HomeMy WebLinkAboutFIR2019-00035 Final Fireworks Stand - FIR Application - 4/16/2019 MASON COUNTY (360)427-9670 Shelton ext.352
DEPARTMENT OF COMMUNITY DEVELOPMENT (360) 275-4467 Belfair ext. 352
BUILDING• PLANNING• FIRE MARSHAL (360)482-5269 Elma ext.352
Mason County Bldg. III, 426 West Cedar Street
4x51 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us
FIR20 - ,
Mason County Fireworks Permit Application
Incomplete applications will not be accepted
A permit for retail sales or public display of fireworks is required. A completed
application with required documentation and fees shall be submitted for Fire Marshal
review. A permit will be issued upon satisfactory site inspection by the Fire Marshal.
Applicant Information:
Owner: Johnathan Miller
Mailing Address: 15156 NW Hite Center Rd City: Seabeck State: WA Zip: 98380
Phone #: 360.620.1732 Email: millerj736hotmail.com
Sponsor Information:
Name: Boomtown Productions, LLC
Address: 15156 NW Hite Center Rd City: Seabeck State:WA Zip: 98380
Phone #: 360.620.1732 Email: millerj73@hotmail.com
Washington State Fireworks License Information (Copy Required):
License Number:_WSPFL-02027 Date of Issuance April 16, 2019
❑ Pyrotechnic Operator License a Fireworks Stand License
Bond or Certificate of Insurance (Copy of Certificate/Bond Required):
Provider: David Connolly Connolly Insurance
Insured: Boomtown Productions, Mason County, Joe Solis
Certified Holder: Boomtown Productions LLC
Location of Stand/Display:
Site Address: 22950 State Hwy 3, Belfair
Directions to Site: Corner of NE State Route 3, Belfair NE, Roessel Rd, next to Belfair Elementary
Parcel Number: (twelve digit number) 123325 - 25 - 000044
Legal Property Owner Joe Solis, EFM Properties
"Please see reverse side to complete your application"
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The following pertinent information MUST be provided on the site diagram below
Location and Setback distances from the back, sides and front of retail sales stands or
designated display areas to:
Fire Hydrants Property Lines Mortar separation distance
Combustibles Parking Designated landing area
Fire Lanes Public Roads and Right of Ways
Trees/Brush Private Roads and Right of Ways
Utilities Landmarks
See attached Site map
Applicants Affidavit
I certify that the information provided herein is accurate and that compliance with all
County, State and Federal laws pertaining to the sales or discharge of fireworks shall be
maintained.
Signed Qe'6 iC WdiZ4, Date 12/8/2019
3
:::_ FIREWORKS STAND SITE PLAN
SITE DIAGRAM
DATE UPDATED: 12/8/2019 LOCATION NAME: Belfair Stand
PARCEL NUMBER: 123325000044 ORDINANCE OF: Boomtown Productions
SITE ADDRESS: 22950 NE State Route 3 STRUCTURE TYPE: Wood
CITY&STATE: Belfair,WA STUCTURE SIZE: 32 x 8
CROSS STREETS: State Route 3 & NE Roessal Rd STRUCTURE FACES: West
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A� � CERTIFICATE OF LIABILITY INSURANCE �� '�'
03C25t2019
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 ALTER THE COVERAGE AFFORDED BY THE 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. It the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to
the to rTit'Arrd Condkkne of t4 V pfQttiC'y',CW t#)tr POMd*s may toquke art endarSBtneW. A st&Varent oit tttr'8 C*Wft&e does trot c ttrMr ttWds to ttt@
certificate holder In lieu of such endorsements).
PRODUCERPHONE X
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David Connolly Insurance Agency Inc 1AIC A IC,
No):
9393 Sayshore Drive NW ADDRESS:
INSURER[SI AFFORDING COVERAGE NAIL sr
Silverdale WA 98383 INSURERA: National Fire&Marine Insurance Co. 72 20079
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INSURED INSURER B:
Halo Fireworks,LLC INSURER C
15156 NW Hltecenter Rd INSURERD:
M3URER E:
Seebeck WA 98380 IMURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS°ISTO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIREMENT,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.
