Rev 7/18 MINNESOTA BOARD OF PHARMACY 2829 UNIVERSITY AVE SE #530, MINNEAPOLIS, MN 55414 - 3251 Phone: ( 651 ) 201 - 2 825 Fax: (6 1 2 ) 6 1 7 - 2 262 Relay Service: Metro Area (651) 297 - 5353 Non - Metro Area 800 - 627 - 3529 E - Mail: pharmacy.board@state.mn.us - Web: www.pharmacy.mn.gov APPLICATION FOR A PHARMACY LICENSE LICENSE EXPIRES JUNE 30 OF EACH YEAR FEE FOR NEW PHARMACY AND OWNERSHIP CHANGE: $ 225 .00 ( NO FEE FOR NAME CHANGE , REMODEL OR ADDRESS CHANGE ) Make Check Payable to: Minnesota Board of Pharmacy ( State of Minnesota Taxpayer Identification Number: Federal 41 - 6007162 - State 4405717 ) NO RETURN OR REFUND OF FEES NEW PHARMACY: Date of proposed opening in Minnesota - - NAME, ADDRESS OR REMODEL : Date of proposed change - - CURRENT LICENSE NUMBER: Ownership Formerly: Name Formerly: Address Formerly: Location/dimension /physical layout - Please attach copies of the plans or a sketch of the new location or a remodel . Make sure the plans or sketches provide the dimensions of the pharmacy and of features such as countertops and the counseling area. Amount of space being licensed: square feet HOURS: M - F to Saturday to Sunday to PHONE NUMBER: FAX NUMBER: E - MAIL ADDRESS: 1. Print, type, or check all applicab le boxes ( the physical address m ust be entered ). Pharmacy Name: Street Address: City , State , Zip : 2. Check the appropriate item and complete ownership information: Sole Proprietor; Partnership; Limited Liability Partnership; Corporation; Limited Liability Co Fill in: Name of Sole Proprietor, Partnership, or Corporation: Address: City , State , Zip: Partnership or Limited Liability Partnership: List all active and inactive partners. If a new partnership or limite d liability partnership, please attach a copy of the partnership papers. Name Address RPh? % of Ownership American LegalNet, Inc. www.FormsWorkFlow.com Rev 7/18 Name Address RPh? % of Ownership List the state of incorporation: List the number of shares of common or voting stock issued: A LL PHARMACIES , IN - STATE AND OUT OF STATE MUST ANSWER THE FOLLOWING : 3. Check all categories of licensure that appl y to your pharmacy. Note that a pharmacy also operating as an outsourcing facility must submit separate manufacturer and wholesale distributor license applications . A.Community/Outpatient E.Nuclear I.Federal B.Hospital F.Central Service C.Home Health Care G.Veterinary D.Long Term Car e H.Limited Service * * If the limited service category is selected, no other category should be selected and you must submit a detailed description of the services that will be provided. For all other categories of licensure, submit a description of any additional services that you propose to provide . 4. Are all prescriptions labeled and dispensed pursuant to a valid, patient specific prescription order that is received in advance of the dispensing? Yes No 5. Will your pharmacy prepare compounded preparations? (Check each category of service that applies b elow , and a ttach a complete listing of all compounded preparations prepared by the pharmacy ) . Sterile Pre paration Comp ounding (if checked, complete 3a. & 3c . below) Non s terile Preparation Compounding (if checked, complete 3a. & 3b. below) 3a. For Non s terile & Sterile Preparation Compounding, do you follow United States Pharmacopeia (U SP) 795 and USP 797 standards? Yes No 3 b . For Non s terile Preparation Compounding, do es your pharmacy prepare hazardous drugs? Yes No 3c . For Sterile Preparation Compounding , do es your pharmacy prepare high risk and/or hazardous compounded sterile preparations (CSPs)? Yes No Or, Sterile or non - sterile preparation compounding services will not be provided at this pharmacy (Note: per MN Rule 6800.0350, a pharmacy must receive Board approval before providing services in a license category not listed on its license). 