Medical Marijuana Dispensary Permit Application

Department of Health Use Only

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Received

Medical Marijuana Dispensary Permit Application

You may apply for one dispensary permit in this application for any of the medical marijuana regions listed below. A separate application must be submitted for each primary dispensary location sought by the applicant. Please see the Medical Marijuana Organization Permit Application Instructions for a table of the counties within each medical marijuana region and the counties in which you are eligible to locate your primary dispensary.

Please check to indicate the medical marijuana region, and specify the county, for which you are applying for a dispensary permit:

Northwest Southwest

Northcentral Southcentral

Northeast Southeast

County 1 (Primary Dispensary Location): Bucks County 2 (if applicable): Montgomery County 3 (if applicable): n/a

1 Updated February 1, 2017 ? See Guidance

Pennsylvania Department of Health Medical Marijuana Dispensary Permit Application

Medical Marijuana Dispensary Permit Application

Part A - Applicant Identification and Dispensary Information

(Scoring Method: Pass/Fail) FOR THIS PART, THE APPLICANT IS REQUIRED TO PROVIDE BACKGROUND AND CONTACT INFORMATION FOR THE BUSINESS OR INDIVIDUAL APPLYING FOR A DISPENSARY PERMIT, THE PRIMARY DISPENSARY LOCATION, ALONG WITH ANY SECOND OR THIRD DISPENSARY LOCATIONS THAT ARE BEING SOUGHT UNDER THE APPLICATION.

Section 1 ? Applicant Name, Address and Contact Information

Business or Individual Name and Principal Address Business Name, as it appears on the applicant's certificate of incorporation, charter, bylaws, partnership agreement or other legal business formation documents:

PA Health Concepts, LLC Other trade names and DBA (doing business as) names:

n/a Business Address: 123 East Broad Street

Primary Contact, or Registered Agent for this Application Name: Jon Roska

Section 2 ? Dispensary Information

THE APPLICANT IS REQUIRED TO PROVIDE A PRIMARY DISPENSARY LOCATION. THE APPLICANT MAY INCLUDE A SECOND OR THIRD LOCATION UNDER THIS APPLICATION. A SECOND OR THIRD DISPENSARY MAY BE ADDED TO A DISPENSARY PERMIT AT A LATER DATE THROUGH THE FILING OF AN APPLICATION FOR ADDITIONAL DISPENSARY LOCATIONS.

By checking "Yes," you affirm that you possess the ability to obtain in an expeditious manner the right to use sufficient land, buildings and other premises and equipment to properly carry on the activity described in the medical marijuana dispensary permit application, and any proposed location for a dispensary.

Yes No

Primary Dispensary Location (please indicate dispensary name as you would like it to appear on the dispensary permit)

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Pennsylvania Department of Health Medical Marijuana Dispensary Permit Application

Facility Name: PA Health Concepts, LLC

Address: 5936 Easton Rd

City: Plumsteadville

State: PA Zip Code: 18949

County: Bucks

Municipality: Plumstead Township

PLEASE PROVIDE A DESCRIPTION OF THE PUBLIC ACCESS TO THE DISPENSARY LOCATION, INCLUDING ANY LOCAL PUBLIC

TRANSPORTATION THAT MAY BE AVAILABLE:

Pennsylvania Route 611 (Easton Road in Bucks) is a high trafficked and easily accessible road that includes the PA Health Concepts medical marijuana dispensary at 5936 Easton Road, Plumsteadville, PA 18949

The PA Health Concepts location has a certified daily traffic count of 13,869 autos passing by the dispensary. The dispensary also has 167' of frontage on Easton Road (PA 611) for added visibility.

PA 611 itself runs from Philadelphia North through the Montgomery county towns of Abington, Upper Moreland Township, Willow Grove (the interchange with the Pennsylvania Turnpike Interstate I-276), Horsham Township (PA 463), crossing into the Bucks county Warrington township, Neshaminy, Edison, the Borough of Doylestown, past PA 202, SEPTA's Lansdale/Doylestown train line, Doylestown township, Plumstead township to Plumsteadville where the dispensary is located. Continuing north on Easton Road/PA 611 it enters Bedminster township, Pipersville, Tinicum township, Ottsville, Nockamixon township, Revere, Ferndale, Kintersville, Durham township to Riegelsville.

The dispensary is located just 8 miles north of Doylestown ? the County seat ? where Route 202 connects with many other Bucks County & Montgomery County towns south all the way to Norristown and North to New Hope.

SEPTA public transportation is Bus Route 55 which winds from the Olney Transportation Center (where it connects Bus Routes 6, 8, 16, 18, 22, 26, 55, and 80) through Jenkintown/Wyncotte, Abington, Willow Grove Park Mall, Willow Grove, Horsham, Warminster, to Doylestown where there will be many car services like Bucks County Transport, Uber , Lyft and multiple car/taxi services to the dispensary.

