Fillable Fillable Cannabis Regulatory Permit Application MD 1-24 (City of Banning)

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Fillable Cannabis Regulatory Permit Application MD 1-24 (City of Banning)

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1
CITY OF BANNING
Community Development Department
99 East Ramsey Street
Banning, CA 92220
Tele: (951)922-3125
Fax: (951) 922-3128
CANNABIS REGULATORY PERMIT APPLICATION
Type of Cannabis Regulatory Permit Requested (Please Check Applicable Box)
Commercial Cultivation $4,700
Manufacturing $4,700
Testing $4,700
Retail Sales/Delivery $5,000
CONTACT INFORMATION (Please type or print clearly using ink)
Business Name: Phone Number:
Business Street Address: Business Fax Number:
Business City, State, Zip: Federal EIN:
Business Web Site Address: Business ID Number:
Business Email Address:
Type of Business (Circle one): Sole Proprietor, General Partnership, LLP, LLC, CORP
Applicant’s Legal Name: Applicant’s Phone Number:
Applicant’s Street Address:
Applicant’s City, State, Zip:
Applicant’s Email Address:
Does the Applicant have an ownership interest in the business (Circle one) Yes No
If the property where the business will be conducted is not owned by the applicant, this section must be filled out:
Property Owner’s Name Phone Number:
Property Owner’s Street Address:
Property Owner’s City, State, Zip: Property Owner’s Email Address:
Date Stamp
2
PROPOSED BUSINESS DESCRIPTION (Provide the following information
regarding the proposed cannabis business and the proposed location for the cannabis
business)
Proposed Street Address:
City, State, Zip:
Proposed Location Assessor’s Parcel Number:
Building Size (Square Feet of Floor Area):
Telephone Number (if any):
Description of Cannabis Activity to be conducted on the premises: (may be attached)
Number of Parking Spaces
Required
Number of Parking Spaces
Provided
Number of Accessible Spaces:
Number of Employees:
Hours of Operation:
Name of, 24 Hour On-Call Manager:
On-Call Manager Work Phone Number:
On-Call Manager Email Address:
On-Call Manager Cell Phone Number:
APPLICANT’S CERTIFICATION
I hereby certify, under penalty of perjury, that the information contained within and submitted with the application is
complete, true and accurate. I understand that a misrepresentation of fact, whether intentional or not, is cause for
rejection of this application, denial of the permit, or revocation of a permit issued.
Date:
Signature:
Print Name and Title:
Date Received
Time Received
Fees Received
$
Receipt No.
Received By
3
CITY OF BANNING
Community Development Department
99 East Ramsey Street
Banning, CA 92220
Tele: (951)922-3125
Fax: (951) 922-3128
ADDITIONAL
APPLICATION
REQUIREMENTS
The application shall include the following information and unless otherwise stated
below, must be attached to the application as a separate document. All applicants
must provide information/documents responsive to 1 through 24. Applicants for
cultivation, manufacturing or testing laboratory facilities must also provide
information/documents responsive to 25-29.
Any reference below to a “State licensing authority” means the Bureau of Cannabis Control, Department of Food
and Agriculture, or the Department of Public Health.
Description
Included in the
Application?
1. Payment of the Cannabis Regulatory Permit Application Fee.
Yes
No
2. Identify the type of cannabis business the applicant seeks to operate in the City, a
description of the commercial cannabis activity that will be conducted on the
premises, and a general description of the products that will be sold,
manufactured, cultivated, or tested on the premises.
Yes
No
3. A description of the statutory entity or business form that will serve as the legal
structure for the cannabis business; a copy of its formation and organizing
documents, including, but not limited to, articles of association, bylaws,
partnership agreement, operating agreement, and fictitious business name
statement; and the name and address of its agent for purposes of service of
process.
Yes
No
4. A list of every fictitious business name the cannabis business is operating under.
Yes
No
5. The legal name of the applicant. (Included in application form, separate
attachment is not required)
Yes
No
6. The current name and primary and secondary telephone numbers and email
addresses of at least one twenty-four (24) hour on-call manager to address and
resolve complaints and to respond to operating problems or concerns associated
with the cannabis business. (Included in application form, separate attachment is
not required).
Yes
No
7. If applicable, the business trade name (“DBA”) of the cannabis business.
Yes
No
8. A list of the license types and the license numbers issued by any State licensing
authority to the applicant, or to any other owner of the cannabis business,
including the date the license was issued, the date the license will terminate, and
the licensing authority that issued the license.
Yes
No
9. Identify if the applicant, or any owners of the cannabis business, has been denied
a license or had a license suspended or revoked by any State licensing authority.
