No preview available
 /
     
3035 Denmark Ave - Firework Permits & PaperworkCity of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675-5675 www.ci.eagan.nm.us PERMIT Permit Type: Fireworks 4110, Permit Number: EA099597 Date Issued: 06/16/2011 Cityof Eaaan Site Address: 3035 Denmark Ave Lot: 3 Block: 1 Addition: Eagandale Center Industrial Pk 9th PID: 10-22508-01-030 Use: Sam's Club Description: Sub Type: Indoor Retail Sales Sign Permit Required: N Work Type: Legal Consumer Fireworks Tent Permit Required: N Description: Temporary Event: N Sales Dates: 06/16/2011 to 11/01/2011 Number of Days: 0 to to Comments: Fee Summary: Indoor Sales Surcharge -Fixed $100.00 $5.00 0801.4097 9001.2195 Total: $105.00 Contractor: Owner: - Applicant - Wal-Mart Prop Tax De Sams Real Est Bus Trust PO Box 8050 MS 0555 Bentonville AR 72712--805 I hereby acknowledge that I have read this application and state that the 'nformation is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. 411,11 CityofEaQau 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Use BLUE or BLACK Ink 995y 2011 FIREWORKS SALES AND STORAGE APPLICATION Applicant requirements 1. An application must be completed and returned at least 30 days prior to outdoor sales and/or storage of fireworks. 2. An applications for indoor sales of fireworks must be submitted between April 1st and June 1st to obtain a permit. 2. A letter from the property owner granting permission to the applicant to sell and/or store fireworks on the property shall accompany the application. 3. A floor plan designating the area where the fireworks will be sold and/or stored shall accompany the application. 4. A list of the fireworks that will be sold and/or stored along with the name, weight, quantity, and material safety data sheets (MSDS) shall be included. 5. A copy of the certificate of insurance coverage as per City of Eagan City Ordinance No. 387, Chapter 6, Section 6.53 Fireworks is required. 6 The Fire Marshal or his/her designee will inspect the proposed location for selling and/or storing fireworks to determine if it is a suitable location. 7 A criminal record check will be done on all applicants. 8. A copy of the City of Eagan license (permit) shall be displayed by the register. Date: 1-1 /\.$1 Business Name: Sam's Club #4738 Telephone#: ( 651 ) 405-0079 Display Address: 3035 Denmark Avenue Applicant Name: Street Address: Sams Club #4738 / State: ✓ v t l Zip: 55- Telephone #: City: Eti (GSM DC -00-7? Retail seller selling exclusively consum fir works: Yes _ No Phe x Indoor Sales Dates: 1 to 07/07/2011 and New Years Season Outdoor Sales Dates: to to Please check the selections that apply to this permit to Outdoor Sales $415.00 X All other retail sellers $105.00 (includes: $280.00 Fireworks Permit; $128.50 Tent Permit; $6.50 State Surcharge) (1/UD . ° PF2a T i SS. oa s'n}7& SuecHRP E) Sign Permit $ 25.00 Temporary outdoor event means an exhibition or sale with a duration of 10 or Tess continuous days which does not occur more than once every 30 days and more than three times per year or a combination of 20 days total in a calendar year. (See Outdoor Sales of Fireworks). Fireworks are regulated by MN Statutes 624.20-624.25. In addition to these state Taws, all displays, sales, storage and use of fireworks shall comply with City of Eagan Ordinance No. 387, Section 6.53 Fireworks and NFPA 1124 Standards. I understand and agree to comply with all the provisions of this application al • the requirements of the moi cif ��� s-goir c-nt Signure ng authorit A ss -e+ Pr vi-ec-+ v\ M s -KtCCiw►, L(- ousts 45 .O° P 1- + i,l CoQ ,��,�,n, b5.?.th-ll (-J210 LCAfekalVeith j40)-6- $5; tt, 610 6)/14' . Cfla ti -M4411 (ma SS*60 gI4 o (ti,./ Indoor Fireworks Sales — 2011 Applicant: BRA/kJ fs y N R D E S 1 N le, Phone: (651- 40 5 - 6019 Sales Location Name & Address: SAM'S CLUB - ?v-C3S 13 EA) UE_ Location within store: X Clear background check from PD "No sales to under 18" form posted 2 ea 2-1/2 gallon pressurized fire extinguishers Two exits to the outside when required 48" minimum width display aisles 6' maximum height display of product Fireworks fuses covered or arranged out of touch X. Posted list of consumer fireworks (MSDS, name, weight & quantity of fireworks) C o chut, X Certificate of Insurance provided (minimum of $1M per claim per incident; City named as add'l insured; gen liability, property damage, bodily injury) ktin4Auttattut 11/024,101 ( Application Approved: Date: Inspection Approved: Date: ZONING: Property is zoned: PSD (Allowed in: GB (retail sales), NB, CSC, PD retail sales). No sales on R or mixed with R. SALES ONLY ON PREMISES: Retail