6 . Does the owner of this pharmacy own 4 or more pharmacies under this ownership: Yes No 7 .Employees: (Please attach another sheet if necessary) Pharmacist Name Full - time and Part - time License # Full or part - time American LegalNet, Inc. www.FormsWorkFlow.com Rev 7/18 Technician Name Full - time and Part - time Regis. # Full or part - time Please answer the following:On behalf of the owner, if the applicant is a sole proprietorshipOn behalf of each partner, if the applicant is a partnership or a limited liability partnershipOn behalf of the corporation, if the applicant is a corporation or a limited liability co, and onbehalf of each officer, director, or shareholder owning 20% or more of the voting stock of thecorporation. a. Has the applicant been convicted in any court of a fe lony? Yes No b.Has the applicant habitually indulged in the illegal use of narcotics, stimulants, or depressant drugs; or habitually indulged in intoxicating liquors in a manner which could cause incompetence in the practice of pharmacy? Yes No c.Has the applicant ever made application for a license to operate a pharmacy in this state or any other state? Yes No (1) If yes, was the application denied by the Board of Pharmacy? Yes No (2) If denied, for what reason? (3) If the license was granted, was it later suspended, revoked, or placed on probation? Yes No (4)Did the Board, in connection with any violations, issue any warnings or reprimands? Yes No (5)If yes, what was the nature of the violation ? d. Has the applicant been convicted of theft of drugs or the unauthorized use, possession, or sale thereof? Yes No 9 . Federal Tax ID If MN Resident, MN Tax ID MINNESOTA IN - STATE PHARMACIES PLEASE COMPLETE # 10 1 5 . 10 . PLEASE COMPLETE THE FOLLOWING: 1981 Laws, Chapter 346 re quires compensation insurance, for this firm, prior to the issuance of the license. Please check the applicable box below: Self - insured, please attach a copy of the Certificate of Exemption from the Insurance Commissioner. I DO NOT employ anyone. I HAVE paid or otherwise compensated employees, therefore, I am furnishing the following information: Insurance Company Name: Street Address: City, State, Zip Code: Insurance Policy Number: Expir ation Dat e: 11 . Does the pharmacy have all the required equipment listed in 6800.105 0? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Rev 7/18 1 2 . If this application is for a new pharmacy, submit a scaled drawing or blueprint, indicating the following, with this application: A. Access B. Floor space dimensions C. Physical security around the proposed pharmacy area D. Location of the insulin E. Location of prescription compounding area F. Refrigerator G. Location of the hypodermic syringes and needles H. Non - Prescription area I. Patient counseling area (with dimensions) J. S ink K. 1 3 . Does the applicant plan to extend drug storage/distribution to off - site locations, i.e., emergency kits, automated drug distribution systems, etc.? Yes No If yes, please list: 1 4 . If this application is for a hospital pharmacy, please submit the following with the application: A. A copy of the procedure used to obtain emergency drugs, when the pharmacy is closed. B. Samples of drug orders, prescriptions, requisitions, or other records used to order medications and filed in the pharmacy to account for drugs dispensed. 1 5 . If this application is for a hospital pharmacy, please check the scope of services provided: H ospital in - patients Emergency out - patients Long - term care residents Other, please explain: MINNESOTA OUT - OF - STATE PHARMACIES MUST CO MPLETE # 1 6 and # 1 7 : 1 6 . Attach a copy of: a. Your current license or registration from the state in which your facility is located b. Per MN Statute 247151.19, subd. 1(f), the board shall not issue a license unless the pharmacy passes an inspection conducted by a n authorized representative of the board. You must attach a copy of an inspection report issued by the appropriate regulatory authority for your state, and any related documents. The inspection must have occurred within the 24 months immediately preceding receipt of the initial application , and must be appropriate for the services provided by the pharmacy. You must also submit any FDA inspection reports issued for the pharmacy. All applicants must subm