The applicant shall identify the type of license applied for, the name of the
licensing authority that denied the application, and the date of denial, suspension
or revocation.
Yes
No
4
CITY OF BANNING
Community Development Department
99 East Ramsey Street
Banning, CA 92220
Tele: (951)922-3125
Fax: (951) 922-3128
ADDITIONAL
APPLICATION
REQUIREMENTS
10. Premise information - provide the assessor’s parcel number, physical address,
telephone number and website address and email address of the cannabis
business (Included in application form, separate attachment is not required)
Note: If the business will be conducted on a lot that is vacant at the time that the
application is submitted, the applicant shall amend the application at such time
that a physical address and telephone number is issued for the business.
Yes
No
11. The cannabis business federal employer identification number. (Included in
application form, separate attachment is not required)
Yes
No
12. A complete list of every owner of, or person with a financial interest in, the
cannabis business. Each individual named on this list shall submit the following
information:
a. Their full name.
b. Their title within the applicant entity, if applicable.
c. Their date of birth and place of birth.
d. Their social security number or individual taxpayer identification number.
e. Their mailing address.
f. Their home, business, or mobile telephone number and email address.
g. Their current employer.
h. Their percentage of ownership interest held in the applicant entity, or
other financial interest held in the applicant entity.
i. Whether the individual has an ownership or a financial interest in any
other cannabis business licensed by a State licensing authority.
j. A copy of the individual’s government-issued identification that includes
the name, date of birth, physical description and picture of the owner or
person with a financial interest in the cannabis business.
k. A copy of the DOJ and NCIC fingerprint background check for each
owner and person with a financial interest in the cannabis business
procured through the Banning Police Department.
l. If applicable, a copy of any certificate of rehabilitation issued under Penal
Code section 4852.01 or dismissal issued pursuant to Penal Code
section 1203.4 or 1203.41.
m. If applicable, a detailed description of any suspension or revocation of a
cannabis related license or sanctions for unlicensed or unlawful cannabis
activity by a state or local governmental agency against (1) the applicant,
or any of its owners or persons with a financial interest in the cannabis
business, or (2) any business entity in which the applicant or any of its
owners or person with a financial interest in the cannabis business was
an owner or officer within the five (5) years immediately preceding the
date of the application.
n. If applicable, a detailed description of any civil and/or criminal suit and/or
judgement relating to unlawful cannabis activity against (1) the applicant
or any of its owners or person with a financial interest in the cannabis
business, or (2) a business entity in which the applicant or any if its
owners or persons with a financial interest in the cannabis business was
an owner or officer within the five (5) years immediately preceding the
date of the application.
Yes
No
5
CITY OF BANNING
Community Development Department
99 East Ramsey Street
Banning, CA 92220
Tele: (951)922-3125
Fax: (951) 922-3128
ADDITIONAL
APPLICATION
REQUIREMENTS
13. A list of all owners, managers, and employees that are authorized to carry
concealed weapons.
Yes
No
14. If the applicant is the landowner upon which the premises is located, a copy of
the title or deed to the property.
Yes
No
15. If the applicant does not own the land upon which the cannabis business will be
located, a written, notarized statement from the owner of the property where the
cannabis business will operate evidencing unqualified consent to the applicant
operating a cannabis business on the property including a description of the type
of business that will be operated on the property (i.e. cultivation, manufacturing,
retailer, testing laboratory) (See attached form - Page 8).
Yes
No
16. A copy of the following State licensing application to engage in commercial
cannabis activity in the City:
a. For a cannabis retailer or testing laboratory, a copy of the applicant’s
application with the Bureau of Cannabis Control.
b. For a cannabis cultivator, a copy of the applicant’s application with the
California Department of Food and Agriculture.
c. For a cannabis manufacturer, a copy of the applicant’s application with
the California Department of Public Health.
Yes
No
17. Evidence that the cannabis business will be compliant with the location
restrictions set forth in Business and Professions Code section 26054 (b) and the
zoning restrictions set forth in Title 17 of the Banning Municipal Code.
Yes
No
18. The physical address of any other premises owned or operated by the applicant,
or any other owner of the cannabis business, and a brief summary of the
business operations at each premises.
Yes
No
19. A premises diagram which meets the requirements set forth in section 5006 of
Title 16 of the California Code of Regulations, as the same may be amended
from time to time.
