Fillable Commonwealth of Massachusetts Medicinal Use of Marijuana Program Application of Intent Request for a Certificate of Registration

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Commonwealth of Massachusetts Medicinal Use of Marijuana Program Application of Intent Request for a Certificate of Registration

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
Medical Use of Marijuana Program
99 Chauncy Street, 11
th
Floor, Boston, MA 02111
CHARLE
S D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor
MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD, MPH
Commissioner
Tel: 617-660-5370
www.mass.gov/medicalmarijuana
APPLICATION OF INTENT
Request for a Certificate of Registration to
Operate a Registered Marijuana Dispensary
INSTRUCTIONS
This application form is to be completed by an entity that wishes to
apply for a Certificate of Registration to
operate a Registered Marijuana Dispensary (“RMD”) in Massachusetts (“applicant”).
If seeking a Certificate of Registration for more than one RMD, the applicant must submit a separate Application of
Intent, all required attachments, and an application fee for each proposed RMD. Please identify each application of
multiple applications by designating it as Application 1, 2 or 3 in the header of each application page. Please note
that no executive, member, or any entity owned or controlled by such an executive or member, may directly or
indirectly control more than three RMDs.
Unless indicated otherwise, all responses must be typed into the application forms. Handwritten responses will not
be accepted. Please note that character limits include spaces.
Attachments should be labeled or marked so as to identify the question to which it relates.
Each submitted application must be a complete, collated response, printed single-sided on 8 ½” x 11” paper, and
secured with a binder clip (no ring binders, spiral binding, staples, or folders).
Mail or hand-deliver the Application of Intent, with all required attachments, the $1,500 application fee, and
Remittance Form to:
Department of Public Health
Medical Use of Marijuana Program
RMD Applications
99 Chauncy Street, 11
th
Floor
Boston, MA 02111
Application fees are non-refundable and non-transferable.
Application ____ of _____ Name of Applicant Corporation _________________________________
Information on this page has been reviewed by the applicant, and where provided by the applicant, is accurate and complete, as
indicated by the initials of the authorized signatory here: _______
Application of Intent – Page 2
REVIEW
Applications are reviewed in the order they are received.
After a completed application p
acket and fee is received by the Department of Public Health
(“Department”), the Department will review the information and will contact the applicant if clarifications
or updates to the submitted application materials are needed. The Department will notify the applicant
whether it has met the standards necessary to be invited to submit a Management and Operations Profile.
If invited by the Department to submit a Management and Operations Profile, the applicant must submit
the Management and Operations Profile within 45 days from the date of the invitation letter, or the
applicant must submit a new Application of Intent and fee in order to proceed in the application process.
Applicants must receive an invitation from the Department to submit a Siting Profile within 1 year of the
date of submission of the Management and Operations Profile.
PROVISIONAL CERTIFICATE OF REGISTRATION
Applicants must receive a Provisional Certificate of Registration from the Department within 1 year of the
date of the invitation letter from the Department to submit a Siting Profile. If the applicant does not meet
this deadline, the application will be considered to have expired. Should the applicant wish to proceed
with obtaining a Certificate of Registration, a new application must be submitted, beginning with an
Application of Intent, together with the associated fee.
REGULATIONS
For complete information regarding registration of an RMD, please refer to 105 CMR 725.100, as well as
materials posted on the Medical Use of Marijuana Program website: www.mass.gov/medicalmarijuana.
It is the applicant’s responsibility to ensure that all responses are consistent with the requirements of 105
CMR 725.000, et seq., and any requirements specified by the Department, as applicable.
PUBLIC RECORDS
Please note that all application responses, including all attach
ments, will be subject to release pursuant to
a public records request, as redacted pursuant to the requirements at M.G.L. c. 4, § 7(26).
QUESTIONS
If additional information is needed regarding the RMD application process, please contact the Medical
Use of Marijuana Program at 617-660-5370 or RMDapplication@state.ma.us.
Application ____ of _____ Name of Applicant Corporation _________________________________
Information on this page has been reviewed by the applicant, and where provided by the applicant, is accurate and complete, as
indicated by the initials of the authorized signatory here: _______
Application of Intent – Page 3
CHECKLIST
The forms and documents listed below must accompany each application, and be submitted as outlined
above:
A fully and properly completed Application of Intent, signed by an authorized signatory of the
applicant
A copy of the applicant’s Certificate of Good Standing (as outlin
ed in Section B)
Financial account summary(ies) (as outlined in Section D)
A completed Remittance Form (use template provided)
A bank or cashier’s check made payable to the Commonwealth of Massachusetts for $1,500
Application ____ of _____ Name of Applicant Corporation _________________________________
Information on this page has been reviewed by the applicant, and where provided by the applicant, is accurate and complete, as
indicated by the initials of the authorized signatory here: _______
Application of Intent – Page 4
SECTION A. APPLICANT INFORMATION
1.
Legal name of Applicant Corporation
2.
Mailing address of Applicant Corporation (Street, City/Town, Zip Code)
3.
Applicant Corporation’s point of contact (the person the Department should contact regarding this
application)
4.
Point of contact’s telephone number
5.
Point of contact’s e-mail address
6. Number of applications: How many Applications of Intent does the applicant intend to submit?
SECTION B. INCORPORATION
