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HomeMy WebLinkAboutFIR2024-00015 Fireworks Stand - FIR Inspections - 4/25/2024 � y1NGTOp BT'TE Washington State Patrol Fire Protection Bureau C24180 Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES CFRS FACILITY LICENSE It "HAvs p'��, Stand Number: SN-15923 Licensee Data Operational Data Jeff Boatwright Wholesaler: [MULTIPLE SUPPLIERS] Post Office Box 97 County of Operation: Mason Alsea, OR 97324 Operated For: Licensee License Number: WSPFL-00929 Stand Operated By: Deanna Yoba Phone Number: (541) 981-3123 Date of Issue-April 25, 2024 Date of Expiration.-January 31, 2025 Consumer Fireworks Retailer Licenses issued after May are ONLY valid for New Years Sales This license is NOT valid without a permit from a local fire code officialiauthority having jurisdiction This license allows for operation of a single location/stand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. 30D0-420-041(10118) SURRENDER THIS PORTION OF THE LICENSE TO THE FIREWORKS WHOLESALER y_,uxGTG"s,4, Washington State Patrol Fire Protection Bureau C24180 V''' Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE '+Ey,R,MAy OtF``� Stand Number-, SN-15923 Licensee Data Operational Data Jeff Boatwright Wholesaler: [MULTIPLE SUPPLIERS] Post Office Box 97 County of Operation:Mason Alsea, OR 97324 Operated For:Licensee License Number: WSPFL-00929 Stand Operated By: Deanna Yoba Phone Number,(541) 981-3123 Date of Issue:April 25, 2024 Date of Expiration-January 31, 2025 Consumer Fireworks Retailer Licenses issued after May are ONLY valid for New Years Sales This license is NOT valid without a permit from a local fire code official/authority having jurisdiction. This license allows for operation of a single location/stand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. THIS LICENSE PORTION ACCOMPANIES YOUR LOCAL PERMIT APPLICATION 3000-420-041(1 Oil 8) r0H1NGT0HST'T� Washington State Patrol Fire Protection Bureau C24180 Office of the State Fire Marshal j CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE Stand Number: SN-15923 Licensee Data Operational Data Jeff Boatwright Wholesaler: [MULTIPLE SUPPLIERS] Post Office Box 97 County of Operation: Mason Alsea, OR 97324 Operated For: Licensee License Number: WSPFL-00929 Stand Operated By: Deanna Yoba Phone Number: (541) 981-3123 Date of Issue:April 25, 2024 Date of Expiration:January 31, 2025 Consumer Fireworks Retailer Licenses issued after May are ONLY valid for New Years Sales This license is NOT valid without a permit from a local fire code official/authority having jurisdiction. This license allows for operation of a single locationrstand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. 3000-420-041(10118) THIS PORTION OF THE LICENSE MUST BE POSTED AT THE STAND AT ALL TIMES THIS FORM IS INTENDED FOR USE BY LOCAL AUTHORITIES HAVING JURISDICTION(AHJ)IN THE EVENT THEY DO NOT HAVE A PERMIT FORM SPECIFIC FOR RETAIL FIREWORKS SALES ATA CONSUMER FIREWORKS RETAIL SALES(CFRS)FACILITY. IT IS NOT MEANT TO BE REQUIRED IN ADDITION TO OR IN LIEU OF ANY LOCAL PERMITTING FORM AND/OR PROCESS THAT MAY EXIST WITH THE LOCAL AHJ. Directions: Provided the local jurisdiction has no permit form of their own,complete this permit application and submit it with the local AID portion of pour Retail Fireworks Stand License to the jurisdiction in which you wish to run)our CI`RS facility. WASHINGTON STATE FIREWORKS RETAIL SALES PERMIT APPLICATION Applicant Information ❑ New/First Time Applicant Previous Permit Holder 9-k A I-Wgt � l% 2EIrF /i 21Z77zl ro Name of Group,Organi tion,or Oerson(Last,First,Middle Initial,and Date of Birth)Issued the Fireworks Retailer License BOI}7W2 I(�II F. `,Ff )4 3/ L"7 � � (., Name of Permit Applicant(oast,First,Middle Initial,and Date of Birth) PO Box `17 A-USEA 02 'i:7 3"2-q _ Permit Applicant Mailing Address(Complete