sale of consumer fireworks shall occur only on the premises for which the permit is issued. SMOKING WITHIN 50' OF BUILDING: Smoking within 50 feet of the retail consumer fireworks sale and storage areas is prohibited. USE OF FIREWORKS WITHIN 100' OF BUILDING: No consumer fireworks shall be discharged, exploded or used within 100 feet of the building in which the consumer fireworks are being sold or stored. FIRE EXTINGUISHERS: The building in which the consumer fireworks are sold shall have at least two, 2- 1/2 gallon pressurized fire extinguishers in the area where the consumer fireworks are sold or stored in accordance with the 2000 International Fire Code. EXITS, AISLE WIDTH, PRODUCT HEIGHT: The building in which the consumer fireworks are being sold or stored shall have at least two exits to the outside and all consumer fireworks display aisles shall be a minimum width of 48 inches. The height of the consumer fireworks display shall not exceed six feet. COVERED FUSES AND PACKAGING: All consumer fireworks fuses shall be covered or arranged so fuses cannot be touched directly by a person handling the consumer fireworks without that person puncturing or tearing the package. SPRINKLER SYSTEMS & PYROTECHNIC COMPOSITION: In buildings in which consumer fireworks are sold or stored, and do not have an approved automatic sprinkler system, consumer fireworks sales, displays or storage shall be limited to 50 pounds net pyrotechnic composition or 200 pounds gross weight, if the pyrotechnic composition weight is unknown. In buildings with an approved automatic sprinkler system, fireworks sales, displays and storage shall be limited to 100 pounds net pyrotechnic composition or 400 pounds gross weight, if the pyrotechnic composition weight is not known. LIST OF SALES PRODUCT & MSDS: A list of all consumer fireworks displayed for sale or stored on the permitted property shall be posted in a conspicuous location near the display and storage areas. The list shall contain the name, weight and quantity of the consumer fireworks and shall be accompanied by the material safety data sheets. Upon request, samples of the consumer fireworks shall be made available to the fire chief or his/her designee for testing. NOT TRANSFERABLE: A permit granted under this subdivision shall not be transferable. BUILDING AND FIRE CODE REQUIREMENTS: The building in which retail sale consumer fireworks are permitted hereunder shall meet all applicable provisions of the State Building Code and Fire Code. EMPLOYEE ACTIONS: The permit holder shall be responsible for the actions of its employees or agents with regard to the sale of consumer fireworks on the licensed premises and for purposes of this provision, the sale of consumer fireworks by an employee or agent will be considered a sale by the permit holder. INSURANCE COVERAGE: The permit holder shall maintain at all times during the duration of the permit and as a condition thereof, general liability, bodily injury and property damage insurance approved by the city in a minimum amount of $1,000,000.00 per claim and for each incident. The city shall be named as an additional insured and the permit holder shall provide to the city clerk a current certificate of insurance. The permit holder shall notify the city clerk at least 30 days in advance of any insurance cancellation or threat of cancellation of insurance. EFFECTIVE PERMIT DATES: The permit shall be effective for a period of 12 months, expiring March 31st of each year. SUSPENSION OR REVOCATION OF PERMIT: Suspension or Revocation of Consumer Fireworks Permit. The city fire marshal shall have the authority to immediately suspend or revoke any consumer fireworks permit for any violation of this Section, or any other provision of the City Code or state statutes. The permit holder has a right to appeal the suspension or revocation of the permit upon filing a request for hearing with the city clerk. The hearing shall be held before the city council at its next regular meeting after the filing of the request for hearing, but in no case less than five days from the date of the request. The suspension or revocation of the permit by the city fire marshal shall remain in effect pending the hearing, if any, before the city council. The Police Department has conducted a criminal background check on the aforementioned applicant. Comments: Police Department Representative Date Conditions of Issuance: Background check completed and approved by EPD: X Yes No Zoning approval Yes No Facility inspection complete and all violations corrected -- Yes No Insurance policy approved _X_ Yes No Need Site plan, _': : - z . . ... _ X Yes No Building Permit Application for Tent Yes _X__ No License approved by Date approved: Fireworks Application Page 4 of 9 A �® CCC........ CERTIFICATE OF LIABILITY INSURANCE DATE /21 /2011 Y) 03/21/2011 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 MCGRIFF, SEIBELS & WILLIAMS, INC. P.O. Box 10265 Birmingham, AL 35202 CONTACT NAME: mic.14o. Extl: NE 800476-2211 (AJ , No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Liberty Surplus Insurance Corporation 10725 INSURED American Promotional Events, Inc. dba TNT FireworksINSURER P.O. Box 1318 Florence, AL 35631 INSURER B :Ironshore Specialty Insurance Company 25445 C :Lexington Insurance Company 19437 INSURER D : $ 1,000,000 INSURER E : $ 100,000 INSURER F : COVERAGES CERTIFICATE NUMBER:6MVBHLK7 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 LTRINSR TYPE OF INSURANCE ADDLISUBR WVD POLICY NUMBER POLICY EFF (MMIDDM(YY) POLICY EXP (MMIDDIYYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY DGLB00810581 11/01/2010 11/01/2011 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ EXCLUDED PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIESPL,IEPER: 7 POLICY n JECT I ^ I LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE — LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _AUTOS SCHEDULED AUTOS NON -OWNED COMBINED SINGLE LIMIT (Ea accident) i $ BODILY INJURY (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 000788300 11/01/2010 11/01/2011 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED RETENTION $10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY.r / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ C EXCESS UMBRELLA POLICY Per Occurrence 013136604 11/01/2010 11/01/2011 XS of Primary $5,Mil $ 5,000,000 $ $ $ $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) This certificate only applies to INSIDE THE STORE OF MINNESOTA APPROVED FIREWORKS SALES @ SAM'S CLUB 4738, 3035 DENMARK AVENUE, EAGAN, MN, 55121. The Certificate Holders are named as Additional Insureds with respect to General Liability as required by written contract subject to policy terms, conditions, and exclusions. CERTIFICATE HOLDER CANCELLATION CITY OF EAGAN 3830 PILOT KNOB ROAD EAGAN, MN 55122 USA ACORD 25 (2010/05) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Page 1 of 1 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ""S3-01180411 - REPRINT - PACK LIST - REPRINT - Order #: 1180411-S3-00002 Order Date: 3/31/11 CUST PO: NEED PO SLSMN: Chain Stores - East 21369 Chain Store Sales -Wisconsin Terms: Net 30 Days Sold To: 1410002 WALMART - CORPORATE 00001 702 SW 8TH STREET BENTONVILLE, AR 72716 Desc/Case Packing Item CP # Ship To: 1027002 - SAM4738 SAM'S CLUB 4738 3035 DENMARK AVENUE EAGAN, MN 55121 Quantity Ordered Selling Suggested Units Sell Price *************************** PPK MEGA BLAST SS CLUB J10 60/1 PPK - PYRO TIME SS -CLUB J09 76/1 PPK - SHOW STOPPER SS -ALL CLU 14/1 PPK - TNT POWER #2 SS -COM -CLU 16/1 PPK - TUB 0 FUN SPIN CLUB J09 144/1 PPK MAXIMUM POWER SS 500G J10 10/1 PPK-SPIRIT OF AMERICA SSCOMJ1 24/1 *************************** PPK - TNT 6 PACK J07 72/1 PPK ALL AMERICAN 2 PK CLUB J1 40/1 *************************** Assortments 102021P 621967749 101888Q 621968659 101946P 621967959 101751S 621968099 101893P 621968309 102083P 624416699 102133P Base Fountains 200745P 621968239 200851P 624418669 Novelties PPK - TNT SNAPS CELLO J09 CLU 320534P 144/1 621986929 Case Totals: Total Pallets: Total Repack Cases: DECLARATION OF COMPLIANCE 5 CS 1 CS 3 CS 4 CS 1 CS 1 CS 5 CS *********************** 300 EA 76 EA 42 EA 64 EA 144 EA 10 EA 120 EA 29.88 19.98 139.88 99.88 14.98 199.99 49.87 *********************** 1 CS 72 EA 1 CS 40 PK 29.88 23.99 *********************** 1 CS 144 EA 23 CS PL CS 9.88 American Promotional Events, Inc., dba TNT Fireworks, certifies that all consumer fireworks identified on this invoice have been tested by the American Fireworks Standards Laboratory and found to conform with all Page No 1 "'S3-01180411 Bill Shipper: 22069 TNT WAREHOUSE - WISCONSIN 223 COUNTY HIGHWAY A BLACK RIVER FALLS, WI 54615 WLSL Lic #: Vendor #: VENDOR # 608872 Sold To: 1410002 WALMART - CORPORATE 00001 702 SW 8TH STREET BENTONVILLE, AR 72716 SFM #: Put Pro Number Sticker Here TNT Fireworks of Lading - REPRINT Sales Assoc: CUST PO #: Order #: Route: Zone: Freight Code: Chain Stores - East NEED PO 1180411-S3-00002 MN 435 Stop: Ship To: 1027002 SAM'S CLUB 4738 3035 DENMARK AVENUE EAGAN, MN 55121 SFM #: Phone #: 651-405-0079 ******************************************************************************** Emergency Response Nbr: (800)255-3924 Payment Terms: Net 30 Days Contract Number: MIS0006877 ******************************************************************************** HM Description of Articles Weight Shipping # of Cases Class Pieces X UN 0336, FIREWORKS 1.4G, PG II NOVELTIES - NMFC 56290-4 Totals: 7079 LBS 85 22 [X] 397 LBS 150 1 [X] 7476 LBS 23 ******************************************************************************** Net Explosive Mass: 1770 LBS ******************************************************************************** Checked By: Received By: Delivered By: Order: Ship To: Sold To: Received Date: Placards Tendered By: Delivery Instructions Page No 1 TNT® FIREWORKS Site Plan Worksheet ADDRESS 30 3 5 t (Yl CITY STATE ZIP PHONE STORE NAME / LOCATION # 546k -(W S Gii) P� TYPE OF EVENT: In-store retail sales of state -approved fireworks NORTH SO1-66 FRom FRoniT 000R ctorex Ri tt_ i;e-U AT SoUTt+ ENO OF 8u136 !►u PUSH- 14264 SOUTH SPECIAL INSTURCTIONS SIGNATURE DATE STORE MANAGER / TNT® Representative MATERIAL SAFETY DATA SHEET — Consumer Fireworks SECTION 1— IDENTITY: Consumer Fireworks at Retail Locations Importer's Name American Promotional Events/TNT Fireworks Emergency Telephone Number Normal Business Hours — 800-243-1189 After Hours — ChemTel — 800-255-3924 Address Corporate Office 4511 Helton Dr. Florence, AL 35630 SECTION 2 - Hazardous Ingredients/Identity Information Consumer fireworks contain various mixtures of oxidizers and fuels, and are designed to burn and produce visible and audible effects when they are caused to ignite by a user. The oxidizers include potassium nitrate, strontium nitrate and potassium perchlorate. Fuels include charcoal, sulfur, starch, and aluminum. All chemical composition is contained within the device, and there should be minimal -to -no exposure to the chemicals under normal conditions of handling of the type typically involved in retail sales operations. The chemical mixtures are stable to temperatures up to at least 250°F, and no ignition of these devices should occur during normal handling, transportation, movement, and storage. A match or other flame or heat source is required to ignite the fuse on the devices in order to cause the devices to operate. SECTION 3- PHYSICAL/CHEMICAL CHARACTERISTICS Boiling Point N/A Specific Gravity (H20=1) N/A Vapor Pressure (mm Hg) N/A Melting Point N/A Vapor Density (AIR=1) N/A Evaporation Rate (Butyl Acetate = 1) N/A - All solids Solubility in Water: slight Appearance and Odor: All chemical composition is contained inside a cardboard or other container SECTION 4- FIRE AND EXPLOSION HAZARD DATA Flash Point (Method Used) Ignition temperature exceeds 250°F Flammable Limits N/A — no vapor present LEL N/A UEL N/A Extinguishing Media Water Special Fire Fighting Procedures: Evacuate the area if a fire reaches the fireworks and they begin to burn vigorously. Allow sprinklers to function, if present — they should control the fire. Otherwise, evacuate the area and await arrival of fire fighters. Unusual Fire and Explosion Hazards — Suffocation methods should not be used — the devices contain their own oxygen. Use a strong water flow instead. A fire that has reached consumer fireworks may produce substantial smoke as well as flame, sparks, and burning projectiles. Once consumer fireworks begin burning, all persons must immediately evacuate the area. Only fire fighters wearing appropriate safety equipment should ever consider approaching an area where consumer fireworks are on fire. Remote firefighting methods should be use whenever possible. Where conditions permit, it may be advisable to allow the fireworks to burn to completion — this will greatly simplify clean-up efforts. SECTION 5- REACTIVITY DATA Stability Unstable Health Hazards (Acute and Chronic) Conditions to Avoid: Open flames, hot surfaces, rough handling Stable X Incompatibility (Materials to Avoid) none Hazardous Decomposition or Byproducts Considerable smoke may be produced in a fire Hazardous Polymerization May Occur Conditions to Avoid: N/A Will Not Occur X SECTION 6 - HEALTH HAZARD DATA Routes of Entry Inhalation N Skin N Ingestion N Health Hazards (Acute and Chronic) Health hazards should be minimal — all chemical composition is contained inside sealed devices. If leakage occurs and contact with skin occurs, be sure to wash hands promptly, and before eatin_ or drinkin:. Carcinogenicity NTP N/A 1ARC Monographs N/A OSHA Regulated N/A Signs and Symptoms of Exposure N/A Medical Conditions Generally Aggravated by Exposure None, except in case of fire. Smoke exposure is then the greatest possible concern (in addition to fire). Emergency and First Aid Procedures Evacuate area if a fire reaches the fireworks. If smoke