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Public Display Fireworks Operator Guidelines <br />June 2011 Page 6 <br />Application Form <br />The sponsor must, at a minimum, provide the following information to the city clerk (county auditor) in <br />writing when applying for a permit to conduct a fireworks display: <br /> <br />1. The name of the organization sponsoring the fireworks display, including the name, address and <br />phone number of the authorized agent of that organization. Permits are not transferable. <br /> <br />2. The name of the certified public display fireworks operator, and the operator’s certificate number <br />issued by the Minnesota State Fire Marshal, responsible for supervising the display. <br /> <br />3. The date, time of day and exact location of the proposed display. <br /> <br />4. Outdoor Displays: A diagram of the grounds where the display will be conducted. At the minimum, <br />the diagram must show the point at which the fireworks are to be discharged; the location of all <br />buildings, highways, streets, communication lines and other possible overhead obstructions; and the <br />lines behind which the audience will be restrained. <br /> <br /> Indoor / Proximate Audience Displays: A diagram of the facility where the display will be <br />conducted. At the minimum, the diagram must show the point at which the fireworks will be <br />discharged and the fallout radius for each pyrotechnic device used during the display. <br /> <br />5. The approximate number and types of fireworks and / or pyrotechnic special effect devices to be <br />discharged. <br /> <br /> Changes in the Display: For indoor and proximate audience displays, any changes adding fireworks <br />or pyrotechnic special effects different from those described in the initial application must be <br />approved in advance by the authority issuing the permit. Unless otherwise acceptable to the authority <br />issuing the permit, all requests for changes must be submitted at least 24 hours prior to the display. <br /> <br />6. The name(s) and birth date(s) of all assistants who will assist with the display. Assistants must be at <br />least 18 years of age. The names of all assistants must be recorded on the Fireworks Operator <br />Display Report which must be filed with the Minnesota State Fire Marshal Division following the <br />display. <br /> <br />7. Proof of bond or certificate of insurance in an amount deemed appropriate by the city or county for <br />the payment of damages that could be caused, either to persons or property, as a result of the display <br />and arising from acts of the sponsor, the pyrotechnic operator, their agents, employees or <br />subcontractors. It is recommended that the city or county be named as a co-insured on any certificate <br />of insurance. <br /> <br />8. A site safety plan which, at the minimum, must include procedures and actions to be taken in the <br />event a shell fails to ignite in, or discharge from a mortar, fails to function over the fallout area, or <br />otherwise malfunctions. <br /> <br />Permit and Inspection Fees <br /> <br />Outdoor Displays: The permit cannot be granted until the sponsor pays the permit fee, if any, <br />established by the city or county. <br />