Department of Health Use Only # 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 ☐ Northcentral ☐ Northeast ☐ Southwest ☐ Southcentral ☒ 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 Yes No properly carry on the activity described in the medical marijuana dispensary permit application, and any proposed location for a dispensary. Primary Dispensary Location (please indicate dispensary name as you would like it to appear on the dispensary permit) 2 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 fixed- route bus service for some or all of their transportation needs. Eligible individuals can travel 3 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: 4 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. 5 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