Pennsylvania Department of Health – 03/2021

WIC Retail Store Application

PENNSYLVANIA DEPARTMENT OF HEALTH Bureau of Women, Infants and Children (WIC)

Please Print In Ink (Legibly) Or Type Except For Signature

Date: _____________

Select one: New application for store not currently authorized

Reauthorization application for a currently authorized vendor. If vendor is currently authorized, please enter your WIC vendor number (id):_______

PART I – STORE IDENTIFICATION

1. NAME OF STORE:___________________________________________________

WIC Only Store

5. STORE MAILING ADDRESS (if different from store location above):

2. STORE TYPE: Full Line Grocery Store

3. STORE LOCATION:a) Plaza S/C:or b) Street:c) City, State & Zip:

4. STORE COUNTY:

a) Plaza S/C:or b) Street:c) City, State & Zip:

6. STORE TELEPHONE & FAX NUMBERS:

Area Code, Number, and Extension Ext._______ Fax:________________

7. STORE EMAIL ADDRESS:

8. STORE CONTACT PERSON:a) Name:b) Position Title:c) Contact email address: ___________________________________________________________

9. STORE SIZE: Approximate size of sales area in square feet:

10. STORE EQUIPMENT

STORE SCANNERS:a) Does your store have check out scanners? YES NO

b) Do scanners identify WIC Items? YES NOc) Does your store have a computer with internet access? NO

11. FOOD SALES: Gross volume of Food Sales for Last Completed Tax Year: $

Last quarter gross food sales $__________ Last month’s gross food sales $__________

YES

__________________

Pennsylvania Department of Health – 03/2021

Friday _______ a.m. to _______ p.m. Saturday ________ a.m. to _______ p.m. Sunday ________ a.m. to _______ p.m.

12. STORE HOURS:Monday ________ a.m. to ________ p.m.Tuesday ________ a.m. to ________ p.m.Wednesday ________a.m. to ________ p.m.Thursday ________ a.m. to ________ p.m.

13. NUMBER OF CASH REGISTERS: _____

14. SNAP PROGRAM PARTICIPATION:a) Does this store currently participate in the USDA Supplemental Nutrition Assistance Program (SNAP)?

YES NOIf yes, give SNAP Number ________________________

b) Is this store currently sanctioned or disqualified from the USDA Supplemental Nutrition Assistance Program?YES NO

If yes, give period of disqualification or sanction (if any).

TO________________Give reasons for sanction(s) or disqualification(s). If more than one, give details.

______________________________________________________________________________________

PART II - OWNERSHIP/IDENTIFICATION

15. Type of Business Structure: Corporation LLC Partnership Sole Proprietorship

16. Name of corporation, the names of all partners, or the name of the individual owner if a soleproprietorship:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

17. Have any of the store's current owners, officers, or managers been convicted of a criminal offense or had acivil judgment entered against them relating to conduct demonstrating a lack of business integrity?

YES NO

18. FEDERAL IDENTIFICATION NUMBER:_________________________

19. OWNER’S LOCATION: (address)a) Plaza o : r S/Cb) Street:c) City, State & Zip

20. OWNER’S MAILING ADDRESS (if different than owner’s location above):a) Plaza o : r S/Cb) Street:c): City, State & Zip

21. OWNER’S TELEPHONE NUMBER:Area Code, Number, and Extension

22. OWNER’S EMAIL ADDRESS:

23. STORES OWNED:Total Number of Stores Owned:

Ext. _______

FROM ________________

_______________________________________

_______

_______________

Store open 24 hours, 7 days per week

Pennsylvania Department of Health – 03/2021

PART III – UNDERSTANDING AND COMMITMENT

24. I have legal authority to apply for and sign this application seeking authorization for the store toparticipate in the WIC Program.

25. The state regulations governing the WIC Program, 28 Pa. Code §1101.1 – 1113.5, have beenreviewed by me, and I am in compliance with §1103.4(13) concerning business integrity.

26. I understand that if the store’s application to become a WIC-authorized vendor is accepted, suchauthorization to participate in the WIC Program does not constitute a license or property interest andbecomes null and void if there is a change of ownership of the store. I also understand that I mustnotify the Department and local agency immediately when I become aware that such a change willoccur.

