Florida Fish and Wildlife Conservation Commission PDF

Florida Fish and Wildlife Conservation Commission Application for ESC - LICENSE TO POSSESS CLASS III WILDLIFE FOR EXHIBITION OR PUBLIC SALE --- $50.00 P.O. Box 6150, Tallahassee, FL 32314-6150 (850) 488-6253 New Applicant – yes ✔ no Applicant ID (if renewal) ______________ Business Name Solid Rock C...

Florida Fish and Wildlife Conservation Commission Application for ESC - LICENSE TO POSSESS CLASS III WILDLIFE FOR EXHIBITION OR PUBLIC SALE --- $50.00 P.O. Box 6150, Tallahassee, FL 32314-6150 (850) 488-6253 New Applicant – yes ✔ no Applicant ID (if renewal) ______________ Business Name Solid Rock Community School, Inc. DBA Sanctuary at Solid RockE-mail Address [email protected] City Tarpon Springs State FL Zip 34688 City Tarpon Springs State FL Zip 34688 Business Phone ( 727 _) 9340909 2801 Keystone Road Facility Address 3561 Keystone Road County (where the facility is located) Pinellas Mailing Address Note: Corporations or Fictitious Names must be registered COMMERCIAL ACTIVITY: (check all applicable) Pet Shop Exhibition of Wildlife: ✔ Sale of Wildlife: Permanent Exhibit Mobile Exhibit (attach 12 month itinerary) _ Non-Venomous Reptiles or Amphibians Venomous Reptiles (Additional License Required) Mammals Birds INVENTORY OF ANIMALS (Attach Completed Inventory Page – ESC) All applicants (new or renewal) must provide an inventory of the animals that you are requesting the authority to possess REQUIRED DOCUMENTATION: CRITICAL INCIDENT/DISASTER PLAN All Applicants (new or renewal) must provide Part A of their Critical Incident/Disaster Plan. REQUIRED DOCUMENTATION: CAPUCHIN, SPIDER & WOOLLY MONKEYS - New applicants must attach the following: Documentation of experience from applicant 2 Letters of Reference I swear and affirm that the information provided is true and correct. I agree to adhere to the provisions of Chapter 379 Florida Statutes, and the rules and regulations of the Commission pertaining to the possession of wildlife. I understand that my wildlife facilities are subject to inspection by Commission personnel as required by Florida Statute. Michele Fasnacht 7276562920 Owner/Contact Name (Please Print) Home Phone Date of Birth 06 / 19 / 1969 Social Security # 05 / 22 / 2023 Owner/contact Name (Signature) 216866296 Sex F Race W FOR COMMISSION USE ONLY: Approved by Denied by Date Date Code: Reason: INCOMPLETE APPLICATIONS WILL BE RETURNED MM DD Height 5 YY ft 4 in INSTRUCTIONS FOR COMPLETING APPLICATION BIOGRAPHICAL DATA Complete all information in this section. The information must pertain to the person (possessor, manager or owner) applying to possess the wildlife. Corporations or Fictitious Names must be officially registered. The facility address, including the county, should indicate the physical location where the wildlife is to be housed or possessed. The Florida Fish and Wildlife Conservation Commission (FWC) collects social security number (SSN) for the issuance of recreational and professional wildlife, fishing or hunting licenses or permits to an individual in accordance with s. 379.352F.S. and 42 USC 666 for the purposes of administration of the Title IV-D program for child support enforcement, use by the commission, and as otherwise provided by law. COMMERCIAL ACTIVITY Check the appropriate box(es), which best describes your intended activity. All traveling acts and exhibits must attach a 12-month itinerary. Additional permits are required for wildlife rehabilitation and possession or exhibition of venomous reptiles. INVENTORY Complete the inventory page(s) attached to the application. Indicate the number of each species that you currently possess by entering the quantity in the “QTY” field. For species that you plan to possess put a “P” in the “QTY” quantity field. For species that you currently possess but do not house in Florida put a zero (0) in the “QTY” field. REQUIRED DOCUMENTATION FOR CRITICAL INCIDENT/DISASTER PLAN Critical Incident/Disaster Plan: A completed Part A (first page) must be attached with each initial and renewal application. REQUIRED DOCUMENTATION FOR CAPUCHIN, SPIDER & WOOLLY MONKEYS Documentation of Experience: In order to possess capuchin, spider or woolly monkeys, the applicant must meet the experience requirements for Class II Wildlife. Documentation of such experience shall include a description of the specific experience