Fillable Commercial Cannabis Business Application (CCBA) (City of El Monte)

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Commercial Cannabis Business Application (CCBA) (City of El Monte)

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The Commercial Cannabis Business Application (CCBA) (City of El Monte) form is 2 pages long and contains:

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  • 11 check-boxes
  • 52 other fields

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File type: PDF

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WORKING DRAFT/MOCKUP
DEPARTMENT USE ONLY
APPLICATION # _________________
SUBMITTAL DATE
__________________________
CITY OF EL MONTE
Commercial Cannabis Business License Application
11333 Valley Blvd.
El Monte, CA 91731
Phone: (626) 258-8626
cannabis@elmonteca.gov
GENERAL INFORMATION
Corporate Name
Business Name (DBA) [If Applicable]
Business Address
City
State
Zip Code
Area Code/Telephone
Mailing Address
(if different from Business Address)
Sole Proprietor
Partnership
Corporation
L.L.P.
L.L.C.
Business E-Mail
Fed Tax ID No.
State ID No.
Does your business have a California State License?
Yes
No
State License Number
Classification(s)
Applicant Contact Name
Home Address
Area Code/Telephone
Driver's License No.
State
Expiration Date
Social Security No.
Property Owner 1 Name
(Attach sheet with
additional owners if necessary)
Home Address
Area Code/Telephone
Driver's License No.
State
Expiration Date
Social Security No.
Business Owner 1 Name
(Attach sheet with
additional owners if necessary)
Home Address
Area Code/Telephone
Driver's License No.
State
Expiration Date
Social Security No.
ly City of El Monte
e Friendly City of El Monte
Monte
CITY OF EL MONTE
Commercial Cannabis Business License Application
11333 Valley Blvd.
El Monte, CA 91731
Phone: (626) 258-8626
cannabis@elmonteca.gov
The Friendly City of El Monte
Sales Tax (Seller's Permit) # _________________
ATTACH COPY
DATE
APPLICANT SIGNATURE
BUSINESS OPERATIONS INFORMATION
PROPERTY INFORMATION
1.
License Type Sought (Mark ALL that apply)
Retail Cultivation Manufacturing Distribution Testing Microbusiness
2.
Zoning Designation
General Plan Designation
Assessor Parcel Number(s)
3.
4.
Has the applicant obtained a Letter of Zoning Compliance? ATTACH COPY
YES NO
Has the applicant been previously applied for a Medical Business License
from the City of El Monte under Ordinance No. 2924?
Application Number: # MMCB __________________________
YES NO
Current Description of Property
DISCLOSURES
List whether the applicant(s) have other licenses and/or permits issued to and/or revoked from the applicant in the three years prior to the year of this permit application, such other licenses
and/or permits relating to similar business activities as in this permit application. If yes, list the type, current status, and issuing/denying agency for each license/permit. Attach a separate
page for explanation if necessary.
List any and ALL Owners who have been convicted of a felony or have engaged in misconduct that is substantially related to the qualifications, functions or duties of a cannabis operator,
applicant, owner or employee. A conviction within this section means a plea or verdict of guilty, or a conviction following a plea of no contest. Attach a separate page for explanation if
necessary.
ACKNOWLEDGEMENT
I hereby certify that I am the applicant or designated agent named herein and that I am familiar with the rules and regulations with respect to preparing and filing this petition for ministerial
action, and that the statements and answers contained herein and the information attached are in all respects true and accurate to the best of my knowledge and belief.
In addition, I understand that the filing of this application grants the City of El Monte permission to reproduce submitted materials, including but not limited to: plans, exhibits, and
photographs for distribution to staff, Commission, Board, and City Council members, and other Agencies in order to process the application. Nothing in this consent however, shall entitle
any person to make use of intellectual property and confidential personal information in plans, exhibits and photographs for any purpose unrelated to the City's consideration of this
application.
Furthermore, by submitting this application, I understand and agree that any business resulting from an approval shall be maintained and operated in accordance with El Monte Municipal
Code and California State Law.
Please note all correspondence will be directed to the designated applicant.
The property owner further certifies that they are the legal owner of the property, consent to the filing of this application and have authorized the applicant below to represent them with
respect to the processing of this application.
PRINT NAME/TITLE
PROPERTY OWNER SIGNATURE
DATE
PRINT NAME/TITLE
click to sign
signature
click to edit
click to sign
signature
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APPLICANT CERTIFICATION
I hereby certify, under penalty of perjury, on behalf of myself and all owners, managers and supervisors identified
in this application that the statements and information furnished in this application and in the attached exhibits
present the data and information required for this initial evaluation to the best of my ability, and that the facts,
statements, and
information presented are true and correct to the best of my knowledge and belief. I understand
that a misrepresentation of fact is cause for rejection of this application, denial of the permit, or revocation of a
permit issued.
In addition, I understand that the filing of this application grants
the City of El Monte permission to reproduce
submitted materials, including but
not limited to, plans, exhibits, and photographs, for distribution to staff,
consultants, and other Agencies in order to process the application. Nothing in this consent, however, shall
entitle any person to make use of the intellectual property in plans, exhibits and photographs for any purpose
unrelated to the City's consideration of this application.
Furthermore, by submitting this application I understand and agree that any business resulting from an approval
