Fillable pplication for Renewal of a Permanent Retail Consumer (Pennsylvania)

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pplication for Renewal of a Permanent Retail Consumer (Pennsylvania)

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  • 12 check-boxes
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A
pplication for Renewal of a Permanent Retail Consumer Fireworks Facility
Check One: A Natural Person Corporation Partnership Other
Business Name
License #
Mailing Address
City
State
ZIP
Phone Number
FAX Number
E-Mail & Website
Physical Address
(if different from above) County:
City
State
Type of Operation Year-Round Seasonal Opening Date: Closing Date:
24/7 Contact Name
Phone Number
FAX Number
E-Mail Address
Please print the requested information for all individuals with any ownership interest (include
partnerships, associations, corporations, etc.). If more space is needed please attach a blank sheet.
Name
Title
Address
City
State
ZIP
Date of Birth
Maiden Name/Alias:
Has the above person ever been convicted of a felony? �Yes �No
Name
Title
Address
City
State
ZIP
Date of Birth
(only if new)
Maiden Name/Alias:
Has the above person ever been convicted of a felony? �Yes �No
Name
Title
Address
City
State
ZIP
Date of Birth
Maiden Name/Alias:
Has the above person ever been convicted of a felony? �Yes �No
2
A. Pennsylvania Department of Agriculture (“PDA”) Information
The Applicant or any person may contact PDA at the following address for any purpose related
to this application or any license issued pursuant to this application:
Pennsylvania Department of Agriculture Telephone: 717-787-9089
Bureau of Ride and Measurement Standards Fax: 717-783-4158
ATTN: Fireworks E-mail: RA-wghts&measures@pa.gov
2301 North Cameron Street
Harrisburg, PA 17110-9408
B. Applicant’s Acknowledgments.
The Applicant acknowledges the following:
1. The statutory authority for this license is Act 43 of 2017. The Applicant has been
provided a copy of that statute within this licensure packet.
2. The referenced statute may change after a license is issued. If this occurs, the revised
or new statute supersedes any contradictory or inconsistent provision or requirement set
forth in this application.
3. The Facility is in compliance with the act of November 10, 1999 (P.L.491, No.45), known
as the “Pennsylvania Construction Code Act.” Proof of that compliance (Certificate of
Occupancy or other appropriate document) is attached as “
Attachment 1.
” Failure to
resolve temporary occupancy issues will make the licensee unable to renew until
properly resolved.
4. The Facility shall remain in compliance with the Pennsylvania Construction Code Act at
all times when the license is in effect. If the Facility is not in compliance, the Applicant
will notify PDA within 24 hours of learning of that noncompliant condition, advise PDA of
the specific noncompliant condition and provide the timetable for rectifying this
noncompliant condition. Failure to resolve the noncompliant condition may result in
suspension, revocation or denial of the license.
5. The Facility is a stand-alone building dedicated exclusively the to the storage and sale of
consumer fireworks and related items.
6. When consumer fireworks are delivered to the Facility, they shall be unloaded in
compliance with all applicable Federal, State and Local standards.
7. Storage areas in the Facility are separated from wholesale or retail sales areas to which
a person may be admitted by appropriately rated fire separation.
8. The Facility is no closer than two hundred fifty (250) feet from any facility selling or
dispensing gasoline, propane or other such flammable products. This 250-foot distance
shall be measured by the shortest line from the exterior of the Facility building to any
gasoline, propane or flammable product storage tank or dispensing device at a facility
that sells or dispenses gasoline, propane or other such flammable products.
3
9. The Facility is located at least one thousand five hundred (1,500) feet from any other
Facility newly licensed to sell consumer fireworks. This includes other facilities owned or
operated by the Applicant. This 1,500-foot distance shall be measured by the shortest
line from exterior of the existing Facility building to the closest exterior point of the
Applicant’s building.
10. The Facility conducts quarterly fire drills.
11. The Applicant has contacted the primary fire department within which the Facility is
located, and has fully apprised that fire department of the nature of the business to be
conducted at the Facility. The Facility is in compliance with any preplanning meeting
requirements imposed by that fire department.
12. While the license is in effect, the Applicant shall, at a minimum, have security personnel
on the premises of the Facility for the seven (7) days preceding and including July 4 and
for the three (3) days preceding and including January 2.
13. No smoking is permitted in the Facility.
14. No cigarettes or tobacco products, matches, lighters, or any other flame-producing
devices are permitted to be taken into the Facility.
15. No minors are permitted in the Facility unless accompanied by an adult. If a minor is
admitted in the company of an adult, the minor is required to stay with the adult at all
times while in the Facility.
16. The Facility carries at least two million dollars ($2,000,000) in public and product liability
insurance. The insurance policy has been procured from an insurer or surety authorized
to do business within the Commonwealth of Pennsylvania. The Applicant is responsible
for assuring that the insuring company notifies PDA immediately upon cancellation or
change of this insurance coverage. A valid certificate of insurance is attached as