acquired, dates and times experience was obtained and the specific location(s) where acquired. CLASS II: Applicants must document no less than one (1) year of substantial practical experience (to consist of no less than 1,000 hours) as described above, or demonstrate 500 hours of substantial practical experience and successfully complete a written examination (80%) which is administered by the Division of Law Enforcement. Application should not be submitted until notification by FWC that you have passed the exam. References: Attach two letters of reference from individuals having personal knowledge of your stated experience. Only one reference letter may be from a relative. One reference letter must be from an individual licensed by FWC for wildlife of the same or higher class and family or a professional organization or governmental institution. Failure to complete the application will result in application being returned and/or denied. ESC – INVENTORY PAGE BUSSINESS NAME: Solid Rock Community School, Inc. WILDLIFE THAT YOU CURRENTLY POSSES IN FLORIDA: Please indicate the exact number of species you currently possess in the “QTY” field. If you do not house these species in Florida, put a zero (0) in the “QTY”. WILDLIFE THAT YOU DO NOT POSSESS IN FLORIDA: For the species that you do not currently possess but plan to possess put a “P” in “QTY”. For species that you possess but do not house in Florida, put a zero (0) in “QTY”. Please list all animals by species (except Capuchin, Spider, and Woolly Monkeys) in the species list. Class III CODE Capuchin Monkey Spider Monkey Woolly Monkey All other Class III Mammals (complete species list) All Class III Reptiles/Amphibians (complete species list) All Class III Birds (complete species list) Venomous Reptiles* (complete species list) MA1 MB3 MB2 QTY 0 0 0 SPECIES LIST M7 12 V 3 1 tortoise, 1 bearded dragon U 8 2 parrots, 2 parakeets, 2 finches, 2 doves 1 squirrel, 2 chinchillas, 2 tamarinds, 2 marmosets, 2 squirrel monkeys, 3 hedgehogs 0 Z *A License to Possess and/or Exhibit Venomous Reptiles/Reptiles of Concern is also required. CAPTIVE WILDLIFE CRITICAL INCIDENT/DISASTER PLAN INSTRUCTIONS This two part form is to be completed and submitted or retained on file as indicated:  Part-A: To be completed and submitted with the initial or renewal application requesting authorization for the possession of captive wildlife.  Part-B: To be completed and retained at the licensed premises where wildlife is housed or maintained. Part-B of the Captive Wildlife Critical Incident/Disaster Plan shall be made available upon request to Commission personnel. All employees and/or volunteers should be informed of the facilities critical incident/disaster plan. PART-A: Submitted with application for initial or renewal license/permit. Please print form with responses. I. Applicant or Licensee Information: NAME: Enter full name as indicated on the application for a license/permit requesting authorization for the possession of captive wildlife. PHONE NUMBER: Enter emergency contact phone numbers for the applicant or licensee including business, home and/or cellular as applicable. BUSINESS NAME: Enter Business name, if applicable, as indicated in the application for a license/permit requesting authorization for the possession of captive wildlife. MAILING ADDRESS: Enter complete mailing address including City, State and Zip Code as indicated on the application for a license/permit requesting authorization for the possession of captive wildlife. II. Facility Information: (Location where wildlife is maintained) FACILITY ADDRESS: Enter the complete address for the facility location as indicated in the application for a license/permit requesting authorization for the possession of captive wildlife. GPS COORDINATES: Enter the GPS coordinates in Degree, Minutes, and Seconds format for the facility’s main entrance/exit. Leave blank if the coordinates are unknown. III. Emergency Contact (Individual that does not reside at the facility location) NAME: Enter the name of an individual responsible for assisting with emergency response or that may assist in providing contact information for the licensee/permittee in the event of a critical incident or disaster. BUSINESS NAME: Enter the business name for the emergency contact if applicable. MAILING ADDRESS: Enter the complete address including City, State and Zip