inhalation occurs, remove persons to fresh air and contact emergency medical services SECTION 7 - PRECAUTIONS FOR SAFE HANDLING AND USE Steps to Be Taken in Case Material is Released or Spilled Cautiously pick up the spilled devices and place them in a marked container. Contact your American Promotional/TNT representative for removal instructions. Waste Disposal Method Contact your American Promotional/TNT representative for disposal information. Precautions to Be Taken in Handling and Storing Avoid extreme temperatures, open flame and sparks, and rough handling Other Precautions Intentional misuse/mischief poses the greatest concern with these devices in a retail setting. Monitor the fireworks display area on an ongoing basis, and keep young children, intoxicated persons, and any time of open flame out of the fireworks area. No smoking is ever permitted near fireworks. SECTION 8 - CONTROL MEASURES Respiratory Protection (Specify Type) N/A — no vapor or dust exposure with intact items Ventilation Local Exhaust N/A Special N/A Mechanical (General) N/A Other N/A Protective Gloves — not required for retail sales Eye Protection N/A Other Protective Clothing/Equipment — none required for retai sales Work/Hygienic Practices — wash hands after handling fireworks and before eating or drinking 2 April 22, 2011 ATTN: Store Manager — SAM'S CLUB 4738 It is once again fireworks season. As your corporate fireworks vendor, it is our usual policy to take care of all permitting for our customers. However, the City of Eagan will not allow us to apply for/renew your permit to sell Minnesota legal fireworks inside your store this season. Please complete the enclosed application and forward all information to Fire Marshal's office at 3830 Pilot Knob Road. I apologize for this inconvenience but fell that strong 4th of July sales will more than compensate. If you have any questions or if there is any additional information you or the City may require, please do not hesitate to contact me at 1-800-243-1189 ext.492. Charles Walker TNT® Fireworks Director of Compliance AMERICAN PROMOTIONAL EVENTS, INC. P.O. BOX 1318.4511 HELTON DRIVE • FLORENCE, AL 35630 PHONE (256) 764-6131 • FAX (256) 760-0154 www.tntfireworks.com City of Eagan 3830 Pilot Knob Rd Eagan, MN 55122 (651) 675 -5675 www.ci.eagan.mn.us Site Address: 3035 Denmark Ave Lot: 3 Block: 1 Addition: Eagandale Center Industrial Pk 9th PID: 10- 22508- 030 -01 Use: Sam's Club Description: Sub Type: Indoor Retail Sales Sign Permit Required: N Work Type: Legal Consumer Fireworks Tent Permit Required: N Description: Temporary Event: N Sales Dates: 11/01/2009 to 11/01/2010 Number of Days: 0 to to Comments: *CERTIFICATE OF INSURANCE DUE AGAIN 11 -1 -2010 FOR NEW YEARS SEASON SALES* Fee Summary: Contractor: Indoor Sales Surcharge -Fixed PERMIT 4 C!tyofEaaan $99.50 $0.50 Total: $100.00 Permit Type: ; "'Fireworks Permit Number: 'EA094536 Date Issued: 06/17/2010 0801.4097 9001.2195 Owner: - Applicant - Wal-Mart Prop Tax De Sams Real Est Bus Trust PO Box 8050 MS 0555 Bentonville AR 72712 - -805 I hereby acknowledge that I have read this application and state that the 'nformation is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. City or6apn 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 2010 FIREWORKS SALES AND STORAGE APPLICATION Applicant requirements 1. An application must be completed and returned at least 30 days prior to outdoor sales and /or storage of fireworks. 2. An applications for indoor sales of fireworks must be submitted between April 1st and June 1st to obtain a permit. 2. A letter from the property owner granting permission to the applicant to sell and /or store fireworks on the property shall accompany the application. 3. A floor plan designating the area where the fireworks will be sold and /or stored shall accompany the application. 4. A list of the fireworks that will be sold and /or stored along with the name, weight, quantity, and material safety data sheets (MSDS) shall be included. 5. A copy of the certificate of insurance coverage as per City of Eagan City Ordinance No. 387, Chapter 6, Section 6.53 Fireworks is required. 6 The Fire Marshal or his /her designee will inspect the proposed location for selling and /or storing fireworks to determine if it is a suitable location. 7 A criminal record check will be done on all applicants. 