27. In accordance with state regulations, I understand that if the store’s application to become a WIC-authorized vendor is accepted, such authorization to participate in the WIC Program is valid onlyuntil such time as the Department conducts the next periodic reauthorization review. At such time, Iam aware that I must seek reauthorization by submitting a new WIC Retail Store Application. If Ifail to do so or if my store is denied reauthorization at that time, the Department will notify me of thedate when the store’s current authorization expires.

28. I understand that the store must have a store front sign. The store front sign must be a permanent,fixed sign reflecting the store’s business name or the business name registered with the Departmentof State with no other visible name. The name on the sign must match the name submitted on thestore’s WIC Retail Store Application for the store to be considered for authorization on thePennsylvania WIC Program.

29. I understand that stores may not use the WIC Acronym in the store’s name, registered or notregistered, nor can stores use the letters “W” “I” and “C” in that order in the store’s name. Thepurpose of this restriction is to avoid giving the impression to WIC customers that the business isaffiliated with or sponsored by the State agency, USDA, or the WIC Program.

30. I understand that if the store receives authorization for participation in the WIC program, I shalldesignate personnel to attend an initial mandatory training before the store is authorized. Thetraining shall be conducted by the local agency responsible for the administration of the WICProgram in the area in which the store is located.

31. I understand that if the store is disqualified from participation in the Supplemental NutritionAssistance Program (SNAP) or is assessed a Civil Money Penalty (due to inadequate participantaccess) in lieu of SNAP disqualification, the store will be disqualified from participation in the WICProgram for the same period of time as the SNAP disqualification or for the same period of the storewould have been disqualified had a SNAP Civil Money Penalty not been assessed. I furtherunderstand that if the Department imposes a sanction upon the store which results in disqualificationfrom the WIC Program, the WIC Program is required to notify the SNAP of the disqualification.

32. I am aware that the WIC Program is an equal opportunity program and that I may not discriminate onthe basis of race, color, sex, age, religion, national origin or disability.

33. I have read the application and the state regulations, which includes the terms and conditions ofparticipation set forth in §1105.3 of the state regulations. I agree to comply with the requirements setforth in the application and the state regulations and with any changes made during the agreementperiod.

Pennsylvania Department of Health – 03/2021

34. I assert that all of the statements in this application are true. I understand that false statements madeherein will result in the denial of authorization to participate in the WIC Program or rescission of theauthorization should the information be found to be false after the store has been approved forauthorization.

35. I understand that the State agency will terminate the agreement if the State agency identifies aconflict of interest, as defined by applicable State laws, regulations, and policies, between thevendor and the State agency or its local agencies.

36. The State agency will notify vendors of changes to Federal or State statutes, regulations, policies, orprocedures governing the Program before the changes are implemented. The State agency will giveas much advance notice as possible.

SIGNATURE PAGE

________________________ Date

__________________________________________ Signature

__________________________________________ Name and Title (Please Print)

For State Agency Use Only

_________________________________________________ State Agency Representative Signature

________________________ Date

Send completed applications to: Pennsylvania Department of Health

Bureau of WIC Reauthorization Processing

625 Forster Street 7 West Health & Welfare Bldg.

Harrisburg, PA 17120 Fax: 717-705-0462

Email: RA-DHPAWICVENDOR@PA.GOV

In accordance with Federal law and U.S. Department of Agriculture policy, WIC is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Pennsylvania Department of Health – 03/2021

WIC Retail Store Application Instructions

PENNSYLVANIA DEPARTMENT OF HEALTH Division of Women, Infants and Children (WIC)

A. PURPOSE: The following application is used to apply for authorization or reauthorization as a WIC authorizedvendor in the Pennsylvania WIC Program to provide supplemental foods to women, infants, and children. Theapplication may be used to apply for one (1) store. A separate application is required for each different store.

B. “STORE APPLICATION”: The “WIC Retail Store Application” is divided into three (3) parts. Part 1 is used toidentify the store; Part II is used to identify the ownership of the store; and, Part III is used by theowner/representative to pledge the store’s acceptance of all terms and conditions of participation.

