TOWN OF DOUGLAS
LICENSE APPLICATION
CANNABIS RETAIL SALES
TO THE LOCAL LICENSING AUTHORITIES:
Entity Name:
FEIN:
DBA:
Premises Address:
Manager:
email
Current Date
Alternate Phone #
Mailing Address:
Phone Number
1. Business Information: The entity that will be issued the license and have operational control of the premises.
Having secured a license through the Cannabis Control Commission (CCC), the undersigned hereby applies for a
Cannabis Retail Sales License in the Town of Douglas, in accordance with the provisions of 935 CMR 500.000.
2. Premises:Please provide a complete description of the premises to be licensed, including the number of floors, number
of rooms on each floor, number of exits, and total square footage. You must also submit a floor plan.
Premises
Description:
Days and Hours of Operation:
I do hereby declare under the pains and penalties of perjury that I have personal knowledge of the information submitted
in the Application, and as such affirm that all statements and representations therein are true to the best of my knowledge
and belief, and that I have filed all state tax returns and paid all state taxes required by law.
3. Application Contact: The application contact is the person whom the licensing authorities should contact regarding
this application.
Name:
Phone Number
Title:
email
Signed By
Products Description:
douglas-3/19/19