Yes
No
20. The proposed hours of operation.
Yes
No
21. Signed Authorization and Consent form (See attached form - Page 9).
Yes
No
22. Signed Hold Harmless Agreement (See attached form - Page 9).
Yes
No
23. Signed Applicant’s certification (See application form - Page 2).
Yes
No
24. Copy of DOJ and NCIC fingerprint background check for each owner and person
with a financial interest in the cannabis business procured through the Banning
Police Department
Yes
No
6
CITY OF BANNING
Community Development Department
99 East Ramsey Street
Banning, CA 92220
Tele: (951)922-3125
Fax: (951) 922-3128
ADDITIONAL
APPLICATION
REQUIREMENTS FOR
CULTIVATION,
MANUFACTURING, AND
TESTING LABORATORY
FACILITIES ONLY
25. A detailed security plan outlining the measures that will be taken to ensure the
safety of persons and property on the premises of the cannabis business. The
security plan must be prepared by a licensed security company or individual
licensed by the state. The license number shall be on the face of the security
plan.
Yes
No
26. A detailed plan describing the air treatment system, or other methods which will
be implemented to completely prevent odors generated from cannabis from being
detected outside the buildings on the cannabis business site.
Yes
No
27. For cannabis cultivation facilities, a site plan and floor plan prepared by a
registered civil engineer clearly identifying that the proposed canopy space is a
minimum of 10,001 square feet in size, and a maximum of 22,000 square feet in
size, and that the cultivation activities will occur indoors only.
Yes
No
28. For cannabis manufacturing facilities, a detailed description of the manufacturing
activity that will be conducted on the premises including the type of activity that
will be conducted (extraction, infusion, packaging, labeling), a description of the
extraction and/or infusion methods, and the types of products that will be
manufactured, packaged and labeled. The description must include a statement
that volatile solvents will not be used by the manufacturing facility.
Yes
No
29. For cannabis laboratory testing facilities, proof of ISO/IEC 17025 accreditation by
an accrediting body that is independent from all other persons involved in
commercial cannabis activity in the State.
Yes
No
7
Property Owner Letter of Authorization
APPLICATION FOR CANNABIS REGULATORY PERMIT
TO: Community Development Department
City of Banning
P.O. Box 998
Banning, CA 92220
RE:
I/We, the owner(s) of the above described real property, authorize
, located at
, to operate a cannabis business that will include
_____________________________________________ on the property identified above. Further, I/We,
the owner(s) agree(s) to notify the City of Banning immediately should this authorization be revoked for any
reason.
The undersigned hereby certifies to being the fee owner(s) of the property described herein; that to
the best of my/our knowledge the information contained within this authorization is true and correct.
Date
(Signature)
Address___________________________________ (Print name)
________________________________________
(Phone Number)
State of ) ________________________________________
(email address)
County of )
On before me, personally appeared
(Name and title of officer)
Who proved to me on the basis of satisfactory evidence to be the person(s)
whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/ their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed
this instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature
(Notary seal)
Property Address:
Assessor’s Parcel Number(s):
8
Authorization and Consent Form
APPLICATION FOR CANNABIS REGULATORY PERMIT
TO: Community Development Department
City of Banning
P.O. Box 998
Banning, CA 92220
RE:
I/We, the applicant(s)/owner(s) of the attached Cannabis Regulatory Permit Application, authorize City of
Banning Staff and Police Department to seek verification of the information contained within the application
for a Cannabis Regulatory Permit.
Date
(Signature)
(Print name)
State of )
ss.
County of )
On before me, personally appeared
(Name and title of officer)
Who proved to me on the basis of satisfactory evidence to be the person(s)
whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/ their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed
this instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature
(Notary seal)
Applicant:
Property Address:
Assessor’s Parcel Number(s):
9
Hold Harmless Agreement
APPLICATION FOR CANNABIS REGULATORY PERMIT
TO: Community Development Department
City of Banning
P.O. Box 998
Banning, CA 92220
RE:
I hereby release the City of Banning, its agents, officers, elected officials, employees and attorneys, from
any and all claims, injuries, damages or liabilities of any kind arising from any repeal or amendment of
Chapter 5.33 or Chapter 5.35 of the Banning Municipal Code or any other provision of the Banning
Municipal Code, and any arrest or prosecution of the applicant or its managers, agents, employees,
members or volunteers for violation of state or federal laws. I hereby agree to defend, indemnify and hold
harmless the City of Banning, and its agents’ officers, elected officials, employees, and attorneys from and
against any and all claims or actions brought by adjacent or nearby property owners or any other parties
for any damages, injuries or other liability of any kind arising from operations at the cannabis business.
Date
(Signature)
(Print name)
State of )
ss.
County of )
On before me, personally appeared
(Name and title of officer)
Who proved to me on the basis of satisfactory evidence to be the person(s)
whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/ their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed
this instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature
(Notary seal)
Applicant:
Property Address:
Assessor’s Parcel Number(s):
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Completed 21 September 2021

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