8. A copy of the City of Eagan license (permit) shall be displayed by the register. Date: Business Name: SAM'S CLUB 4738 Telephone #: ( 651 ) 405 -0079 Display Address: 3035 DENMARK AVENUE Applicant Name: cc - SAMS CLUB 4738 / Street Address: J v- i ' -- City: a-c■ State: Zip: S (P-A Telephone #: ((,S I) OS - O 1 4 21 Retail seller selling exclusively consumer fireworks: _ Yes X No X Indoor Sales Dates: 05/2010 to 07/07/2010 and New Years Season Outdoor Sales Dates: to to to Please check the selections that apply to this permit Outdoor Sales $410.50 p01RO z ' CERT 6P /NS 006 )460111U 11 FOR- NEW LIE4k5 S E74so lu S o-tes (includes: $280.00 Fireworks Permit; $128.50 Tent Permit; $2.00 State Surcharge) Sign Permit $ 25.00 X All other retail sellers $100.50 6)6 Use BL E or BLACK Ink Temporary outdoor event means an exhibition or sale with a duration of 10 or less continuous days which does not occur more than once every 30 days and more than three times per year or a combination of 20 days total in a calendar year. (See Outdoor Sales of Fireworks). Fireworks are regulated by MN Statutes 624.20- 624.25. In addition to these state laws, all displays, sales, storage and use of fireworks shall comply with City of Eagan Ordinance No. 387, Section 6.53 Fireworks and NFPA 1124 Stan `ards. I understand and agree to comply with all the provisions of this application - quiz �� ` uthority. ' ACORD CERTIFICATE OF INSURANCE ISSUE DATE 11/04/2009 PRODUCER MCGRIFF, SEIBELS & WILLIAMS, INC. P.O. Box 10265 Birmingham, AL 35202 800 - 476 -2211 This certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the policies below. COMPANIES AFFORDING COVERAGE Company Columbia Casualty Company INSURED American Promotional Events, Inc. dba TNT Fireworks P.O. Box 1318 Florence, AL 35631 Company Lexington Insurance Company Company Colony National Insurance Co. C Company D Company E This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated. Notwithstanding any requirement, term or condition of 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, conditions and exclusions of such policies. Limits shown may have been reduced by paid claims. CO LT TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS OF LIABILITY A GENERAL LIABILITY El Commercial General Liability ❑ Claims Made El Occurrence ❑ Owners' and Contractors' Protection ❑ ❑ General Aggregate Limit applies per: ❑ Policy ❑ Protect ® Location 4015727097 11/01/2009 11/01/2010 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE $ 100,000 MEDICAL EXPENSE $ EXCLUDED PERS. AND ADVERTISING INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS AND COMP. OPER. AGG. $ 2,000,000 AUTOMOBILE LIABILITY ❑ Any Automobile ❑ All Owned Automobiles ❑ Scheduled Automobiles ❑ Hired Automobiles ❑ Non -owned Automobiles ❑ COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ COMPREHENSIVE COLLISION WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY WC Statutory Limit 1 Other 1 EL EACH ACCIDENT $ EL DISEASE (Each employee) $ EL DISEASE (Policy Limit) $ C EXCESS LIABILITY 01 Occurrence ❑Claims Made AR4460275 11/01/2009 11/01/2010 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 Retention /Deductible 10,000 B EXCESS UMBRELLA POLICY Per Occurrence 065302852 11/01/2009 11/01/2010 Excess of Underlying $5,Miilion $ 5,000,000 $ $ $ $ This certificate only applies to INSIDE THE STORE SALES OF MINNESOTA APPROVED FIREWORKS @ SAM'S CLUB 4738, 3035 DENMARK AVENUE, EAGAN, MN, 55121. The Certificate Holders are named as Additional Insureds with respect to General Liability as required by written contract subject to policy terms, conditions, and exclusions. CERTIFICATE HOLDER CITY OF EAGAN 3830 PILOT KNOB ROAD EAGAN, MN 55122 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Authorized Representative s.,ra Page 1 of 1 - Certificate lD# 190GQZGB - S3- 01012703 21369 Chain Store Sales - Wisconsin Terms: Net 30 Days Sold To: 1410002 WALMART - CORPORATE 00001 702 SW 8TH STREET BENTONVILLE, AR 72716 Desc /Case Packing * * * * * * * * * * * * * * * * * * * * * * * * * ** PPK MEGA BLAST SS CLUB J10 60/1 PPK - PYRO TIME SS -CLUB J09 76/1 PPK - SHOW STOPPER SS -ALL CLU 14/1 PPK - TNT POWER #2 SS -COM -CLU 16/1 PPK - TUB 0 FUN SPIN CLUB J09 144/1 PPK MAXIMUM POWER SS 500G J10 10 /1 PPK- FIREPOWER SS COM J08 3 FP 30/1 * * * * * * * * * * * * * * * * * * * * * * * * * ** PPK - TNT 6 PACK J07 72/1 PPK ALL AMERICAN 2 PK CLUB J1 40/1 * * * * * * * * * * * * * * * * * * * * * * * * * ** PPK - TNT SNAPPERS 40 CT 144/1 * * * * * * * * * * * * * * * * * * * * * * * * * ** PPK - #8 SPK 48 CT CLUB J09 144/1 DECLARATION OF COMPLIANCE - REPRINT - PACK LIST - REPRINT - Order #: 1012703 -S3 -00002 Order Date: 3/31/10 CUST PO: SLSMN: Chain Stores East Item CP # Assortments 102021P 27736022991 101888Q 621968659 101946P 621967959 101751S 621968099 101893P 621968309 102083P 27736025077 101424S 621968729 Base Fountains 200745P 621968239 200851P 27736025633 Novelties 