C. PART 1 – STORE IDENTIFICATION: Record data on the form as indicated below, so that the store’s nameand location can be determined. Stores are responsible for updating information upon change.

1. NAME OF STORE: Enter the name of the store as it appears on the storefront sign.

2. STORE TYPE: Fill in the circles that best describe your store.

3. STORE LOCATION:

a) Plaza or Shopping Center (S/C): Enter the name of the plaza or shopping center where the store is located,if applicable.

b) Street: Enter the name of the street, the rural delivery route, box number, name of road highway or routenumber. (Note: This must not be a post office box number.)

c) City, State and Zip Code: Enter the name of city or town, the state, and zip code. (Note: The zip codeshould be that of the store location not the zip code for a store’s post office box number.)

4. STORE COUNTY: Enter the name of county in which the store is located.

5. MAILING ADDRESS: Enter the mailing address of the store, not the owner, for the following:

a) Plaza or S/C: Enter the mailing address of the store (plaza or shopping center);

b) Street: Enter the number and street address, OR the rural delivery route and box number AND name ofroad OR highway route number, OR post office box number considered as mailing address.

c) City, State and Zip Code: Enter the name of the city or town, the state, and zip code.

6. STORE TELEPHONE & FAX NUMBERS: Enter the telephone & fax numbers at the store’s location.

7. STORE EMAIL ADDRESS: Enter Store’s Email Address.

8. STORE CONTACT PERSON:

a) NAME: Enter the name of the person designated as the person to contact at the store regarding the WICProgram. This will be the individual to whom correspondence concerning the store’s participation in theWIC Program will be directed. NOTE: If the person changes at any time during the store’s authorizationas a WIC vendor, the store is responsible for notifying the Department. This will not require a newapplication.

b) TITLE: Enter the title of the store contact person.

9. STORE SIZE: Enter the size of the store’s sales area in square feet.

Pennsylvania Department of Health – 03/2021

10. STORE EQUIPMENT: Circle the appropriate responses.

11. STORE SALES: Enter the gross dollar amount of food sales for the longest period available.

12. STORE HOURS: Record the days and hours of store operation.

13. NUMBER OF CASH REGISTERS: Enter the number of cash registers in the store.

14. SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) PARTICIPATION:

a) Indicate whether the store is currently authorized to participate in the SNAP and enter the store’s SNAPnumber.

b) Enter yes if the store is currently disqualified or has been sanctioned (including a Civil Money Penalty)from the SNAP (USDA). Provide dates and reasons. Otherwise enter No. If more details are necessary,use a separate sheet.

D. PART II – OWNERSHIP IDENTIFICATION

15. TYPE OF BUSINESS STRUCTURE: Enter the appropriate business structure type.

16. ENTER APPROPRIATE NAMES(S). Use an additional sheet, if necessary.

17. CONVICTIONS: Circle the appropriate response.

18. FEDERAL IDENTIFICATION NUMBER: Enter the store’s nine (9) digit identification number provided toyou for tax purposes.

19. OWNER’S LOCATION (address):

a) Plaza or S/C: Enter the address if different from store address.b) Street: Enter the number and street, OR the rural delivery route and box number AND name of road OR

highway route number if different from store address.c) City, State, and Zip Code: Enter the name of the city or town, the state, and zip code if different from

store address.

20. OWNER’S MAILING ADDRESS:

a) Plaza or S/C: Enter the address if different from store address.b) Street: Enter the number and street, OR the rural delivery route and box number AND name of road OR

highway route number if different from store address.c) City, State, and Zip Code: Enter the name of the city or town, the state, and zip code if different from

store address.

21. OWNER’S TELEPHONE NUMBER: Enter the telephone number where the owner may be contacted.

22. OWNER’S EMAIL ADDRESS: Enter Owner’s Email Address.

23. STORES OWNED: Enter the total number of stores owned by the owner/corporation.

PART III – UNDERSTANDING AND COMMITMENT

The owner representative must sign and date the application prior to the Local Agency on-site review.

WIC is an equal opportunity provider and employer.