate of insurance as evidence that the policy providing the required coverage and limits of insurance are in full force and effect, with your completed SEP application. The certificates of insurance shall name the City as an additional insured of the General Liability Policy as follows: City of Grapevine 200 S. Main Street Grapevine, TX 76051 Certificates of insurance for permit holder furnished insurance and notices or cancellations, terminations, or alterations of such policies shall be sent to: Post mail — The REC of Grapevine Attn: Sasha Haverkamp 1175 Municipal Way Grapevine, TX, 76051 Electronically shaverkamD a cirapevinetexas.ao = Comprehensive General Liability — This insurance shall be an 'occurrence" type policy written in comprehensive form and shall protect the permit holder and the additionally insured against all claims arising from bodily injury, sickness, disease or death of any person, as well as damage to property of the City of Grapevine or others arising out of the act of omission of the permit holder or their agents or employees. The liability shall not be less than: Each Occurrence: $1,000,000 General Aggregate: $2,000,000 Products and Completed Operations Aggregate: $2,000,000 Please answer the following questions that will provide the City a communication/emergency plan. Where will the access routes be for ambulance pick up, first aid, and weather shelter/s? Silver Lake Marina • List event staff leaders and the role they play: NAME ROLE PHONE Jessica Amspoker Lead Tech 214-646-7878 Joshua Silvas Tech 512-626-9207 Nathan Swanson Tech 972-979-1635 • Fire Protection — Required for structures, tents or processes. Where will you keep a fire extinguisher? on boat near barge Who is in charge of it, and how is it communicated? Lead technician • Emergency Medical Services Who is coordinating any emergencies/communication plan? Lead technician Where is the first aid station if provided? N/A • Evacuations Who oversees the evacuation and how is this information communicated to the event attendees? Lead technician How is the crowd managed? N/A • Severe Weather Who monitors and tracks the weather, and how are severe weather notifications made? Lead technician Who determines what severe weather will close the event? Lead technician and Fire Marshal Are there shelters to go to during the event? N/A What is your location and how are you communicating to N�Aendees/participants? • Parking and Traffic Control Plan Where will the emergency vehicles get access to event? How are issues communicated if there is a problem? N/A N/A • Communications Plan Who oversees the communications plans? N/A How is staff communicating normal business during the event? N/A How are emergencies reported? N/A Training — Provide any briefings to volunteers, workers, or staff as to the elements of the plan. All crew members are trained annually *This is not a complete list of items for a plan but is a guide to aid you in development of your event emergency preparedness. If you need assistance, please contact Randie Frisinger with the Fire Department, 817.410.3482. Does event use any Corps of Engineer (CoE) property? (meaning, your event is in a lake park) *1 Yes ❑ No If yes, an additional CoE permit is required. Please contact: U.S Army Corp of Engineers — 817.865.2619 Application and payment submitted to: U.S. Army Corps of Engineers ATTN: Kenneth Myers 110 Fairway Drive Grapevine, Texas 76051 There are two types of CoE permits, only one or the other will be submitted. Two types listed below. A) Corr) of Emineers Lake Activitv Permit— Complete a CoE Lake Activity Permit if your event is intended to occur at a City of Grapevine Lake Park and: • WILL NOT have a significant impact on resources or significantly restrict the intended use of the property by others • WILL NOT require special exclusive use of water surface, does not involve parasails, hang gliders, parachutes, or any type of airborne craft • WILL NOT require additional facilities or services such as: temporary restrooms, parking, concessions, police, fire, EMS, etc. • WILL NOT generate revenue for a profit • WILL NOT include the sale or distribution of alcoholic beverages • IS NOT expected to draw a large number of participants and/or spectators • WILL NOT involve the exchange of money, e.g. sales of goods/supplies, food, refreshments, etc. B) Core, of Engineers Special Event Permit— Complete a CoE Special Event Permit if your event is intended to occur at a City of Grapevine Lake Park and: 0 WILL involve one or more of the above bulleted items Does your event require road/lane closures? ❑ Yes L No If yes, please provide a route map with your completed SEP application. (Fees