2014-00338CITY OF MONTICELLO 1111111
2 0 1 4- 0 0 3 3 8
505 WALNUT STREET DATE ISSUED: 06/12/2014
MONTICELLO, MN 55362-
763) 295-3060 FAX: (763) 295-4404
ADDRESS 9320 CEDAR ST S
PIN 155169001010
LEGAL DESC MONTICELLO BUSINESS CTR 3RD ADDN
LOT 001 BLOCK 001
PERMIT TYPE BUILDING
PROPERTY TYPE COMMERCIAL
CONSTRUCTION TYPE TEMPORARY
VALUATION 500.00
APPLICANT BUILDING PERMIT FEE 24.91
STATE SURCHARGE, BLDG VAL 5.00
WAL-MART REAL EST BUSINESS TR
TOTAL 29.91
1301 IOTH ST SE
Payment(s)
PROP TAX DEPT #8013
CHECK 10062842 29.91
AR 72716-0555
OWNER
WAL-MART REAL EST BUSINESS TR
1301 LOTH ST SE
PROP TAX DEPT #8013
AR 72716-0555
AGREEMENT AND SWORN STATEMENT
I agree that the work will be conducted in conformance with
the ordinances of the City of Monticello and with the
Minnesota State Building Code. I understand that the work
will be in accordance with the plan that has been approved by
the Building Official. I agree that any damage caused to
public property including but not limited to curb, sidewalk,
public utilities and signs will be repaired at my expense.
Applicant
Date
Bldg Official Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
CITY OF
Monticeno
BUILDING SAFETY
COMMERCIAL / INDUSTRIAL BUILDING PERMIT APPLICATION
505 Walnut Street, Suite #1 Monticello, MN 55362 Phone: 763-295-3060 Fax: 763-295-4404
Walmart parking lot - 9320 Cedar Street
BLOCK PI.D. NUMBER
ZONDED
Name) (Address)
Walmart Stores - 702 SW 8th Street, Bentonville, AR 72716
olo (Tel. No.)
Anthony.Hylton@wal-mart.com 479-204-2581
0 V!, i'Z '10 R (Name) (Address)
Chris Ulmer 2109 59th Avenue South, Fargo, ND 58104
I ('s () iZ ", LICL N SENI liNl Bl,'I' , (IF APPLICABLE)
10 1" — N 1A L A 1) D RE 'SS:
ulmerc@tntfireworks.com
Name) (Address)
1" 1, ALDORLSS
Name) (Address)
S V ADDIAESS:
ol" erection of tent
Tel. No.)
701-400-7661
Tel. No.)
Tel. No.)
TYPE OF WORK (Please Circle One)
New
Addition
Alteration
Repair
Move
Other erection of tent
ADDITIONAL INFORMATION
Valuation: $
2009.56
Construction Type:
Occupancy Group:
Square Footage:
of Stories:
Maximum Occupancy:
TYPE OF COS TRUCTION (Please Circle One)
Commercial
Industrial
Institutional
Multi -Family
Other
MISC. NOTES:
Fire Suppression: Yes No
ESTIMATED VALUE OF CONSTRUCTION
I hereby apply for a permit for construction as described and acknowledge that the information I have
provided above is complete and accurate. I agree that the work will be conducted in conformance with
the ordinances of the City of Monticello and with the Laws of the State of Minnesota; and that I under-
stand that this application is not a permit and that the work is not to start without a permit. I further un-
derstand that the work will be in accordance with the plan that has been approved by the Building Offi-
cial. I agree that any damage caused to public property including but not limited to curb, sidewalk, pub-
lic utilities and signs will be repaireot my-expett .
Applicant Signature
Print Name /Title
Date
Approved by Building Official:
a
Date Approved:
702 SW Bth Street
Benton Nl lie AR 72716
P hone 4i'J _?7 C 1 4 2
Fax 472 273 8676
To: Walmart Management Team —Select Stores
From. Anthony Hylton
Walmart Services
Sr. Director, Store Channel Operations and Execution.
Dare: 12111/2013 Re. Fireworks programs
on Walmart parkinq lots L -. This letter
serves
as authorization for American Promotional Events, Inc. dba TNT Fireworks to conduct fireworks promotion at
your store during the time frame June 17" through and including July 8'h, 2014. They are an approved
supplier tc conduct fireworks sales on our stores' parking lots where this type of promotion is legal. TNTO
Fireworks is responsible for obtaining all necessary permits and/or licenses and must display such permits and/
or licenses at each location. Walmart grants permission for ali patrons of the sale to utilize the restrcom facilities
at each participating store. If there are any concerns, please do not hesitate to contact me. Store Action:
The
Store Manager
to approve the store's participation and placement on the parking lot by stamping the Pre -
Sale Survey with a store stamp that has the store number and address imprinted on it. The
stamp will provide an acknowledgement that TNTO Fireworks has received approval to conduct the event
in the parking lot. TNTO Fireworks Customer
Support Hotline at 1-800-243-1189 We appreciate your
support! Should you have any questions, please feel free to contact our team —we're here to help.
Best Regards, Anthony
Hylton Sr.
Director, Store
Channel Operations and Execution Walmar Services. Phone
479 204.
2581 Anthony. HV tonnwal-
mart.com Y Date:'2'--
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Aco CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
11 / 1 /2014 I 2/24/2014
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).
CONTACT
PRODUCER 1_.ockton Companies. L,L.0 I NAME,
3280 Peachtree Road NE. Suite #250 I PHONE FAX
INC. No, Ezt): (A/C, No):
Atlanta GA 30305 I E-MAIL
404)460-3600
ADDRESS.