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LTR TYPE OF INSURANCE POLICY NUMBER MMIC? dY tYYA NMI I LIMITS
X COMMERCIAL GENERAL LIABILITY EAC'Ii OCCL1RRE11, 1,0011,000
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'MEP EXP MV',Y On-)utmsof). „ 6,Ot?s?
A Y 72LPS'033771 041010019 04N1l2020 r•ERSONAL&ADV INJJRY 1.000,000
G N'LAGGPEC-ATE LIMIT APPLIESPER: ENERAL.AGGREGASE 2,000,000
X POLICY® OT I_oc $ 2,000,000
fYIHER $
AUTOMOBILE LIABILffY
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BODILY INJJiR Y(Perpefson)
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ALL OWNED SCHELYY1z.f=:CJ BODILY INJJnY(Per ocdd t) .
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UMBRELLA LIAS OCCUR EACH O CCUP.RENC.E S
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WORXCRSCOMPENSATION
AND EMPLOYERS'LIABILITY Y tN c J
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DESCRIPTION OF OPERATION81 LOCATIONS I VEHICLES IACORD 101,Addfflonal Remark*SaMdulo,may he attached If more space Is required)
Boorntown Production LLC,Mason County and Joe Solis are listed as Additional Insured per form M5350a(05109)Tor the fireworks stand at 22950 State Hwy.
3,Belfair,WA 98528.
CERTIFICATE LDER CANCELLAT12N
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Boomtown Production LLC ACCORDANCE WITH THE POLICY PROVISIONS,
1515E NW Hite Center Rd. AUTHORIZED REPRESENTATIVE
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Seabeds WA 98380
tB 1988-2014 ACORD CORPORATION, All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
TO: Governing body of city, town, or county in which DATE OF
fireworks stand will be located. APPLICATION: 12/8/2019
Applicant Name: Address, City, State:
Johnathan Miller 15156 NW Hite Center Rd, Seabeck, WA 98380
Sponsor(If other than applicant): Address, City, State:
Location of proposed fireworks stand: [Enclose drawing of stand location]
22950 NE State Route 3, Belfair, WA
Manner and place of storage prior, during, and after sales dates:
ATF and L & I approved storage. Fireworks to
be delivered on site
State Licensed Fireworks Supplier:
Jakes Fireworks & NW Pyro
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FIREWOI�:KS STAND PERMIT
For The Fireworks Sales Year Of:
(Must be conspicuously displayed at all times while the stand is open to the public)
By virtue of having been granted a license by the State of Washington and this permit from
as the local governing authority, the named person, firm or
organization is hereby authorized to sell U.N. 0336 I AG Consumer fireworks at the location designated
herein between the following date and times:
Sales For July 41h Sales For December 31s'
From: From:
To: To:
Sponsor:
Location:
/s/ /s/
Signature of Official Granting Permit Signature of Applicant
Title: Agency:
Date: Permit Number:
Licensee Name: License Number:
FIREWORKS LICENSE AGREEMENT
This agreement is made between Joe Solis,as licensor and Boomtown Productions, LLC
as licensee for the said purpose of allowing retail sales of Consumer Fireworks from the
following location:
22950 NE STATE ROUTE 3 BELFAIR
Parcel tax ID#123325000044
The licensor represents that it owns,or controls the use of the lot as listed above and
agrees to grant licensee the right to operate a retail firework stand on the premises for the
period of Dee 19,2019 through Jan 5,2019 for a license fee of IMISM due no later
than Jan. 5`h,2019.
The licensee shall pay all cost involved in the erection,operation and maintenance of the
stand,and shall guarantee that the premises shall be returned to the original condition
after removal of the stand.
The licensee will provide liability insurance coverage and provide to the licensor,before
occupancy. The insurance shall name the licensor as an additional insured,and licensee
will hold the licensor harmless from any claims arising from the maintenance or
operation of the structure.
The licensee shall pay for and obtain licenses and permits required by law and post any
performance bonds which might be required. The licensee shall guarantee that the stand
is operated in a business like manner and adhere to all local state regulations.
If the property is sold,ingress/egress changed,or location impacted due to construction
or the like,then this license is subject to revocation and refund of any payments made.
LICENSOR• LICENSEE:
y,y2� r �11A 11/18/2019
Joe Solis-Owner Boomtown Productions,LLC
Phone: 360.440-4873 Phone: 360.620.1732