Bucks County Transport provides shared ride transportation to persons with physical and/or mental health disabilities at a discounted rate. You may qualify if you are a Bucks County resident between the ages of 18 and 64, can provide written verification of disability, and you need transportation beyond SEPTA'S ADA service area. Counties BCT serves: Philadelphia, Montgomery, Lehigh and Northampton.

Both ADA Paratransit Service and the Shared-Ride Program are provided by contract carriers within the City of Philadelphia and each suburban county. Carriers provide rides to customers, train drivers and maintain vehicles. SEPTA oversees the carriers, provides centralized driver training, and also directly manages the reservation, scheduling and service monitoring functions for Philadelphia, Bucks, Chester, Delaware and Montgomery Counties. In accordance with the Americans with Disabilities Act (ADA), SEPTA provides comparable service for people with disabilities who are functionally unable to use regular accessible fixedroute bus service for some or all of their transportation needs. Eligible individuals can travel

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Pennsylvania Department of Health Medical Marijuana Dispensary Permit Application whenever and wherever buses operate in SEPTA's five-county service region. Uber and Lyft both have vehicles that can accommodate the wheelchair bound and people with vision & hearing disabilities. Uber is looking to expand their Special Needs programs they are testing in about 10 cities. For some patients with one of the 17 serious medical conditions, there are condition specific organizations that provide transportation for those patients:

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Pennsylvania Department of Health Medical Marijuana Dispensary Permit Application

Second Dispensary Location

Facility Name: PA Health Concepts, LLC

Address: Unit #3, 668 Bethlehem Pike

City: Montgomeryville

State: PA Zip Code: 18936

County: Montgomery

Municipality: Montgomery Township

PLEASE PROVIDE A DESCRIPTION OF THE PUBLIC ACCESS TO THE DISPENSARY LOCATION, INCLUDING ANY LOCAL PUBLIC

TRANSPORTATION THAT MAY BE AVAILABLE:

Pennsylvania Route 309 (Bethlehem Pike in Montgomeryville) is a major highway which runs for 134 miles (216 km) through Pennsylvania in the United States between Philadelphia to the South and ends in Monroe County/Wyoming Township to the North.

The location at 668 Bethlehem Pike (PA Route 309) is one of the finest locations in Montgomery County. This location has a certified daily traffic count of 35,000 autos passing by the dispensary location. But, even more importantly, the dispensary will be a destination for patients needing medical marijuana, and the following details the communities within a half hour drive to the dispensary. It is an impressive list encompassing a very large and diverse part of Montgomery County.

PA 309 begins at an interchange between PA 611 and Cheltenham Avenue on the border between Cheltenham township in Montgomery County to the north and the East Oak Lane section of the city of Philadelphia to the south. From the south, Route 309 connects the following communities with the PA Health Concepts medical marijuana dispensary: from Philadelphia Route 309 crosses through Cheltenham township, Springfield township, Whitemarsh township, Upper Dublin township, the Borough of Ambler, Lower Gwynedd Township, Spring House, Horsham Township, and Montgomery Mall. Going north from the PA Health Concepts medical marijuana dispensary, Route 309/Bethlehem Pike crosses the following communities: Hatfield township, Colmar, New Britain township, Hilltown township, Souderton, West Rockland township, Sellersville, the Borough of Telford, the Borough of Perkasie, Richland township, the Borough of Quakertown, and Springfield township.

In addition to these many communities on the north/south axis, Route 309/Bethlehem Pike is crossed by some major routes that connect it to other communities to the east and west. Route 309/Bethlehem Pike in Montgomery Township intersects with US 202 connecting it with the densely-populated communities of Doylestown to the east and Norristown to the southwest. It also intersects with PA463/Cowpath Rd connecting it to the densely-populated communities of Lansdale to the west and Hatboro to the east. This allows patients from many communities in Montgomery County to easily and quickly come to the PA Health Concepts medical marijuana dispensary.

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Pennsylvania Department of Health Medical Marijuana Dispensary Permit Application

Septa (Southeast Pennsylvania Transit Association) provides public transportation nearby both by rail and bus. Bus lines #94, 96 & 132. The Colmar Septa Station is walking distance to the dispensary.

Lastly, we have easy access to three Interstate highways. Nearby Interstate I-476 is an auxiliary Interstate Highway in Pennsylvania designated between Interstate I-95 and Interstate I-81, serving as the primary north?south Interstate corridor through eastern Pennsylvania. It will make access to the dispensary available to an even greater community of patients.

The Pennsylvania Turnpike (I-76) and (I-276) are toll highways operated by the Pennsylvania Turnpike Commission in the U.S. state of Pennsylvania. The highways run east?west through the state, connecting the Pittsburgh, Harrisburg, and Philadelphia areas. They connect with Interstate I-95 and they are also close to the dispensary.

