Fillable MDAR - Commercial Industrial Hemp DUAL Application

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MDAR - Commercial Industrial Hemp DUAL Application

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Directions
Complete all parts of the following application to be licensed for growing and processing industrial hemp
in the Commonwealth and submit along with the $100 non-refundable application fee, and all required
Mail to:
Massachusetts Department of Agricultural Resources
Hemp Program
251 Causeway Street; Suite 500
Boston, MA 02114
attn.: Sarah Grubin
Please type or print clearly. Incomplete or illegible forms will be returned.Please list the Applicant Name as the individual
or business entity to which you would like the License issued.
Applicant Information
Is this a renewal? ☐ Yes ☐ No If Yes, license number:
Applicant Name (Individual or Business Entity):
Primary Contact Name:
Business Name (if different):
Mailing Address:
City: State: ZIP Code:
Phone: ☐cell ☐ home ☐ work Phone: ☐cell ☐ home ☐ work
Email: Website:
Will you be breeding hemp? ☐ Yes ☐ No If yes, ☐ seeds ☐ clones
Seed Source Details
Acquisition of seed must be from a distributor that is approved by the Department. The distributor must have its seed
certified that it meets Association of Official Seed Certifying Agencies (“AOSCA”) or other seed certification standards
approved by the Department and that the plant(s) from which seeds were produced were tested by a third party
laboratory during the active growing season as producing industrial hemp having a total THC concentration that does
not exceed 0.3% on a dry weight basis.
(please initial) I certify that the seeds obtained for planting will be of a type and variety
that do not exceed the maximum concentration of tetrahydrocannabinol as set forth in
M.G.L. c 128, Section 116.
Varieties to be planted (if known):
MA Commercial Industrial Hemp Grower/Processor Dual License Application
MA Commercial Industrial Hemp Grower/Processor Dual License Application
Gro
wing Location Information
Please provide the following information for each Growing Location. You may have multiple growing
areas (i.e. fields or greenhouses) at each location. If you would like to license multiple locations, you may download additional copies of this
sheet at https://www.mass.gov/service-details/hemp-program
.
Site Designation and Maps:
Each location must be designated by a specific address. You may have multiple growing sites at each
location. For each site, you are required to provide an aerial photograph map that includes
Site Name and Address
GPS coordinates in decimal degrees (ex. 42.3664, -71.0588)
Site features including clearly marked boundaries of the proposed growing areas
Instructions for creating a map using google are available on our website: https://www.mass.gov/service-details/hemp-program
Growing Location and Property Information
Growing Location Name:
Property Owner or Manager Name (if different from Applicant):
Phone: ☐cell ☐ home ☐ work
Email:
Physical Address:
City:
State:
Total acreage of all hemp to be planted outdoors at this location:
Total square footage of all hemp to be planted indoors at this location:
Statement of Property Ownership:
Are you (the applicant) the owner of the property listed below? ☐ Yes ☐ No If No, attach the required
Notarized Statement of Property Owner Form indicating property owner consent for the use of their property for
growing industrial hemp.
Agricultural Preservation Restriction (APR): Is this property subject to an APR?
☐
Yes
☐
No
Is this property subject to an Agricultural Covenant?
☐
Yes
☐
No
Please provide the following information for each Growing Area at the Location listed above (attach separate sheets if necessary):
Growing Area Detail
Growing Area Name: ☐ indoor ☐ outdoor
Size:
☐
acres
☐
ft
2
Latitude: Longitude:
Varieties to be planted on site:
Site Description:
Growing Area Detail
Growing Area Name: ☐ indoor ☐ outdoor
Size:
☐
acres
☐
ft
2
Latitude:
Longitude:
Varieties to be planted on site:
Site Description:
Growing Area Detail
Growing Area Name: ☐ indoor ☐ outdoor
Size:
☐
acres
☐
ft
2
Latitude: Longitude:
Varieties to be planted on site:
Site Description:
Note: If your sites are approved, site names and grow area names will be required for filing planting and harvest reports.
____________________________________________________________________________________________________________________________________________________________________
Processing Site Information
Please provide the following information for each Processing Site. If you would like to license multiple
processing sites, you may download additional copies of this sheet at: www.mass.gov/how-to/ma-
industrial-hemp-program-licensing
Site Designation and Maps:
The processing site must be designated by a specific address. For each site, you MUST to provide an
aerial photograph map that includes:
Site Name and Address
GPS coordinates in decimal degrees (ex. 42.3664, -71.0588)
Site features including clearly marked boundaries of the proposed processing area
Instructions for creating a map using google are available on our website:
https://www.mass.gov/industrial-hemp-program
Property Information
Statement of Property Ownership:
Are you (the applicant) the owner of the property listed below? □YES □NO
If No, attach the required Notarized Statement of Property Owner Form indicating property owner
consent for the use of their property for processing industrial hemp.
Property Owner or Contact Name (if different from Applicant):
Phone: ☐cell ☐ home ☐ work
Email:
Mailing Address:
City: State: Zip Code:
Processing Site
Processing Site Name:
Physical Address:
City: State: Zip Code:
Latitude: Longitude:
Site Description:
MA Commercial Industrial Hemp Grower/Processor Dual License Application
MA Commercial Industrial Hemp Grower/Processor Dual License Application
____________________________________________________________________________________________________________________________________________________________________
Certification language:
By signing this application and initialing where required, the individual signing hereby acknowledges that they have the