“
Attachment 2
,” naming PDA as an additional certificate holder for notification
purposes, and evidencing proof of required insurance coverage. If the Applicant has
more than one licensed facility and there is a single certificate of insurance covering
more than one facility, the certificate shall reflect that there is at least $2,000,000 in
coverage with respect to each facility. Insurance coverage must be maintained for the
duration of the license, failure to maintain coverage may be cause to suspend or revoke
the license. It is the responsibility of the licensee to ensure the Bureau receives a
current certificate of insurance from the insurance company before there is a lapse in
coverage.
17. The Applicant provides its employees with documented training in the area of
operational safety of the Facility. A PDA-issued form describing this training is attached
as “
Attachment 3.
” The Applicant has completed this form and it is attached.
18. The Facility has a monitored burglar and fire alarm system. Proof of monitoring is
attached as “Attachment 4.”
19. No display fireworks are stored or located at the Facility (1.3 G).
4
20. No person who appears to be under the influence of intoxicating liquor or drugs is
admitted to the Facility. No liquor, beer, or wine are permitted in the Facility.
21. No consumer fireworks or display fireworks shall be ignited within three hundred (300)
feet of the Facility.
22. Emergency evacuation plans are conspicuously posted in appropriate locations within
the Facility.
23. PDA may, as part of its consideration of this application, or in its role as licensor, request
such additional information, access and records as are reasonably necessary to
determining whether the Applicant or licensee is in compliance with the statute and the
conditions of licensure. The Applicant will cooperate with PDA in this regard.
24. The Applicant agrees that, if a license is issued, the Applicant shall apprise PDA of any
procedures, conditions or events that violate any of the acknowledgments made in this
application.
25. If the Applicant is an individual, he/she has never been convicted of a felony criminal
offense. If more than one person has an equitable ownership interest in the Applicant
business, none of these persons has ever been convicted of a felony criminal offense.
26. If the Applicant has been issued a license relating to consumer fireworks by another
jurisdiction, that issuer is listed as follows:
If any such license has been suspended or revoked by the issuing jurisdiction, an
explanation of the suspension or revocation follows:
C. License Fee and Attachments.
A
certified check, money order or cashier’s check
, made payable to the “Commonwealth of
Pennsylvania” the annual licensing fee (see below) bearing the Applicant’s name, is enclosed
with this application.
Annual Licensing Fee Schedule:
• Up to 10,000 square feet - $7,500
• Greater than 10,000 and up to 15,000 square feet - $10,000
• Greater than 15,000 square feet - $20,000
(Square feet is determined by measuring the exterior walls of the facility)
In addition, the following documents are attached and incorporated herein by reference:
1.
Attachment 1
: An occupancy permit or similar proof that the building in which the
Facility is located is compliant with the Pennsylvania Construction Code Act. If one is not
already on file or a change has occurred during the licensing period.
2.
Attachment 2
: Proof of current and appropriate insurance coverage (pending receipt
direct to the Bureau from insurance provider).
3.
Attachment 3
: A complete “Employee Training Record” form.
5
4.
Attachment 4
: Proof of monitored burglar and fire alarm system.
Additional attachments, such as Corporate Resolutions or Partnership Agreements, may be
required as part of the signature process, below.
D. Signature.
The signature of the Applicant below is legally sufficient to bind the Applicant. There are no
misrepresentations or false statements in this document. All representations in this application
are made subject to the criminal penalties for unsworn falsification to authorities (Pennsylvania
Crimes Code, 18 Pa. C.S.A. § 4904).
Select Appropriate Signature Section (based upon type of Applicant):
If the Applicant is an Individual Person:
Signature of Applicant:
Printed Name of Applicant:
Date of Signature:
If the Applicant is a Corporation and the
Corporate Officers
are signing:
Complete Name of Corporation:
Signature of President or VP
(indicate which):
Printed Name of Signer:
Date of Signature:
Signature of Secretary or Treasurer
(indicate which):
Printed Name of Signer
If the Applicant is a Corporation and the
Authorized Representative
is signing:
Complete Name of Corporation:
Signature of Authorized
Corporate Representative:
Printed Name of Signer:
Date of Signature:
ATTACH A COPY OF A CORPORATE RESOLUTION GRANTING THE SIGNER AUTHORITY TO
BIND THE CORPORATION.
6
If the Applicant is a Partnership,
all Partners
must sign:
Name of Partnership:
Signature of Partner:
Printed Name of Partner:
Date of Signature:
Signature of Partner:
Printed Name of Partner:
Date of Signature:
Signature of Partner:
Printed Name of Partner:
Date of Signature:
Signature of Partner:
Printed Name of Partner:
Date of Signature:
Signature of Partner:
Printed Name of Partner:
Date of Signature:
Signature of Partner:
Printed Name of Partner:
Date of Signature:
ATTACH A COPY OF THE PARTNERSHIP AGREEMENT AND ALL DOCUMENTATION
DEMONSTRATING IDENTITY OF PARTNERS.
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pplication for Renewal of a Permanent Retail Consumer (Pennsylvania)

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Completed 22 December 2020

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