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Packet3-siting-profile

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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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
SITING 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 Siting Profile (“applicant”).
If invited by the Department to submit more than one Siting Profile, the applicant must submit a separate Siting Profile and
attachments 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.
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).
CHARLES D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor
MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD, MPH
Commissioner
Tel
: 617-660-5370
www.mass.gov/medicalmarijuana
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: _______
Siting Profile – Page 2
Mail or hand-deliver the Siting Profile, with all required attachments, to:
Department of Public Health
Medical Use of Marijuana Program
RMD Applications
99 Chauncy Street, 11
th
Floor
Boston, MA 02111
REVIEW
Applications are reviewed in the order they are received. After a completed application packet 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 receive a Provisional Certificate of
Registration.
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 Applicant 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.
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: _______
Siting Profile – Page 3
PUBLIC RECORDS
Please note that all application responses, including all attachments, will be subject to release pursuant to a public records request, as
redacted pursuant to the requirements at M.G.L. c. 4, § 7(26).
QUESTIONS
If additional information is needed regarding the RMD application process, please contact the Medical Use of Marijuana Program at
617-660-5370 or RMDapplication@state.ma.us.
CHECKLIST
The forms and documents listed below must accompany each application, and be submitted as outlined above:
A fully and properly completed Siting Profile, signed by an authorized signatory of the applicant
Evidence of interest in property, by location (as outlined in Section B)
Letter(s) of support or non-opposition (as outlined in Section C)
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: _______
Siting Profile – Page 4
SECTION A: APPLICANT INFORMATION
1.
Legal name of Applicant Corporation
2.
Mailing address of Applicant Corporation (Street, City/Town, Zip Code)
3.
Applicant Corporation’s point of contact (name of person Department should contact regarding this application)
4.
Point of contact’s telephone number
5.
Point of contact’s e-mail address
6. Number of applications: How many Siting Profiles does the applicant intend to submit?
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: _______
Siting Profile – Page 5
SECTION B: PROPOSED LOCATION(S)
Provide the physical address of the proposed dispensary site and the physical address of the additonal location, if any, where
marijuana for medical use will be cultivated or processed.
Attach supporting documents as evidence of interest in the property, by location. Interest may be demonstrated by (a) a clear legal
title to the proposed site; (b) an option to purchase the proposed site; (c) a lease; (d) a legally enforceable agreement to give such title
under (a) or (b), or such lease under (c), in the event that Department determines that the applicant qualifies for registration as a RMD;
or (e) evidence of binding permission to use the premises.
Location Full Address County
1
Dispensing
2
Cultivation
3
Processing
Check here if the applicant would consider a location other than the county or physical address provided within this application.
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 initia
ls of the authorized signatory here: _______
Siting Profile – Page 6
SECTION C: LETTER OF SUPPORT OR NON-OPPOSITION
Attach a letter of support or non-opposition, using one of the templates below (Option A or B), signed by the local municipality in which the
applicant intends to locate a dispensary. The applicant may choose to use either template, in consultation with the host community. If the applicant is
proposing a dispensary location and a separate cultivation/processing location, the applicant must submit a letter of support or non-opposition from
both municipalities. This letter may be signed by (a) the Chief Executive Officer/Chief Administrative Officer, as appropriate, for the desired
municipality; or (b) the City Council, Board of Alderman, or Board of Selectmen for the desired municipality. The letter of support or non-opposition
must contain the language as provided below. The letter must be printed on the municipality’s official letterhead. The letter must be dated on or after
the date that the applicant’s Application of Intent was received by the Department.
Template Option A: Use this language if signatory is a Chief Executive Officer/Chief Administrative Officer
I, [Name of person], do hereby provide [support/non-opposition] to [name of applicant corporation] to operate a Registered Marijuana Dispensary (“RMD”) in [name of city or
town].
I have verified with the appropriate local officials that the proposed RMD facility is located in a zoning district that allows such use by right or pursuant to local permitting.
_______
__________________________________________
Name and Title of Individual
_________________________________________________
Signature
_________________________________________________
Date
Template Option B: Use this language if signatory is acting on behalf of a City Council, Board of Alderman, or Board of Selectman
The [name of council/board], does hereby provide [support/non-opposition] to [name of applicant corporation] to operate a Registered Marijuana Dispensary (“RMD”) in [name
of city or town]. I have been authorized to provide this letter on behalf of the [name of council/board] by a vote taken at a duly noticed meeting held on [date].
The [name of council/board] has verified with the appropriate local officials that the proposed RMD facility is located in a zoning district that allows such use by right or pursuant
to local permitting.
_______
__________________________________________
Name and Title of Individual (or person authorized to act on behalf of council or board) (add more lines for names if needed)
_________________________________________________
Signature (add more lines for signatures if needed)
_________________________________________________
Date
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 initia
ls of the authorized signatory here: _______
Siting Profile – Page 7
SECTION D: LOCAL COMPLIANCE
Describe how the applicant has ensured, and will continue to ensure, that the proposed RMD is in compliance with local codes, ordinances, and
bylaws for the physical address(es) of the 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 o
f the authorized signatory here: _______
Siting Profile – Page 8
SECTION E: THREE-YEAR BUSINESS PLAN BUDGET PROJECTIONS
Provide the three-year business plan for the proposed RMD, including revenues and expenses.
Projected Start Date for the First Full Fiscal Year:
Fiscal Year
FIRST FULL FISCAL
YEAR PROJECTIONS
SECOND FULL FISCAL
YEAR PROJECTIONS
THIRD FULL FISCAL
YEAR PROJECTIONS
Projected Revenue
Projected Expenses
VARIANCE:
Number of unique patients for the year
Number of patient visits for the year
Projected % of patient growth rate annually ---
Estimated purchased ounces per visit
Estimated cost per ounce
Total FTEs in staffing
Total marijuana for medical use inventory
for the year (in lbs.)
Total marijuana for medical use sold for the
year (in lbs)
Total marijuana for medical use left for roll
over (in lbs.)
Projected date the RMD plans to open:
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: _______
Siting Profile – Page 9
ATTESTATIONS
Signed under the pains and penalties of perjury, I, the authorized signatory for 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
I, the authorized signatory for the applicant, hereby attest that the applicant has notified the chief administrative officer and the chief of police of the
proposed city or town in which the RMD would be sited, as well as the sheriff of the applicable county, of the intent to submit a Management and
Operations Profile and a Siting Profile.
____________________________
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: _______
Siting Profile – Page 10
I, the authorized signatory for the applicant, hereby attest that if the corporation is approved for a provisional certificate of registration, the applicant
is prepared to pay a non-refundable registration fee of $50,000, as specified in 105 CMR 725.000, after being notified that the RMD has been
approved for a provisional certificate of registration.
____________________________
Signature of Authorized Signatory Date Signed
Print Name of Authorized Signatory
Title of Authorized Signatory
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Completed 4 December 2019

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