will be applied if Traffic Operations requires barricades) Number of Lanes Requested for Closure: Street(s): If you are requesting a road/lane closure you MUST include a route map and a traffic control plan. If you have questions or need assistance with your traffic control plan, please contact Robert Eberling or Barry Bowling with the Police Department at 817.410.3276. Person responsible for implementing traffic control plan is: Name: Phone: Will you be charging participants and/or spectators a fee? ❑ Yes 1-W No If yes, list fee. Participants $ Spectators $ Will there be any food or beverages sold or served at the event? ❑ Yes F=1 No If yes, you must contact the Tarrant County Health Department separately at 817.321.4960. Will there be any tents larger than 10x10, temporary structures, stages or fencing? ❑ Yes! No If yes, contact Building Inspections/Permits Department at 817.410.3154. Will there be alcohol at the event? ❑ Yes * No If yes, glass bottles and containers are prohibited in Grapevine City Parks and Lake Parks. Will there be any entertainment, such as bands, DJ's, outside speakers, microphone, etc.? ❑ Yes 41 No Will inflatables/ bounce house(s) be used in this event? ❑ Yes !1 No If yes, a Certificate of Liability Insurance listing the City of Grapevine as additionally insured must be provided from vendor providing the inflatable/bounce house. You may turn this into Sasha Haverkamp with your application. Will portable restrooms be needed? ❑ Yes U No If yes, how many? (fees will be applied) List any additional vendors and their services provided for the event: VENDOR SERVICE PROVIDED PAYMENT INFORMATION To pay over the phone: Please provide a MasterCard or Visa and call 817.410.3122 To pay in person. visit: Sasha Haverkamp, 2"d floor The REC of Grapevine 1175 Municipal Way Grapevine, TX 76051 You may pay with credit card, cash, or check To pay by mail: OFFICE USE ONLY ADMINISTRATIVE FEE PAID CIRCLE ONE: CASH I CHECK I CREDIT CARD CHECK NUMBER (if applicable) Please make check payable to "City of Grapevine Parks & Recreation", and mail to: City of Grapevine, Parks & Recreation ATTN: Sasha Haverkamp P.O. Box 95104 Grapevine, TX 76099 The complete_ d Special Event Permit application form and supplemental documents may be emaiied to shaverkam ra evinetexas. ov OR mailed to the above P.O. address. "Payment must be received prior to routing the completed special event permit application" L XO Marriage Fellowship Church ` 2450 Hwy 121 North Grapevine, Texas Firing Site is located on a park path. The safety perimeter is a 4circle with a radius of 200 feet, centered on the firinc site. The safety perimete 400 encompasses the fallout Ii' There are no boats in the %Vto— water and no hazardous material stored within 80C Parking lot is closed dowr public The audience is located a Church. There are no occupied churches, dorms, classroi health care or correctiona facilities within 600'.! There are two security gu for the firing site (•). Aftil.12 C Convriaht 2022 - Pvrote, Issued To: Amspoker, Jessica Nichole 10534 LE MANS DR DALLAS TX 75238-3638 FI QW1101M C0if7-*1RA*0 ps�r E r of rlysuxo ``X,+�rW , AL'S OFF10 License Number FP0-1741590 Expiration Date: 11-18-2022 EFFECTIVE DATE: 11-18-2ow LICENSE DATE ISSUED: October 21, 2021_ +-�_ " `"� Orlando P. Hemandez, State Fire Marsh Registered Location(s): —, Registration Number 4368 FM 1553 e� �� FWD-0052 � LEONARD TX 75452 ,' _= —` "f . Expiration Date: 05-22-2022 f e�FEC1sVeDATE rrs:zz•Ms FIREWOR0 DTRIBUTOR'S LICENSE TEXAS 4E R O F!N RANGE STA L'S`�FICf Issued To: PYROTEX, INC. DATE ISSUED: March 16. 2021 c SF081Iills s: Orlando F. Hernandez, State Fire Marshal SF044 10215 �z of f TEXAS DEPARTMENT OF INSURANCE j z State Fire Marshal's Office (112-FM) wp 333 Guadalupe, Austin, Texas 78701 * PO Box 149221, Austin, Texas 78714-9221 (512) 676-6800 1 F: (512) 490-1063 1 (800) 578-4677 1 TDI.texas.gov I @TXSFMO APPLICATION FOR CLASS B FIREWORKS (FIREWORKS 1.3G) SINGULAR OR MULTIPLE DISPLAY PERMIT This application must be accompanied by the appropriate fee and all documents and information required by Chapter 2154 of the Texas Occupations Code and the Fireworks Rules. Complete answers must be given to all questions. Please print or type. A public fireworks display permit may not be issued to any person who is under 21 years of age. Any fraudulent representation on this application shall be cause for denial, suspension, or revocation of a permit. All fees are non-refundable, except for overpayments resulting from mistakes of law or fact. II PERMIT 1 CHECK ONE TYPE OF PERMIT PERMIT FEE CODE I r l Singular Display Permit $50.00 570-07 I Multiple Display Permit $400.00 570-08 