Including Street,City,State,and ZIP Code) (5`( -) 981- 31 Z3 ,f SLv1A1t, ( n,-►-1 Phone Number E-Mail Address Local Business Number(if required) CFRS Facility Information ❑ Stand Tent Other: Size: 3&)' $p 2 b S D syT Specify Square FeeVDimensions 2351 s� 3 13�L ¢At,c , IAlh I�;6 Z16 CFRS Facility Address(Complete Including Street,City,State,and ZIP Co e) EN'TER AftS-S LL 75: 42ZX!5- — `J' 2-9 -( 3 00 f CrI3 Name of Property Owner Phone Number Parcel Number for Stand Location Fireworks Supplier Information List all of the licensed fireworks wholesalers who will be supplying this stand product IeEo i2Af38i-( Fi2 ,wc�,2�S Storage Information On Site ❑ Off Site: Storage Address(Complete Including Street,City,State,and ZIP Code) ❑ Sales Structure ❑ Detached Building ❑ TruckfTrailer ❑ Other. Specify CHECKLIST FOR SUBMISSION Check with the local AHJ for all applicable submission dates and deadlines: Application/Permit Fee LA Insurance Certificate($1,000,000) ❑ Clean-Up Bond Fee(if applicable) Valid Washington State Fireworks Retailer License ® Property Owners Written Permission Detailed Site Plan ® Interior Plan (required for tents and "other" facilities) I hereby certify the information in this application is true and correct. I am aware of and agree to comply with all relevant provisions of law, rule, and any ordinance of the state of Washington and the city/county permitting this CFRS Facility / / � r� >� Fr- C�e.4 i w21 u 1�+ _ Z Signatu a of Perm t p licant Printed Name of Permit App ant ��alqte! f Sig ah lure FIRE CODE AUTHORITY HAVING JURISDICTION ❑APPROVED ❑ DENIED Permit Number Approved By Date of Approval SEE BACK OF THIS FORM FOR ANY RESTRICTIONS, CONDITIONS, OR NOTATIONS ON THIS PERMIT Signature of Permitting Official Printed Name and Title Date of Signature THE FIREWORKS RETAILER LICENSE HOLDER(LICENSEE)SHALL RETAIN THIS PERMIT WITH THE ASSOCIATED FIREWORKS RETAILER LICENSE AND MAKE THEM BOTH AVAILABLE FOR INSPECTION AT ANY TIME THE STAND IS IN OPERATION 3000420-013(R 11/16) AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 6/3/2024 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: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Acrisure, LLC dba Britton Gallagher&Associates PHONE FAx 3737 Park East Dr. STE 204 A N •216-658-7100 A/c No:216-658-7101 E-MAIL Beachwood OH 44122 ADDRESS, INSURERS AFFORDING COVERAGE NAIC II INSURER A:Arch Speciality Ins Co 21199 INSURED 2587 INSURER B:Lexington Ins Co 19437 Jake's Fireworks Inc. 1500 E 27th Terr. INSURER C: Pittsburg KS 66762 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1652679032 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 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. INSR TYPE OF INSURANCE ADDL SUBR POLPOLICY NUMBER MMIDIDY EFF POLICY EXP MM DDIYYYY LIMITS LTR B GENERAL LIABILITY 052115105 2/15/2024 2/15/2025 EACH OCCURRENCE $1.000,000 4—clo DAMAGE TORENTED MMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $sm,000 CLAIMS-MADE �OCCUR MED EXP(Any one person $ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident A UMBRELLA LIAB X OCCUR UXPI037038-04 2/15/2024 2/15/2025 EACH OCCURRENCE $1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION $ —TTOWORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement. Sales Location:23541 Hwy 3,Belfair,WA 98528; La caner: MJ Scott Enterprise ,4elfair,WA 9852- N Itty,NoPth Mason r r5"d their agents,615 W Alder Shelter,WA 98584; Term:February 15,2024 through February 14,2025; The Certificate Holder and the above listed are Additional Insureds with respects to General Liability policy as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Jeff Boatwright P.O. Box 97 AUTHORIZED REPRESENTATIVE Alsea OR 97324 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �y .n I ,5 + c � e w.. 4 a. �. <x J� � `U t, I ,P �. 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