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: E\,ereSt Indemnity Insurance Company 10851
INSURED .17]ellcaI] Promotional E\'ents, Inc, `` INSURER B
1 359629 DBA TNT Fireworks. Inc. I INSURER C :
P.O. BOX 13I 8 I INSURER D :
4511 Helton Drive
INSURER E
Florence AL 35630
I '
INSURER F
COVERAGES CERTIFICATE NUMBER: 12209708 REVISION NUMBER: XXXXXXX
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 RAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
a
GENERAL LIABILITY Y N S18G1_00242-131 1 1i 1'2013 1 1r 1i2014 EACH OCCURRENCE $ 1 _000_000
XMMERCIAL GENERA LABILITY DAMAGES (RENTED
J
PREMISES (Ea occurrence) $ 300,000
CLAIMS -MADE }{JOCCUR
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY 7 X LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED 1 SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS y AUTOS
UMBRELLA LIAB OCCUR
EXCESS LAB CLAIMS -MADE
DEDI, RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y 1 N
ANY PROPRIETOR/PARTNER/EXECUTIVE I
OFFICER/MEMBER, EXCLUDED' u N / A
Mandatory in NH)
14 yes, describe under
DESCRIPTION OF OPERATIONS below
MED EXP (Anv one Derson) 5.000
PERSONAL & ADV INJURY 1,000,000
GENERAL AGGREGATE 1000.000
PRODUCTS - COMP/OP AGG 2.000.000
NOT APPLICABLE cur dwCS SINGLL LIMI I
Ea accident) S XXXXXXX
BODILY INJURY (Per person) XXXXXXX
BODILY INJURY (Per accident) XXXXXXX
PROPERTY DAMAGE
Par a ,.Oentl XXXXXXX
XXXXXXX
NOT APPLICABLE- EACH OCCURRENCE XXXXXXX
AGGREGATE XXXXXXX
f XXXXXXX
NOT APPLICABLE I We STATU- OTH- ITORY LIMITSI I ER
E.L. EACH ACCIDENT XXXXXXX
E L. DISEASE - EA EMPLOYEE $ XXXXXXX
E.L. DISEASE - POLICY LIMIT $ XXXXXXX
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
THIS CERTIFICATE SUPERSEDES ALL PRE\ IOUSL)' ISSUED CERTIFICATES FOR TI [IS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(SI REFERENCED
Additional Insured: Jordan Serfling(TNT Customer) property located at Walmart Parking Lot-9320 Cedar Street Monticello, IN4N 55362 (MN 9320). Certificate
holder Is an additional Insured on the General Liabilitc as required by written contract sublect to polio terms, conditions, and exclusions.
CERTIFICATE HOLDER
I
12209708
Walmart Stores. INC
702 SW 8th St
Bentonville AR 72716
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.
AUTHORIZED REPRESENTATIVE
CERTIFICATION OF COMPLIANCE-
MIINNESOTA NVORIaRS' COMPENSATION LAW
Minnesota Statute, Section 176.182 requires every state and local licensing agency to
withhold the issuance or renewal of a license or permit to operate a business or engage in
an activity in Minnesota until the applicant presents acceptable evidence of compliance
with the workers' compensation insurance coverage requirement of MSS Chapter 176.
The information required is: the name of the insurance company, the policy number, and
dates of coverage or the.permit to self -insure. This information mill be cnllected by the
licensin4 agency and retained in their files.
This information is required by lam-, and Licenses and permits to operate a business may
not be issued or renewed if it is not provdded and/or is falsely reported: Furthermore, if
this information is not provided or falsely stated, it may result in a S1,000 penalty assessed
against the applicant by the Commissioner of the Department of Labor and Industry_
Insurance Company Name:
NOT the insurance agent)
Policy Number
Dates'of Coverage: to
or)
I am not required to have workers' compensation liability coverage because:
FI hale no employees
I am self insured (include permit to self -insure)
I hat e no employees -ho are covered by the workers' compensation Iaw (these include:
Spouse, Parents,- Children"and certain farm•employees) "
I certify that the information provided above is accurate and complete and that a valid workers'
compensation policy will be kept in effect at all times as required by law.
N.,-.ChristopherJon Ulmer last,
first, middle) TNT
Fireworks Doing
Business As: business
name if different than your name) Business
Aadress:2109 '59th Avenue South Cit}•,
State; Lip: Fargo, ND 58104 Phone:(701)400-766 1 Date:.
3/1$/2014 . Signature: ,
j_
To Whom It May Concern:
We plan to sell Minnesota -approved Consumer Fireworks during the July 4`
h
holiday season in the Walmart parking lot at 9320 Cedar Street.
We are allowed 12 days of operation at the said location, which we plan to operate
from June 21 to July 7. Our normal business hours are from 10:00 A.M. to 10:00
P.M.
We can concur with all the following criteria:
Not be detrimental to property or improvements in the surrounding area or
to the public health, safety, or general welfare.
Be compatible with the principal uses taking place on the site.
Not have substantial adverse effects or noise impacts on nearby residential
neighborhoods.
Not include permanent alterations to the site.
Not maintain temporary signs associated with the use or structure after the
activity ends.
Not violate the applicable conditions of approval that apply to a site or use on
the site.
Not interfere with the normal operations of any permanent use located on the
property; and
Contain sufficient land area to allow the temporary use, structure, or special
event to occur, as well as adequate land to accommodate the parking and
traffic movement associated with the temporary use, without disturbing
environmentally sensitive lands.
Thanks,
Chris Ulmer
TNT Fireworks - Minnesota - Area Manager
ulmerc(d),tntfireworks.com
Cell: 701.400.7661
Fax: 866.807.1722