APPLICANT NAME OF APPLICANT Telephone No. 903-587-8000 Pyrotex, Inc. Fax No. 903-587-8001 ADDRESS CITY STATE ZIP E 4368 FM 1553 Leonard TX 75452 E-MAIL ADDRESS FOR NOTIFICATION PURPOSES (optional) WEB SITE ADDRESS (optional) www.pyrotex.com Applicant doing business as (Check One) uIndividual. YesIs Corporation the individual 21 years of age or older.? I I u Partnership. No � ❑ Other- describe: Is each partner 21 years of age or older? I I Federal employer's identification (FEI) number: 75-1979109 Ill DISPLAY INFORMATION Date of display February 11, 2022 Time 9:20 PM Alternate date of display None Time None Exact location description or address of display and/or alternate location for the display Fellowship Church - 2450 Hwy 121 - Grapevine, TX 76051 u Firing site is walking path on southeast side of lake Pyrotechnic operator licensed in Texas who will be at the display site to supervise the display: Name Jessica Amspoker License number FP0-1741590 Name License number Name License number Texas Department of Insurance I www.tdi.texas.gov 1/5 SF044 1 0215 I[ QUESTIONS Size and estimated number of 1.3G fireworks to be discharged: 20 GFX boxes s 2.5" diameter * 108 - 2.5" shells Other items (1.4G fireworks, flame effects, set pieces, etc.) 10 - 1.4G ciround effect boxes s 2.5" diameter Manner and address of storage of fireworks prior to and during the display Product is stored in Pyrotex magazines located at 4368 FM 1553, Leonard, TX 75452 Product is transported to site day of the event in a locked truck and loaded. No product is stored on site during display. Manufacturer or distributor licensed in Texas who is to supply the fireworks: Name PyrOtex, Inc. License number FWD-0052 SIGNATURES In applying for a fireworks permit, I certify that I am familiar with and will comply with Chapter 2154 of the Texas Occupations Code and the Fireworks Rules. I hereby authorize the state fire marshal or any of his duly authorized deputies, upon notice, to enter, examine, and inspect any premises, building, room, or establishment used in connection with the permit for which I am applying to determine compliance with the provisions of Chapter 2154 and the Fireworks Rules. By my signature, I verify that the information on this application and its attachments are true. I understand that knowingly providing a false. answer to any question or submitting false information or documents with this application may be tampering with a governmental record which is punishable under the Texas Penal Code Chapter 37, §37.10. Printed name Title Derek Willingham General Manager Signature Derek Digitally signed by Derek Date Willingham Datte:2022.01.20 January 18, 2022 Willingham 10:28:54-06'00' Printed name Title Signature Date APPLICATIONS MUST BE SIGNED BY AN INDIVIDUAL APPLICANT, BY AN OFFICER OF A CORPORATION, BY THE SOLE PROPRIETOR, BY EACH PARTNER OF A GENERAL PARTNERSHIP, BY THE GENERAL PARTNER OF A LIMITED LIABILITY PARTNERSHIP OR BY AN OFFICER OR MEMBER OF A LIMITED LIABILITY COMPANY. APPLICATIONS SUBMITTED BY A GOVERNMENTAL ENTITY MUST BE SIGNED BY THE APPROPRIATE OFFICER. FOR EXAMPLE, A CITY'S APPLICATION SHOULD BE SIGNED BY THE MAYOR, CITY MANAGER, CITY ADMINISTRATOR, CITY SECRETARY, ETC. Check or money order should be made payable to the TEXAS DEPARTMENT OF INSURANCE. Mail this completed application along with the appropriate fee and additional documents to: Mail Address: State Fire Marshal's Office Mail Code 9999 P. O. Box 149221 Austin, TX 78714-9221 (512)676-6808 Physical Address: State Fire Marshal's Office 333 Guadalupe Austin, TX 78701 Fax No. (512) 490-1056 Web Site Address: www.tdi.texas.gov/fire NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you. Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information. However, TDI may withhold information for reasons other than to prated your right to privacy. Under section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the Agency Counsel Section of TDI's General Counsel Division at (512) 676-6551 or visit the Corrections Procedure section of TDI's website at www.tdi.texas.gov Texas Department of Insurance I www.tdi.texas.gov 2J5 SF044 10215 Texas Department of Insurance State Fire Marshal's Office Application for Class B Fireworks (Fireworks 1.3G) Singular or Multiple Display Permit Site Inspection Certification 1. Name of applicant PyroteX, Inc. Address 4368 FM 1553 Telephone 903-587-8000 City Leonard State TX zip code 75452 2. Date of display February 11, 2022 Time 9:20 PM Alternate date of display None Time None 3. Location and/or alternate location for the display Fellowship Church - 2450 Hwy 121 - Grapevine, TX 76051 Firing site is walking path on southeast side of lake 4. As the fire prevention officer, I approve of the display site and have reviewed the site diagram. E� Yes B No 5. 