CITY OF PORTLAND
Permitting and Inspections Department
389 Congress Street, Room 307
Portland, Maine 04101
207-874-8557
marijuana@portlandmaine.gov • www.portlandmaine.gov
Application for Marijuana Food Service Establishment License
Business Information
Business Name (d/b/a):
Phone:
Location Address:
Zip:
If new, what was formerly at
this location:
Mailing Address:
Zip:
Contact Person:
Phone:
Contact Person Email:
Manager of Establishment:
Phone:
Owner of Premises
(Landlord):
Address of Premises
Owner:
Zip:
Sole Proprietor/Partnership Information (If Corporation, leave blank)
Name of Owner(s)
Date of Birth
Residence Address
Corporate/LLC/Non-Profit Organization Applicants (If Sole Proprietor or Partnership, leave blank)
Phone:
Principal Officers
Title
Date of Birth
Residence Address
Corporate Name
Corporate Mailing Address
Application Fee: $45 Marijuana FSE with Prep: $459
Health Inspection $150
CITY OF PORTLAND
Permitting and Inspections Department
389 Congress Street, Room 307
Portland, Maine 04101
207-874-8557
marijuana@portlandmaine.gov • www.portlandmaine.gov
Type of Food Made (include a menu):
Hours & Days of Operation:
Certified Food Protection Manager Certificate number & expiration date:
_________________________________________________
If this has not yet been obtained, indicate that it is pending. Please have it ready for your health inspection.
QUESTION- For Food Service Establishments ONLY:
Yes/No
Does the issuance of this license directly or indirectly benefit any City employee(s)?
Y/N
If Yes, list name(s) of employee(s) and department(s):
Have any of the applicants, including the corporation (if applicable), ever held a business license with the City of
Portland?
Y/N
If Yes, please list business name(s) and location(s):
Is any principal officer under the age of 18?
Y/N
Applicant, by signature below, agrees to abide by all laws, orders, ordinances, rules and regulations governing the above licensee and
further agrees that any misstatement of material fact may result in refusal of license or revocation if one has been granted. Applicant
agrees that all taxes and accounts pertaining to the premises will be paid prior to issuance of the license.
It is understood that this and any application(s) shall become public record and the applicant(s) hereby waive(s) any rights to privacy
with respect thereto. I/We, hereby authorize the release of any criminal history record information to the Permitting and Inspections
Department. I/We, hereby waive any rights to privacy with respect thereto.
Signature _________________________________ Title_________________________ Date______________________
For more information about Food Service Establishments and Community Kitchens, see Portland City Code Chapter 11 at:
www.portlandmaine.gov
Date Received in Office:___________________________________
click to sign
signature
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