legal authority to bind the applicant and agrees to the following:
(please initial): I understand that the cultivation or processing of industrial hemp in Massachusetts may
be a violation of state and federal law, unless done so in accordance with applicable state and federal law, including
but not limited to, the 2018 Farm Bill, USDA guidance and regulations, and M.G.L. c. 128, Sections 116 through 123.
(please initial): I understand that growing or processing industrial hemp in violation
of federal law may
include further legal action in accordance with the 2018 Farm Bill and applicable federal law.
(please initial): I understand that state penalties for growing or processing industrial hemp in violation of
state law may include the suspension or revocation or my license and civil administrative fines in accordance with
M.G.L. c. 128, Section 123.
(please initial): I understand that if the growing or processing site(s) is subject to an Agricultural Preservation
Restriction (“APR”) or Agricultural Covenant, the land may not be eligible for use in the Department’s Industrial Hemp
Program. I further understand that it is my responsibility to review and understand the terms and conditions set forth in
the APR or Agricultural Covenant before submitting this application.
(please initial): I understand that it is my responsibility to ensure that I obtain any other applicable
licenses,
permits, or approvals required by local or state law for the type of activity to be conducted.
(please initial): I understand that any individual/entity registered by the Department to grow or process
industrial hemp shall be subject to audit, inspection, and testing pursuant to M.G.L. c. 128, Section 122 by and at
the discretion of the Department.
(please initial): I hereby give consent for the Department to conduct both scheduled and random
inspections
of and around the premises on which industrial hemp is being sown, grown, harvested, stored, and
processed.
(please initial): I understand that upon approval of my application, the Department may share the location
of
my grow sites with municipal officials and local law enforcement in the city or town where hemp will be grown or
processed. I further understand that any information obtained by the Department may be disclosed to the public and/or
to law enforcement agencies without further notice to me, the Applicant, the owner of the property registered for
cultivation or processing of industrial hemp, or any Department representatives, unless otherwise prohibited by law.
(please initial): I understand that it is my responsibility to ensure that the hemp I receive for processing
complies with the testing requirements set forth by the Department, including that it meet all contaminant
limitations, along with any other applicable testing requirements or standards set by local, state, or federal law for
the type of product to be produced.
(please initial): I acknowledge and understand that licensure to grow or cultivate or process industrial hemp
is authorized by M.G.L. c. 128, Sections 116 through 123 and that my actions with respect to the growth, cultivation,
harvest, processing, or transportation of industrial hemp otherwise subject me to obligations and regulations imposed
under federal and state law, and potentially the laws of other states.
(please initial): _ I acknowledge that as a licensed processor in Massachusetts I may only receive hemp
products
from another licensed processor or licensed grower in Massachusetts, unless otherwise authorized by federal
law. In the event that I obtain hemp products from outside of Massachusetts, I may be required to provide the
Department with the origin and copies of any federal approvals required by law.
____________________________________________________________________________________________________________________________________________________________________
A non-refundable application fee of $100 is due with this application.
Make checks payable to: Commonwealth of Massachusetts
I hereby certify that, to the best of my knowledge, all information provided in this application is true
and accurate. I understand that providing false, inaccurate, or misleading information is grounds
for registration denial, suspension, or revocation pursuant to M.G.L. c. 128, Section 120. I further
understand that I am not licensed to plant, grow, and/or harvest industrial hemp in the
Commonwealth until the Department has approved my application.
I have read this application form, understand the requirements in it, and I agree to hold harmless
and release the Commonwealth of Massachusetts, its officers, employees, contractors or agents
from any and all claims, actions, suits, damages, judgments, attorneys’ fees, or prosecution of any
kind, that may arise due to my cultivation of industrial hemp conducted in accordance with the
Industrial Hemp Program administered by the Department of Agricultural Resources pursuant to
M.G.L. c. 128, Sections 116 through 123.
Signature:
Printed Name: Date:
For official use: Date Received:
MA Commercial Industrial Hemp Grower/Processor Dual License Application
Application Checklist
Signed and dated application for Commercial Industrial Hemp Dual License
Maps for each growing and/or processing site (including name, address, GPS coordinates,
site features, and clearly marked boundaries of the growing or processing area)
Notarized statement(s) from property owner(s) consenting to the use of their property
for growing and processing hemp (if applicant is not property owner). Additional forms
may be downloaded from our website: https://www.mass.gov/how-to/ma-industrial-hemp-
program-licensing
$100 non-refundable application fee
Please keep a copy of this application for your records.
Please mail application, supporting materials, and payment to:
Massachusetts Department of Agricultural Resources
Hemp Program
251 Causeway Street; Suite 500
Boston, MA 02114
attn.: Sarah Grubin
Make checks payable to:
Commonwealth of Massachusetts
Questions? sarah.grubin@mas.gov
Or visit: https://www.mass.gov/industrial-hemp-program
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Completed 11 May 2020

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