Fillable Commonwealth of Massachusetts Medicinal Use of Marijuana Program Management and Operations Profile

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Commonwealth of Massachusetts Medicinal Use of Marijuana Program Management and Operations Profile

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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
CHARLES D. BA
KER
Governor
KARYN E. POLITO
Lieutenant Governor
MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD, MPH
Commissioner
Tel: 617-660-5370
www.mass.gov/medicalmarijuana
MANAGEMENT AND OPERATIONS PROFILE
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, and has been invited by the
Department of Public Health (“Department”) to submit a Management and Operations Profile
(“applicant”).
Once 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.
If invited by the Department to submit more than one Management and Operations Profile, the applicant must
submit a separate Management and Operations Profile, attachments, and 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.
However, even if submitting a Management and Operations Profile for more than one RMD, an applicant
need only submit one Employment and Education Form, Character and Competency Form and background
check packet, including authorization forms for all required individuals and entities, and fee associated with
the background checks.
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).
Application ____ 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: _______
Management and Operations Profile – Page 2
Mail or hand-deliver the Management and Operations Profile, with all required attachments, the $30,000
application fee, and completed Remittance Form to:
Department of Public Health
Medical Use of Marijuana Program
RMD Applications
99 Chauncy Street, 11
th
Floor
Boston, MA 02111
All fees are non-refundable and non-transferable.
REVIEW
Applications are reviewed in the order they are received.
After a completed application packet and fee is received by the 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 Siting Profile.
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, or the applicant must submit a new Application of
Intent and fee in order to proceed in the application process.
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 attachments, will be subjec
t to release pursuant to a
public records request, as redacted pursuant to the requirements at M.G.L. c. 4, § 7(26).
Application ____ 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: _______
Management and Operations Profile – Page 3
QUESTIONS
If additional information is needed regarding the RMD application process, please con
tact the Medical Use of
Marijuana Program at 617-660-5370 or RMDapplication@state.ma.us.
Application ____ 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: _______
Management and Operations Profile – Page 4
CHECKLIST
The forms and documents listed below must accompany each application, and be submitted as outlined above:
A fully and properly completed Management and Operations Profile, signed by an authorized signatory of
the applicant
A copy of the applicant’s Articles of Organization (as outlined in Section B)
A copy of the applicant’s Certificate of Good Standing (as outlined in Section B)
A copy of the applicant’s bylaws or operating agreement (as outlined in Section B)
An Employment and Education Form for each required individual (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 $30,000
A sealed envelope with the name of the applicant and marked “authorization forms,” that contains the
background check authorization forms (use forms provided) and fee, for each of the following actors:
The Chief Executive Officer; Chief Operating Officer; Chief Financial Officer; individual/entity responsible for
mariju
ana 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 consulting or contracted company
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 and submit these forms for each said individual.
For entities contributing 5% or more of initial capital to operate the proposed RMD, the forms must be completed
by 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, it must identify the individuals performing the equivalent duties for the entity and submit these forms
for each said individual.
A completed and signed Character and Competency Form for each required actor (as
outlined in Section G)
Application ____ 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: _______
Management and Operations Profile – Page 5
SECTION A. APPLICANT INFORMATION
1.
Legal name of Applicant Corporation
2.
Name of Applicant Corporation’s Chief Executive Officer
3.
Mailing address of Applicant Corporation (Street, City/Town, Zip Code)
4.
Applicant Corporation’s point of contact (name of person Department should contact regarding this
application)
5.
Point of contact’s telephone number
6.
Point of contact’s e-mail address
7. Number of applications: How many Management and Operations Profiles does the applicant intend to
submit?
SECTION B. INCORPORATION
8. Attach a copy of the applicant’s Articles of Organization, documenting that the applicant is an entity
incorporated in Massachusetts.
9.
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 da
ented no earlier than 90 days prior to the
date the Management and Operations Profile is received by the Department.
10.
Attach a copy of the applicant’s bylaws (if a non-profit or domestic business corporation) or operating
agreement (if a limited liability company).
Application ____ 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: _______
Management and Operations Profile – Page 6
SECTION C. NON-PROFIT COMPLIANCE
If the applicant is a non-profit corporation, answer each of the questions in Section C to explain how the
corporation will remain in compliance with the non-profit requirements of Ch. 369 of the Acts of 2012, the
regulations at 105 CMR 725.000, and “Guidance for Registered Marijuana Dispensaries Regarding Non-Profit
Compliance.” Please refer to the “Guidance for Registered Marijuana Dispensaries Regarding Non-Profit
Compliance” document in completing this Section.
11. Please identify any management company that the applicant intends to utilize and summarize the terms
of any agreement or contract, executed or proposed, with the management company.
12. Please identify any agreements or contracts, executed or proposed, in which the applicant will engage in
a Related Party Transaction and summarize the terms of each such agreement.
Application ____ 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: _______
Management and Operations Profile – Page 7
13. Please identify whether any members of the Board of Directors are also serving as employees of the
proposed RMD and, if so, their title and role with the proposed RMD.
14. Please identify whether any members of the Board of Directors are serving as officials, executives,
corporate members or board membe
rs for any management company, investor or other third party
proposed to contract or otherwise conduct business with the proposed RMD.
Application ____ 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: _______
Management and Operations Profile – Page 8
15. Please identify any contract or agreement, executed or proposed, under which a percentage or portion of
the applicant’s revenue will be distributed to a third party and summarize the terms of
any such
agreement or contract.
ATTESTATION
The applicant agrees and attests that it will operate in compliance with th
e “Guidance for Registered Marijuana
Dispensaries Regarding Non-Profit Compliance.”
____________________________
Signature of Authorized Signatory Date Signed
Print Name of Authorized Signatory