1. Attach a copy of the applicant's Certificate of Good Standing from the Massachusetts Secretary
of the Commonwealth. The Certificate of Good Standing must be dated no earlier than 90 days
prior to the date of the Application of Intent is received by the Department.
Application ____ of _____ Name of Applicant Corporation _________________________________
Information on this page has been reviewed by the applicant, and where provided by the applicant, is accurate and complete, as
indicated by the initials of the authorized signatory here: _______
Application of Intent – Page 5
SECTION C. INDIVIDUALS AND ENTITIES AFFILATED WITH APPLICANT
List the full name, title(s) or role(s) at the applicant corporation, and date of birth (if an individual) of the
following individuals and entities. Add more tables if needed:
The Chief Executive Officer; Chief Operating Officer; Chief Financial Officer; individual/entity
responsible for marijuana for medical use cultivation operations; individual/entity responsible for the
RMD security plan and security operations; each individual performing onsite services on behalf of a
contractor or consultant as Cultivation or Security Manager or the equivalent, if known during the
application process; each member of the Board of Directors; each Member of the Corporation, if any; and
each person and entity known to date that is committed to contributing 5% or more of initial capital to
operate the proposed RMD. If the applicant does not have a Chief Executive Officer, Chief Operating
Officer, or Chief Financial Officer, it must identify the individuals performing the equivalent duties for
the applicant.
For entities contributing 5% or more of initial capital to operate the proposed RMD, list the entity’s Chief
Executive Officer or Executive Director and President or Chair of the Board of Directors. If the entity
does not have a Chief Executive Officer or Executive Director or President or Chair of the Board of
Directors, identify the individuals performing the equivalent duties for the entity.
Full Name
Title(s)
Date of Birth
Application ____ of _____ Name of Applicant Corporation _________________________________
Information on this page has been reviewed by the applicant, and where provided by the appli
cant, is accurate and complete, as
indicated by the initials of the authorized signatory here: _______
Application of Intent – Page 6
SECTION D. INITIAL CAPITAL REQUIREMENT
Describe the sources, types, and amounts of required initial capital in the table below, showing that the
applicant has at least $500,000 in its control and available for this Application of Intent and at least
$400,000 in its control and available for each additional Application of Intent, if any, as evidenced by
bank statements, lines of credit, or financial institution statements. Add more tables if needed.
If the required funds are being held in an account in the name of an individual or entity other than the
applicant, the individual or authorized signatory of the entity must provide their signature in the
“Signature of Account Holder” column. Their signature below indicates that they are committing the
amount of their funds identified in the table to the applicant.
I
n
addition to completing this table, submit a one-page financial account summary fo
r each accou
nt listed
below documenting the available funds, dated no earlier than 30 days prior to the date the Application of
Intent was submitted to the Department. Please ensure that the financial account summary contains the
name of the account holder, name of financial institution, and indicates the type of account (e.g.,
checking, savings, etc.).
Name of Account
Holder
Financial
Institution
Type of Account Amount
Signature of
Account Holder
$
$
$
$
$
$
$
-------- -------- ----- --
$
Total
----
0.00
Application ____ of _____ Name of Applicant Corporation _________________________________
Information on this page has been reviewed by the applicant, and where provided by the applicant, is accurate and complete, as
indicated by the initials of the authorized signatory here: _______
Application of Intent – Page 7
ATTESTATIONS
Signed under the pains and penalties of perjury, I, the authorized signatory for the applicant, agree and
attest that all information included in this application is complete and accurate and that I have an ongoing
obligation to submit updated information to the Department if the information presented within this
application has changed.
____________________________
Signature of Authorized Signatory
Date Signed
Print Name of Authorized Signatory
Title of Authorized Signatory
I, the authorized signatory for the applicant, hereby attest that if the applicant is allowed to proceed to
submit a Management and Operations Profile, the applicant is prepared to pay a non-refundable
application fee of $30,000 and the cost of all required background checks, and comply with all
Management and Operations Profile and Siting Profile requirements.
____________________________
Signature of Authorized Signatory
Date Signed
Print Name of Authorized Signatory
Title of Authorized Signatory
Application ____ of _____ Name of Applicant Corporation _________________________________
Information on this page has been reviewed by the applicant, and where provided by the applicant, is accurate and complete, as
indicated by the initials of the authorized signatory here: _______
Application of Intent – Page 8
I hereby attest that I understand that registered marijuana dispensaries are required to conduct background
investigations of proposed Dispensary Agents, that such background investigations are subject to the
Department’s inspection and review, and that the applicant will not engage the services of a Dispensary
Agent that has ever been convicted of a felony drug offense in Massachusetts, or a like violation of the
laws of another state, the United States, or a military, territorial, or Indian tribal authority.
____________________________
Signature of Authorized Signatory
__ ________________
Date Signed
Print Name of Authorized Signatory
Title of Authorized Signatory
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Commonwealth of Massachusetts Medicinal Use of Marijuana Program Application of Intent Request for a Certificate of Registration

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Completed 17 May 2020

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