shall be maintained and operated in accordance with requirements of the El Monte Municipal Code and State law.
Name
Signature
Title
Date
A nota
ry public or other officer completing this certificate verifies only the identity of the individual who
signed the document to which this certificate
is attached, and not the truthfulness, accuracy, or validity
of that document.
State of California
County of
Subscribed and sworn to (or affirmed) before me on this __________ day of ______________, 20___, by
____________________________________ ,
proved to me on the basis of satisfactory evidence to be
the person(s) who appeared before me.
(Seal) Signature
PROPERTY OWNER CONSENT
If applicant is other than the property owner(s), the owner(s) must provide a signed statement consenting to
filing pursuant to Ordinance No. 2960 of the El Monte Municipal Code. Original signatures only.
I/We, as the owner(s) of the subject property, consent to
the filing of this application and use of the property for
the purposes described h
erein. We further consent and hereby authorize City representative(s) to enter upon my
property for the purpose of examining and inspecting the property in preparation of any reports and/or required
environmental review for the processing of the application(s) being filed.
Name
Signature
Title
Date
A notary public or other officer completing this certificate verifies only the identity of the individual who
s
igned the document to which this certificate is attached, and not the truthfulness, accuracy, or validity
of that document.
State of California
County of
Subscribed and sworn to (or affirmed) before me on this __________ day of ______________, 20___, by
____________________________________ , proved to me on the basis of satisfactory evidence to be
the person(s) who appeared before me.
(Seal) Signature
El Monte Limitations on City’s Liability and Certifications,
Assurances and Warranties – (Must be completed by all applicants)
a. WAIVER AND RELEASE OF LIABILITY AND AGREEMENT TO INDEMNIFY THE CITY OF EL MONTE
The applicant and all owners and operators hereby waives and releases the City from any and all
liability for monetary damages related to
or arising from the application for a permit, the issuance of
the permit, or the enforcement of the conditions of the permit. The applicant certifies that under no
circumstances shall the applicant cause any cause of action for monetary damages against the City of
El Monte, the permitting official or any City employee or agent as a result of this permit application or
issuance or the enforcement of the conditions of the permit.
b. RELEASE CITY OF EL MONTE FROM LIABILITY FOR ISSUING THE APPLICANT A PERMIT
By applying for a permit pursuant to the EL Monte Commercial Cannabis Business Permit and
by
accepting a permit, from the City of El Monte Community and Economic Development Department
acting as the El Monte Local Permitting Authority, the applicant/permittee, owners and operators,
and each of them, waives and releases El Monte, and its elected officials, employees, agents, insurers
and attorneys, and each of them, from any liability for injuries, damages, costs and expenses of any
nature whatsoever that result or relate to the investigation, arrest or prosecution of business
owners, operators, employees; clients or customers of the applicant/permittee for a violation of
state or federal laws, rules or regulations relating to cannabis activities.
c. AGREEMENT TO INDEMNIFY CITY OF EL MONTE
By applying for a permit pursuant to the El Monte Commercial Cannabis Permit Program and by
accepting a permit, from the El Monte Community and Economic Development Department acting as
the El Monte Local Permitting Authority, the applicant/permittee, owners and operators, and each of
them, jointly and severally if more than one, agrees to indemnify, defend and hold harmless El
Monte, and its elected officials, employees, agents, insurers and attorneys, and each of them, against
all liability, claims and demands, of any nature whatsoever, including, but not limited to, those
arising from bodily injury, sickness, disease, death, property loss
and property damage, arising out of
or in any manner related to the operation of the commercial cannabis business that is the subject of
the permit.
d. The applicant, commercial cannabis business manager and anyone with an ownership interest in the
business referenced herein represents and certifies they have submitted to
a Live Scan and/or
background check no earlier than 30 days prior to the date of this application.
e. For renewals, the applicant represents and certifies that they continue to hold in good standing any
permit/license required by the State of California where applicable for a commercial cannabis business
operation.
f.
The applicant understands that operators, employees and members of the commercial cannabis
business may be subject to prosecution under Federal Laws.
A notary public or other officer completing this certificate verifies only the identity of the individual who
signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity
of that document.
g.
The person wh
ose signature appears below is authorized to sign this application on behalf of the
business and has submitted this information and all attachments as required by the application process
to obtain a commercial cannabis permit from the City of El Monte.
I declare under penalty of perjury
that the information provided on this form is true and correct and do
hereby apply for a permit pursuant to El Monte Municipal Code Chapter 5.18 and in compliance with
El Monte Ordinance No. 2960, and all other applicable Sections of this Ordinance.
Applicant Signature
Printed Name and Title
Date
State of California
County of
Subscribed and sworn to (or affirmed) before me on this __________ day of ______________, 20___, by
____________________________________ , proved to me on the basis of satisfactory evidence to be
the person(s) who appeared before me.
(Seal) Signature
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Commercial Cannabis Business Application (CCBA) (City of El Monte)

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Completed 3 August 2020

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