Montgomery Mall is just one mile from the PA Health Concepts medical marijuana dispensary. It is a super-regional, two-level, indoor shopping center located conveniently at the intersection of routes 309 and 202 in North Wales, PA. The mall serves the nearby communities of North Wales, Lansdale, Hatfield, Horsham and Montgomeryville, and boasts 116 stores in categories from jewelry to women's apparel to sporting goods and features four department stores: JCPenney, Macy's, Dick's Sporting Goods, Sears and a new Wegmans Super Market & pub. With the thousands of visitors to this mall each day and the entrance to the mall from Bethlehem Pike one mile away, it is another reason making the PA Health Concepts dispensary location ideal for Montgomery County patients.

Third Dispensary Location

Facility Name: n/a

Address: n/a

City: n/a

State: PA Zip Code: n/a

County: n/a

Municipality: n/a

PLEASE PROVIDE A DESCRIPTION OF THE PUBLIC ACCESS TO THE DISPENSARY LOCATION, INCLUDING ANY LOCAL PUBLIC

TRANSPORTATION THAT MAY BE AVAILABLE:

n/a

Part B ? Diversity Plan

(Scoring Method: 100 Points) IN ACCORDANCE WITH SECTION 615 OF THE ACT (35 P.S. ? 10231.615), AN APPLICANT SHALL INCLUDE WITH ITS

APPLICATION A DIVERSITY PLAN THAT PROMOTES AND ENSURES THE INVOLVEMENT OF DIVERSE PARTICIPANTS AND DIVERSE

GROUPS IN OWNERSHIP, MANAGEMENT, EMPLOYMENT, AND CONTRACTING OPPORTUNITIES. DIVERSE PARTICIPANTS INCLUDE A PERSON, INCLUDING A NATURAL PERSON; INDIVIDUALS FROM DIVERSE RACIAL, ETHNIC AND CULTURAL BACKGROUNDS AND COMMUNITIES; WOMEN; VETERANS; INDIVIDUALS WITH DISABILITIES; CORPORATION; PARTNERSHIP; ASSOCIATION; TRUST OR OTHER ENTITY; OR ANY COMBINATION THEREOF, WHO ARE SEEKING A PERMIT ISSUED BY THE

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Pennsylvania Department of Health Medical Marijuana Dispensary Permit Application

DEPARTMENT OF HEALTH TO GROW AND PROCESS OR DISPENSE MEDICAL MARIJUANA. DIVERSE GROUPS INCLUDE THE FOLLOWING BUSINESSES THAT HAVE BEEN CERTIFIED BY A THIRD-PARTY CERTIFYING ORGANIZATION: A DISADVANTAGED BUSINESS, MINORITY-OWNED BUSINESS, AND WOMEN-OWNED BUSINESS AS THOSE TERMS ARE DEFINED IN 74 PA. C.S. ? 303(B); AND A SERVICE-DISABLED VETERAN-OWNED SMALL BUSINESS OR VETERAN-OWNED SMALL BUSINESS AS THOSE TERMS ARE DEFINED IN 51 PA. C.S. ? 9601.

Section 3 ? Diversity Plan

By checking "Yes," the applicant affirms that it has a diversity plan that establishes a

goal of opportunity and access in employment and contracting by the medical

Yes No

marijuana organization. The applicant also affirms that it will make a good faith effort to

meet the diversity goals outlined in the diversity plan. Changes to the diversity plan

must be approved by the Department of Health in writing.

The applicant further agrees to report participation level and involvement of Diverse Participants and Diverse Groups in the form and frequency required by the Department, and to provide any other information the Department deems appropriate regarding ownership, management, employment, and contracting opportunities by Diverse Participants and Diverse Groups.

DIVERSITY PLAN

IN NARRATIVE FORM BELOW, DESCRIBE A PLAN THAT ESTABLISHES A GOAL OF DIVERSITY IN OWNERSHIP, MANAGEMENT,

EMPLOYMENT AND CONTRACTING TO ENSURE THAT DIVERSE PARTICIPANTS AND DIVERSE GROUPS ARE ACCORDED EQUALITY

OF OPPORTUNITY. TO THE EXTENT AVAILABLE, INCLUDE THE FOLLOWING:

1. The diversity status of the Principals, Operators, Financial Backers, and Employees of the Medical Marijuana Organization.

2. An official affirmative action plan for the Medical Marijuana Organization. 3. Internal diversity goals adopted by the Medical Marijuana Organization. 4. A plan for diversity-oriented outreach or events the Medical Marijuana Organization will

conduct during the term of the permit. 5. Contracts with diverse groups and the expected percentage and dollar amount of revenues that

will be paid to the diverse groups. 6. Any materials from the Medical Marijuana Organization's mentoring, training, or professional

development programs for diverse groups. 7. Any other information that demonstrates the Medical Marijuana Organization's commitment to

diversity practices. 8. A workforce utilization report including the following information for each job category within

the Medical Marijuana Organization: a. The total number of persons employed in each job category, b. The total number of men employed in each job category, c. The total number of women employed in each job category, 7

Pennsylvania Department of Health Medical Marijuana Dispensary Permit Application d. The total number of veterans in each job category, e. The total number of service-disabled veterans in each job category, and f. The total number of members of each racial minority employed in each job category. 9. A narrative description of your ability to record and report on the components of the diversity plan.

Introduction

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