320063P 621965929 Sparklers 380234P 621965719 Case Totals: Total Pallets: Total Repack Cases: Ship To: 1027002 - SAM4738 SAM'S CLUB 4738 3035 DENMARK AVENUE EAGAN, MN 55121 Quantity Selling Suggested Ordered Units Sell Price 4 CS 1 CS 2 CS 3 CS 1 CS 1 CS 4 CS 1 CS 1 CS 1 CS 1 CS * * * * * * * * * * * * * * * * * * * * * ** 20 CS PL CS 240 EA 76 EA 28 EA 48 EA 144 EA 10 EA 120 EA * * * * * * * * * * * * * * * * * * * * * ** 72 EA Page No 1 29.88 19.98 139.88 99.88 14.98 199.99 49.87 29.88 40 PK 23.99 * * * * * * * * * * * * * * * * * * * * * ** 144 BX 9.88 * * * * * * * * * * * * * * * * * * * * * ** 144 EA 9.88 - S3- 01012703 • Checked By: Received By: Delivered By: Shipper: 22069 TNT WAREHOUSE - WISCONSIN 223 COUNTY HIGHWAY A BLACK RIVER FALLS, WI 54615 WLSL Lic #: Vendor #: VENDOR # 608872 Sold To: 1410002 WALMART - CORPORATE 00001 702 SW 8TH STREET BENTONVILLE, AR 72716 SFM #: Order: Ship To: Sold To: Bill X UN 0336, FIREWORKS 1.4G, PG II NOVELTIES - NMFC 56290 -4 Totals: TNT Fireworks of Lading - REPRINT ************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Emergency Response Nbr: (800)255 -3924 Payment Terms: Net 30 Days ************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** HM Description of Articles Weight Shipping # of Cases Class Pieces 5683 LBS 85 627 LBS 150 6310 LBS ************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Net Explosive Mass: 1421 LBS ************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Received Date: Placards Tendered By: Delivery Instructions Put Pro Number Sticker Here Sales Assoc: Chain Stores - East CUST PO #: Order #: 1012703 -S3 -00002 Route: MN Zone: 435 Stop: Freight Code: Ship To: 1027002 SAM'S CLUB 4738 3035 DENMARK AVENUE EAGAN, MN 55121 SFM #: Phone #: 651- 405 -0079 18 [X] 2 [X] 20 Page No 1 ADDRESS 3b?)5 Denrilculk__ CITY CU') STATE M ZIP al PHONE — 4 G — Ot STORE NAME / LOCATION # &VI/1S C-1" 4750 TYPE OF EVENT: In -store retail sales of state - approved fireworks SPECIAL INSTURCTIONS SIGNATURE TNT® FIREWORKS Site Plan Worksheet TORE MAI7AGER / TNT® NORTH SOUTH ntative DATE (o/I SECTION 4- FIRE AND EXPLOSION HAZARD DATA Flash Point (Method Used) Ignition temperature exceeds 250 Flammable Limits N/A — no vapor present LEL N/A UEL N/A Extinguishing Media Water Special Fire Fighting Procedures: Evacuate the area if a fire reaches the fireworks and they begin to burn vigorously. Allow sprinklers to function, if present — they should control the fire. Otherwise, evacuate the area and await arrival of fire fighters. N/A Unusual Fire and Explosion Hazards — Suffocation methods should not be used — the devices contain their own oxygen. Use a strong water flow instead. A fire that has reached consumer fireworks may produce substantial smoke as well as flame, sparks, and burning projectiles. Once consumer fireworks begin burning, all persons must immediately evacuate the area. Only fire fighters wearing appropriate safety equipment should ever consider approaching an area where consumer fireworks are on fire. Remote firefighting methods should be use whenever possible. Where conditions permit, it may be advisable to allow the fireworks to burn to completion — this will greatly simplify clean -up efforts. N/A - All solids SECTION 3- PHYSICAL /CHEMICAL CHARACTERISTICS Boiling Point N/A Specific Gravity (H20 =1) N/A Vapor Pressure (mm Hg) N/A Melting Point N/A Vapor Density (AIR =1) N/A Evaporation Rate (Butyl Acetate = 1) N/A - All solids Solubility in Water: slight Appearance and Odor: All chemical composition is contained inside a cardboard or other container SECTION 1— IDENTITY: Consumer Fireworks at Retail Locations Importer's Name American Promotional Events /TNT Fireworks Emergency Telephone Number Normal Business Hours — 800 - 243 -1189 After Hours — ChemTel — 800 - 255 -3924 Address Corporate Office 4511 Helton Dr. Florence, AL 35630 MATERIAL SAFETY DATA SHEET — Consumer Fireworks SECTION 2 - Hazardous Ingredients/Identity Information Consumer fireworks contain various mixtures of oxidizers and fuels, and are designed to burn and produce visible and audible effects when they are caused to ignite by a user. The oxidizers include potassium nitrate, strontium nitrate and potassium perchlorate. Fuels include charcoal, sulfur, starch, and aluminum. All chemical composition is contained within the device, and there should be minimal -to -no exposure to the chemicals under normal conditions of handling of the type typically involved in retail sales operations. The chemical mixtures are stable to temperatures up to at least 250 ° F, and no ignition of these devices should occur during normal handling, transportation, movement, and storage. A match or other flame or heat source is required to ignite the fuse on the devices in order to cause the devices to operate. 