Title of Authorized Signatory
Application ____ 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: _______
Management and Operations Profile – Page 9
SECTION D. EXPERIENCE
16. Attach a completed and signed Employment and Education Form (use template provided) for each
required individual (as outlined in the Employment and Education Form)
17. Describe the experience, and length of experience, of the applicant’s Chief Executive Officer, Chief
Operating Officer, and Chief Financial Officer, or their equ
ivalent, with running a business.
Application ____ 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: _______
Management and Operations Profile – Page 10
18.
Describe the experience, and length of experience, of the application’s Chief Executive Officer, Chief
Operating Officer, and Chief Financial Officer, or their equivalent, with providing health care services.
Application ____ 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: _______
Management and Operations Profile – Page 11
19.
Describe the experience, and length of experience, of the applicant’s Chief Executive Officer, Chief
Operating Officer, and Chief Financial Officer, or their equivalent, with providing services for
marijuana for medical purposes.
Application ____ 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: _______
Management and Operations Profile – Page 12
20.
Describe the experience, and length of experience, of the applicant’s individual/entity responsible for
marijuana for medical use cultivation operations and individual/entity responsible for the RMD security
plan and security operations with providing services for marijuana for medical purposes.
Application ____ 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: _______
Management and Operations Profile – Page 13
SECTION E. OPERATIONS
21. Provide a summary of the applicant’s operating procedures for the cultivation of marijuana for medical use.
Application ____ 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: _______
Management and Operations Profile – Page 14
22.
Describe the types and forms of Marijuana Infused Products (“MIPs”) that the applicant intends to
produce, if any.
23.
Provide a summary of the applicant's methods of producing MIPs, if the applicant intends to produce MIPs.
Application ____ 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: _______
Management and Operations Profile – Page 15
24.
Provide a summary of the applicant’s operating procedures for the provision of security at the proposed
RMD.
Application ____ 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: _______
Management and Operations Profile – Page 16
25.
Provide a summary of the applicant’s operating procedures for the prevention of the diversion of marijuana.
Application ____ 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: _______
Management and Operations Profile – Page 17
26.
Provide a summary of the applicant’s operating procedures for the storage of marijuana for medical use.
27.
Provide a summary of the applicant’s operating procedures for the transportation of marijuana for
medical use.
Application ____ 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: _______
Management and Operations Profile – Page 18
28.
Provide a summary of the applicant’s operating procedures for inventory management.
29.
Provide a summary of the applicant’s operating procedures for quality control and testing of product
for potential contaminants.
Application ____ 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: _______
Management and Operations Profile – Page 19
30.
Provide a summary of the applicant’s operating procedures for maintaining confidentiality of
registered qualifying patients, personal caregivers, and dispensary agents, as required by law.
31.
Provide a summary of the applicant’s personnel policies.
Application ____ 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: _______
Management and Operations Profile – Page 20
32.
Provide a summary of the applicant’s operating procedures for the dispensing of marijuana for medical use.
33.
Provide a summary of the applicant’s operating procedures for record keeping.
Application ____ 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: _______
Management and Operations Profile – Page 21
34.
Provide a summary of the applicant’s plans for providing patient education.
35.
Provide a summary of the applicant’s operating procedures for patient or personal caregiver home-
delivery, if the applicant plans to provide home-delivery services.
Application ____ 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: _______
Management and Operations Profile – Page 22
36.
Provide a summary of the applicant’s policies and procedures for the provision of marijuana for medical
use to registered qualifying patients with verified financial hardship without charge or at less than the
market price.
37.
Provide a summary of the training(s) that the applicant intends to provide to Dispensary Agents.
Application ____ 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: _______
Management and Operations Profile – Page 23
38.
Will the applicant provide worker’s compensation coverage to its Dispensary Agents?
Yes No
39. Will the applicant obtain professional and commercial insurance coverage?
Yes
No
40. Describe the applicant’s plan to obtain liability insurance or place in escrow the required amount to be
expended fo
r the coverage of liabilities.
Application ____ 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: _______
Management and Operations Profile – Page 24
SECTION F. CAPITAL CONTRIBUTORS
List all persons and entities known to date that are committed to contributing 5% or more of initial capital to
operate the proposed RMD. For entities contributing 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, or their
equivalent.
Attach additional tables if needed.
Individual Name
Amount of Initial Capital
Committed
% of Initial Capital
Committed
$
$
$
$
$
Entity Name Leadership Names
Amount of Initial
Capital Committed
% of Initial Capital
Committed
Entity CEO or ED
Entity Pres or Chair
$
Entity CEO or ED
Entity Pres or Chair
$
Entity CEO or ED
Entity Pres or Chair
$
Application ____ 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: _______
Management and Operations Profile – Page 25
SECTION G. CHARACTER AND COMPETENCY FORMS
41.
Attach a completed and signed Character and Competency Form (use templates provided)
for each required actor (as outlined in the Character and Competency Forms). Please note
that there is a “Form for an Individual” and a “Form for an Entity.”
Application ____ 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: _______
Management and Operations Profile – Page 26
ATTESTATIONS
Signed under the pains and penalties of perjury, I, the authorized signatory of 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
The applicant agrees and attests that it will operate in compliance with all applicable state laws and regulations,
including, but not lim
ited to, laws regarding child support and taxation.
____________________________
Signature of Authorized Signatory Date Signed
Print Name of Authorized Signatory
Title of Authorized Signatory
Application ____ 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: _______
Management and Operations Profile – Page 27
I, the authorized signatory for the applicant, hereby attest that if the applicant is allowed to proceed to submit a
Siting Profile, the applicant is prepared to comply with all Siting Profile requirements.
_____________________________
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 Management and Operations Profile

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Completed 16 May 2020

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