Fillable MDAR - MA Commercial Industrial Hemp Processor License Application

Fill Online, Printable, Fillable, Blank MDAR - MA Commercial Industrial Hemp Processor License Application Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MDAR - MA Commercial Industrial Hemp Processor License Application

On average this form takes 9 minutes to complete

The MDAR - MA Commercial Industrial Hemp Processor License Application form is 4 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MA Commercial Industrial Hemp Processor License Application
____________________________________________________________________________________________________________________________________________________________________
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:
Type of Processor
□ Extractor: entity that removes a product from the hemp plant such as fiber, seed, oil, etc.
□ Manufacturer: entity that produces a product that will be packaged, labeled and ready for sale
□ Both
MA Commercial Industrial Hemp Processor License Application
____________________________________________________________________________________________________________________________________________________________________
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 Processor 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.
MA Commercial Industrial Hemp Processor License Application
____________________________________________________________________________________________________________________________________________________________________
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:
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MDAR - MA Commercial Industrial Hemp Processor License Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document