1 approve of the location and manner for storage of display fireworks before and during the display. Yes ❑ No 6. 1 approve of the potential landing area for fireworks debris. [Yes ❑ No 7. The display is to be conducted in compliance with TX Occupations Code, Regulation of Fireworks & Fireworks Displays and the Fireworks Rules. Er Yes ❑ No 8. My approval is subject to the following conditions. List conditions, if applicable, or indicate "None" 40 A) 9. As the appropriate fire prevention officer, I have inspected the display site(s) to determine whether this proposed display is of a nature or in a location that may be hazardous to property or dangerous to any person. This form is my notice to the state fire marshal of the results of the inspection as required in Sec. 2154.206, r 215 , e Occupations Code. _t Signature of fire prevention officer Date ^'" -,2aa� Printed name of fire prevention officer �f �• �rt'Title 44sz<7►A1— Department ( —� �C #��i� Vr 1�%� Telephone No. Email address: P' IfMobile Phone No. Telephone No. (512) 676-6808 Fax No. (512) 490-1056 Web Site Address www.tdi.texas.gov/fire Texas Department of Insurance I www.tdi.texas.gov 4/5 DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 BIRMINGHAM, ALABAMA 35215 PHONE: (205) 854-5806 FAX: (205) 854-5899 CERTIFICATE OF INSURANCE POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35220 EMAIL: dib@draytonins.com NO. We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER NAMED INSURED POLICY TERM COVERAGE LIMIT OF LIABILITY INSURED OPERATIONS Admiral Insurance Company Pyrotex, Inc. 4368 FM 1553 Leonard, Texas 75452 POLICY NO. CA000018899-08 March 1, 2021 to March 1, 2022; Both Days 12:01 A.M. Standard Time Commercial General Liability: ® Occurrence Basis ❑ Claims Made Basis $5,000,000 each occurrence, $6,000,000 general aggregate, $6,000,000 products/completed operations aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. Public fireworks display and special effects contractor It is certified that, if named below, this policy includes as Additional Insureds 1) the sponsor(s), promoter(s), organizer(s) (including other entities having similar interests), of insured pyrotechnic events and/or 2) the owner(s) of real property (or barges) at which insured pyrotechnic events are held and/or 3) the owner(s), manager(s), tenant(s), mortgagee(s) (including other entities having similar interests), of buildings, stadiums, arenas and similar facilities at which insured pyrotechnic events are held and/or 4) the licensing or permitting authority, or other authority having jurisdiction, issuing licenses/permits for insured pyrotechnic events and/or 5) any other entity for which the insurance is required to be afforded under written contract. Coverage applies only as respects the legal liability of such Additional Insured(s) for bodily injury and property damage caused by the operations of the Named Insured. The insurance afforded any Additional Insured excludes liability for bodily injury or property damage arising from the Additional Insureds own negligent acts or omissions or from the failure of such Additional Insured to fulfill its obligations specified in its contract with the Named Insured. NAME(S) OF ADDITIONAL INSURED(S) City of Grapevine Fire Dept. — 601 Boyd Drive, Grapevine, TX 76051 Fellowship Church — 2450 Hwy 121 North, Grapevine, TX 76051 XO Marriage —115 Grand Avenue Ste 213. — Southlake, Texas 76092 DISPLAY LOCATION DISPLAY DATE(S) 2450 Hwy 121 North, Grapevine, TX 76051 February 11, 2022 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. January 18, 2022 DATE OF ISSUE DRAYTON INSURANCE BROKERS, INC. A .. 1t1NGER, PRESIDENT Lisa Cabrera From: Pace Product Support <ProductSupport@i3verticals.com> Sent: Thursday, January 20, 2022 10:44 AM To: fire payments Subject: Payment Receipt #16666683 Importance: High *** EXTERNAL EMAIL COMMUNICATION - PLEASE USE CAUTION BEFORE CLICKING LINKS AND/OR OPENING ATTACHMENTS *** City of Grapevine TX City of Grapevine TX (Fire Department) Fire Dept 1/20/2022 10:42:11 AM Auth Code: 06356G Transaction ID: 16666683 Reference ID: 85915671 Transaction Type: Credit Card Card Type: Visa Card Number: Name: Derek Willingham Amount: $90.00 Payment Reference 1: FDAH—XO Marriage Payment Reference 2: CID:fire, Derek Willingham 903-587-800 Payment Reference 3: 2450 Hwy 121 Payment Reference 4: 2/11/22 - Fireworks display Thank You! ----------------------------------------------------- Please print out this authorization and keep it with your bank records. 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