Code for the individual responsible for assisting with emergency response or that may assist in providing contact information for the licensee/permittee in the event of a critical incident or disaster. PHONE: Enter emergency contact phone numbers for another individual responsible for assisting with emergency response or that may assist in providing contact information for the licensee/permittee in the event of a critical incident or disaster. Include business, home and/or cellular numbers as applicable. IV. Veterinarian Contact Information NAME: Enter the name of the Veterinarian used to provide veterinary services for wildlife maintained at this facility. BUSINESS NAME: Enter the Business name or clinic name for your Veterinarian. MAILING ADDRESS: Enter the complete address including City, State and Zip Code for Veterinarian or Animal Clinic used to provide veterinary services for wildlife maintained at this facility. FWCDLE 619 Instructions (02/06); Revised (06/09) Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Page 1 of 3 PHONE: Enter contact phone numbers for the Veterinarian or Animal Clinic used to provide veterinary services for wildlife maintained at this facility. Include business and/or cellular numbers as applicable. PART-B: This Part is to be kept at the facility location and made available for inspection. I. Emergency Plan Enter a detailed plan that specifies what to do (who, what, where, when and how) in the event of a disaster and critical incident, to include: Levels of Action (Pre-event, Event, and Post-event) Action plan for securing wildlife on site. Action plan for evacuation including: o Stating where all wildlife will be located and providing location and contact information. o State how long the wildlife may be maintained at this location. Action plan for re-entry to facility. All employees and/or volunteers at the facility are to be familiarized with the emergency plan. II. Capture and Transport Equipment Inventory: CHEMICAL CAPTURE EQUIPMENT: Enter a detailed list of all equipment utilized for chemical capture (including drugs, delivery systems and supplies) and the location where this equipment is stored. EMERGENCY CONTACT INFORMATION: Enter the emergency contact information (including name, complete address, and contact phone number(s)) for the person(s) authorized to utilize such equipment. Attach additional sheets as applicable. PHYSICAL CAPTURE EQUIPMENT: Enter a detailed list of all equipment utilized for physical capture (including catch poles, nets, tongs, and other capture equipment) and the location where this equipment is stored. EMERGENCY CONTACT INFORMATION: Enter the emergency contact information (including name, complete address, and contact phone number(s)) for the person(s) authorized to utilize such equipment. Attach additional sheets as applicable. TRANSPORT CAGES AND VEHICLES: Enter a detailed list of all equipment utilized to temporarily house and/or transport wildlife, and the location where this equipment is stored. EMERGENCY CONTACT INFORMATION: Enter the emergency contact information (including name, complete address, and contact phone number(s)) for the person(s) authorized to utilize such equipment. Attach additional sheets as applicable. III. Facility Information Checklist: Attach supporting documentation that includes a schematic or graphic depiction of the facility indicating the location of the following, as applicable: All facility access points (entrance(s) and exit(s)), diagram(s) of areas where wildlife is housed, location where emergency supplies are stored, location of each electrical and gas shut-off switch/valve. IV. Miscellaneous Emergency Supplies Checklist: Check applicable boxes or list any other miscellaneous emergency supplies. Document location where supplies are stored or contact information for obtaining supplies. FWCDLE 619 Instructions (02/06); Revised (06/09) Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Page 2 of 3 V. Current Animal Inventory Attach a complete inventory of the wildlife maintained at the facility location. Include the total number of each species and any identifying methods (microchip number(s), tattoo(s), mark(s), scar(s), etc.). PART-B is to be kept on file at the facility location and made available for inspection upon request of Commission personnel. FWCDLE 619 Instructions (02/06); Revised (06/09) Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Page 3 of 3 FLORIDA FISH AND WILDLIFE CONSERVATION COMMISSION DIVISION OF LAW ENFORCEMENT CAPTIVE WILDLIFE CRITICAL INCIDENT/DISASTER PLAN PART A: Complete and submit with initial or renewal application for license/permit. Please Print. I. Applicant or Licensee Information: Name: Michele Fasnacht Business Name: Solid Rock Community School Mailing Address: 2801 Keystone Road FL Tarpon Springs City Phone: ( 727 Phone: ( 727 34688 State II. Facility Information: Location where wildlife is maintained Facility Address: 3561 Keystone Road FL Tarpon Springs City Flood Zone: State Yes ✔ ) 6562920 ) 9340909 Zip Code 34688 Zip Code GPS Coordinates No III. Emergency Contact: (Person not living at facility location) Name: Eric Fasnacht Business Name: Solid Rock Communtiy School Mailing Address: 2979 Grey Oaks Blvd. FL Tarpon Springs City State IV. Veterinarian Contact Information: Veterinarian: Name: Dr. Shannon Ivy Business Name: Hidden Oaks Mailing Address: 725 East Lake Road North Tarpon Springs FL City State Phone: ( 727 Phone: ( ) 6570245 ) Phone: ( 727 Phone: ( ) 942-3616 ) 34688 Zip Code 34688 Zip Code I certify that as part of the critical incident/disaster plan, Part B of this form is maintained on file at the facility location where wildlife is housed or maintained. Furthermore said information will be made available for inspection upon request of commission personnel. Said information indicates a detailed emergency plan, inventory of capture and transport equipment, and a schematic or graphic depiction of the facility. 5/23/2023 Michele Fasnacht Name (Print) Signature FWCDLE 619 (02/06); Revised (06/09) Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Date Page 1 of 5 PART B: To be retained on file at the facility location and made available for inspection I. Emergency Plan (Attach additional sheets as necessary) Specific plan of action to be taken in the event of an emergency (natural disaster, fire, etc.) and critical incident: FWCDLE 619 (02/06); Revised (06/09) Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Page 2 of 5 II. Capture and Transport Equipment Inventory A. Chemical Capture Equipment ( Emergency Contact Information: Name: Address: City B. Physical Capture Equipment Phone: ( Phone: ( State ) ) – – Phone: ( Phone: ( ) ) – – Phone: ( Phone: ( ) ) – – Zip Code (nets, catch poles, gloves, hooks, tongs, etc.) Emergency Contact Information: Name: Address: City ) Not Applicable State Zip Code C. Transport Cages and Vehicles Emergency Contact Information: Name: Address: City State FWCDLE 619 (02/06); Revised (06/09) Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Zip Code Page 3 of 5 III. Facility Information Checklist (Attach photo or drawing depiction of the facility lay out to indicate the following) Site plan of facility Location of access points to facility if access is controlled by fences, gates, etc. Location of area(s) where captive wildlife is kept Location of supplies (food, medicines, capture equipment, etc.) Location of each electricity and gas shutoff switch/valve IV. Miscellaneous Emergency Supply Checklist Food Generator(s) Water Ice Medical Supplies Misc. Supplies Location of storage and/or contact information for obtaining supplies V. Current Animal Inventory (Attached) FWCDLE 619 (02/06); Revised (06/09) Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Page 4 of 5 Northwest Region North Central Region 3911 Hwy. 2321 3377 E. US Highway 90 Panama City, FL 32409-1658 Lake City, FL 32055-8795 (850) 265-3676 (386) 758-0525 24-Hour Law Enforcement: 24-Hour Law Enforcement: (850) 245-7710 386-758-0529 Northeast Region Southwest Region 1239 S.W. 10th Street 3900 Drane Field Road Ocala, FL 34474-2797 Lakeland, FL 33811-1299 (352) 732-1225 (863) 648-3203 24-Hour Law Enforcement: 24-Hour Law Enforcement: 352-732-1228 863-648-3200 South Region Monroe and Collier County 8535 Northlake Boulevard 24-Hour Law Enforcement: West Palm Beach, FL 33412 305-289-2320 (561) 625-5122 24-Hour Law Enforcement: 561-625-5122 State Warning Point Florida Department of Agriculture and Consumer Services Emergency: 1-800-320-0519 or 850-413-9911 Division of Animal Industry Non Emergency: 850-413-9900 850-410-0900 www.floridadisaster.org www.flsart.org FWCDLE 619 (02/06); Revised (06/09) Incorporated by reference in Rules 68A-6.0022, 68A-6.003, and 68A-6.007, F.A.C. Page 5 of 5