1 SECTION 6 - HEALTH HAZARD DATA Routes of Entry Inhalation N I Skin N I Ingestion N Health Hazards (Acute and Chronic) Health hazards should be minimal — all chemical composition is contained inside sealed devices. If leakage occurs and contact with skin occurs, be sure to wash hands promptly, and before eating or drinking. Carcinogenicity NTP N/A IARC Mono • raphs N/A I OSHA Regulated N/A Signs and Symptoms of Exposure N/A Medical Conditions Generally Aggravated by Exposure None, except in case of fire. Smoke exposure is then the greatest possible concern (in addition to fire). Emergency and First Aid Procedures Evacuate area if a fire reaches the fireworks. If smoke inhalation occurs, remove persons to fresh air and contact emergency medical services SECTION 7 - PRECAUTIONS FOR SAFE HANDLING AND USE Steps to Be Taken in Case Material is Released or Spilled Cautiously pick up the spilled devices and place them in a marked container. Contact your American Promotional /TNT representative for removal instructions. Waste Disposal Method Contact your American Promotional /TNT representative for disposal information. Precautions to Be Taken in Handling and Storing Avoid extreme temperatures, open flame and sparks, and rough handling Other Precautions Intentional misuse /mischief poses the greatest concern with these devices in a retail setting. Monitor the fireworks display area on an ongoing basis, and keep young children, intoxicated persons, and any time of open flame out of the fireworks area. No smoking is ever permitted near fireworks. SECTION 5- REACTIVITY DATA Stability Unstable Local Exhaust N/A Conditions to Avoid: Open flames, hot surfaces, rough handling Stable X Incompatibility (Materials to Avoid) none Hazardous Decomposition or Byproducts Considerable smoke may be produced in a fire Hazardous Polymerization May Occur Conditions to Avoid: N/A Will Not Occur X SECTION 8 - CONTROL MEASURES Respiratory Protection (Specify Type) N/A — no vapor or dust exposure with intact items Ventilation Local Exhaust N/A Special N/A Mechanical (General) N/A Other N/A Protective Gloves — not required for retail sales Eye Protection N/A Other Protective Clothing /Equipment — none required for retail sales Work /Hygienic Practices — wash hands after handling fireworks and before eating or drinking 2 • Fireworks Application Page 2 of 9 Tennessen Warning License Application Minnesota law requires that you be informed of the purposes and intended uses of the information you provide to the City of Eagan (the City) during the license application process. Any information about yourself that you provide to the City during the license application process will be used to identify you as an applicant and to assess your qualifications for selling fireworks within the City. If you wish to be considered for a permit to sell fireworks, you are required to provide the information requested in the permit application. If you refuse to supply information requested by the City, it may mean that your application will not be considered. All individuals in the City who need to know information will have access. 4 - 44 aalag A• •lica • ignature Date Executed this day of g tvAe Authorization and Consent for Release of Information I, JJl 2Ae KuieittiLluvf , freely and voluntarily authorize the City of Eagan to conduct an Name of individual authorizing re se investigation to obtain the following information for the purpose of determining my eligibility for a permit to sell fireworks: Name: KVA - 241 -(71 ! Anne, Last � Q r First Middle /� n Date of Birth: 1 } — 1 ° 1 0 Driver's License #: t'� L 10013W) -1 /� � State Ail t'" 1 also release the City of Eagan from any and all liability for its receipt and use of information and records received pursuant to this consent. I further acknowledge that I have carefully read this release, fully understand its terms and legal significance, and execute it voluntarily. 200. • Fireworks Application Page 3 of 9 The Police Department has conducted a criminal background check on the aforementioned applicant. Comments: Poli Department Representative Date Conditions of Issuance: Background check completed and approved by EPD: Yes No Zoning approval Yes No Facility inspection complete and all violations corrected Yes No Insurance policy approved Yes No Need Site plan, sign permit and written permission of property owner Yes No Building Permit Application for Tent Yes No License approved by Date approved: