Fillable Retail Marijuana Business Application Process The application must (City of Portland, Maine)

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Retail Marijuana Business Application Process The application must (City of Portland, Maine)

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BROWSE CITY OF PORTLAND, MAINE (ME) FORMS

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CITY OF PORTLAND
Permitting and Inspections Department
1
Retail Marijuana Business Application Process
The application must be complete in order to be accepted and processed.
What is needed to apply:
City application for marijuana business
Diagram of facility (§ 35-26). Details to include:
1. Layout of the premises
2. Total square footage under the control of the applicant and dedicated to the retail
facility/dispensary, including ancillary activities
3. Location of retail space, including areas for sale of marijuana and non-marijuana products
4. Other areas supporting retail space, including storage and office space
Operations plan (§ 35-26). Details to include:
1. Overview of policies and procedures to include policies and procedures to prevent sale to minors
Dispersal requirements (§ 35-26)
1. Documentation that the facility meets the dispersal requirements of § 35-43 (not required for
first round of licensing)
Security plan (§ 35-36). Details to include:
1. Lighting
2. Alarm system
3. Security cameras interior & exterior
4. Securing of cash and marijuana products
5. Policies to discourage loitering
Waste Disposal Plan (§ 35-39). Details to include:
1. Containers to store marijuana waste
2. Procedures for modifying waste so that it is no longer useable
Odor mitigation plan (§ 35-40).
Distance from school (§ 14-411). Distance from nearest public school, private school and/or public
preschool.
Payment of application fee
Copy of State license (medical) and/or conditional approval (adult use)
After you submit your application to the Business Licensing Office:
• The Business Licensing Office will let you know if your application is complete. If your application is
incomplete, you will have ten days from notification to supplement your application with all required
materials.
• If you are eligible for a license, you will receive tentative approval from the City to proceed with the
licensing process.
• You must separately apply for all City of Portland permits (electrical, building, plumbing, change of use,
etc.)
• When the Business Licensing Office has received all approvals from the required departments, we will
sign off on your local authorization form (adult use), or issue your license (medical).
• You may contact us for a license status update, but please note that we must receive approvals
directly from all departments.
CITY OF PORTLAND
Permitting and Inspections Department
2
Application for Retail Marijuana License
Application Fee $500 SBI $21.00 each owner
\ Adult Use $10,000 Medical $5,000 Dispensary $5,000
BUSINESS
Business name (d/b/a):
Phone:
Location address:
If new, what was formerly
at this location:
Mailing address:
Additional contact
information (website, fax,
email, etc.)
OWNER (if entity, complete corporate disclosure)
Name:
Phone:
Email:
Mailing Address:
EMERGENCY CONTACT
Name:
Phone:
Email:
Mailing Address:
COMMUNITY RELATIONS LIAISON
Name:
Phone:
Email:
Mailing Address:
LOCAL AUTHORIZED AGENT FOR SERVICE
Name:
Phone:
Email:
Mailing Address:
CITY OF PORTLAND
Permitting and Inspections Department
3
including hours and days of
operation:
Applicant, by signing below, agrees to abide by all laws, orders, ordinances, rules and regulations governing the
above licensee and further agrees that any misstatement of material fact may result in refusal of license or
revocation if one has been granted. Applicant agrees that all taxes and accounts pertaining to the premises will
be paid prior to issuance of the license.
It is understood that this and any application(s) shall become public record and the applicant(s) hereby waive(s)
any rights to privacy with respect thereto. I/We, hereby authorize the release of any criminal history record
information to the licensing authority. I/We, hereby waive any rights to privacy with respect thereto.
Date: ________________________ Signature: ___________________________________________________
Title: ________________________ Printed name: ________________________________________________
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CITY OF PORTLAND
Permitting and Inspections Department
4
CORPORATE DISCLOSURE
The answers to questions 1-4 must match the information on file with the Maine Secretary of State’s office.
Your certification must be in good standing. If you have questions regarding this information, please call the
Secretary of State’s office at (207) 624-7752. Please clearly complete this form in its entirety. Thank you.
1. Exact legal name: ____________________________________________________________________
2. Doing Business As, if any: ____________________________________________________________
3. Date of filing with Maine Secretary of State: ________________
4. If not a Maine business entity:
(a) State in which you were formed: _______________
(b) date on which you were authorized to transact business in the State of Maine: _____________
5. List the names, phone numbers, mailing addresses, email addresses, and titles of the owners, officers,
and directors and list the percentage of ownership (attach additional sheets as needed):
OWNER/OFFICER/DIRECTOR 1
Name:
Title:
Mailing address:
Email:
Percent
ownership:
OWNER/OFFICER/DIRECTOR 2
Name:
Title:
Mailing address:
Email:
Percent
ownership:
OWNER/OFFICER/DIRECTOR 3
Name:
Title:
Mailing address:
Email:
Percent
ownership:
(Stock ownership in non-publicly traded companies must add up to 100%.)
Date: ________________________ Signature: ___________________________________________________
Title: ________________________ Printed name: ________________________________________________
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CITY OF PORTLAND
Permitting and Inspections Department
5
CRIMINAL BACKGROUND AND DISQUALIFICATIONS SUPPLEMENT
Must be completed by each owner, officer, director, manager, and general partner.
Name:
DOB:
Aliases/ former names:
SSN:
CRIMINAL BACKGROUND:
☐ I certify that I have not been convicted of a felony crime where the conviction or completion of any
sentence, whichever is more recent, has been completed within the last ten years.
☐ I certify that I have not been convicted of a drug related crime other than a felony, but not including
convictions for marijuana related crimes, where the conviction or completion of any sentence,
whichever is more recent, has been completed within the last five years.
DISQUALIFYING VIOLATIONS:
List all corporate entities in which you have been an owner, officer, director, manager, general partner,
shareholder, or other responsible party, IF 1) that corporate entity has ever held a marijuana-related license,
permit, certificate, or registration in any jurisdiction; AND/OR 2) that corporate entity has owned property in the
City of Portland or done business in the City of Portland. Please list the entity name, your position/interest in that
entity, and whether
ENTITY 1
Name:
Interest:
Marijuana-related
Y / N
Nature of license,
etc. and jurisdiction:
Portland based
Y / N
Nature of interest
and address(es):
ENTITY 2
Name:
Interest:
Marijuana-related
Y / N
Nature of license,
etc. and jurisdiction:
Portland based
Y / N
Nature of interest
and address(es):
CITY OF PORTLAND
Permitting and Inspections Department
6
ENTITY 3
Name:
Interest:
Marijuana-related
Y / N
Nature of license,
etc. and jurisdiction:
Portland based
Y / N
Nature of interest
and address(es):
☐ I certify that neither I nor any corporate entity in which I have ever had an interest has had any
marijuana-related license, permit, certificate, or registration revoked or suspended.
☐ I certify that, within the previous five years, neither I nor any corporate entity listed above has engaged
in the non-payment or late payment greater than 30 days of any tax or fee.
☐ I certify that, within the previous five years, neither I nor any corporate entity listed above has had any
suspension, revocation, or denial of any license or permit.
☐ I certify that, within the previous five years, neither I nor any corporate entity listed above has made any
false statement on a City form or application.
☐ I certify that, within the previous five years, the following are the only citations for licensing, land use,
life safety, building fire, health, or similar requirements that either I or any corporate entity listed above
has received, all of which were corrected within the timeframe required by the City:
☐ I certify that, within the previous five years, neither I nor any corporate entity listed above has any other
significant failure to comply with City ordinances.
CONFLICT OF INTEREST
☐ I certify that I am not employed by any state agency or City department with regulatory authority over
the marijuana business, including the City Executive Department, Police Department, Permitting and
Inspections Department, Planning Department, Fire Department, and Corporation Counsel’s Office.
☐ I certify that I am not a law enforcement officer.
I certify that these disclosures are true and accurate. I hereby authorize the release of any criminal history
record information to the City of Portland. I understand that this supplement, and any responsive criminal
history information may be considered a public record and I waive any rights to privacy with respect thereto.
Date: ________________________ Signature: ___________________________________________________
Title: ________________________ Printed name: ________________________________________________
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CITY OF PORTLAND
Permitting and Inspections Department
7
LANDLORD STATEMENT OF PERMISSION
I, ______________________________________, am the (authorized agent of the record owner/record
owner) of the property at __________________________________________, Portland, Maine, CBL
___________________ (the “Property”).
___________________________________ (“Tenant”), is a lawful tenant at (unit/apartment) ____ at the
Property (the “Rented Unit”). I give Tenant permission to operate a Retail Marijuana Establishment pursuant to
the City of Portland Code of Ordinances (“City Code”) Chapter 35 at the Rented Unit.
I have reviewed the relevant portions of the City Code and understand the potential consequences of
Tenant’s use of the Rented Unit as a Retail Marijuana Establishment. I also understand and agree that I am
responsible for maintaining the Property in full compliance with state laws and local ordinances.
Date: ________________________ Signature: ___________________________________________________
Title: ________________________ Printed name: ________________________________________________
Personally appeared before me the above-named affiant and made oath that the foregoing affidavit is true
and correct to his/her personal knowledge.
Date: ________________________ Signature: ___________________________________________________
Notary Public/Attorney at Law
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CITY OF PORTLAND
Permitting and Inspections Department
8
RETAIL QUALIFICATIONS
Please check all factors that you believe apply to the retail business applying for licensure. Provide 1) a summary
of the reasons why you believe that the retail business is eligible for those points; and 2) a description of the
evidence supporting your position. All supporting evidence must be attached.
☐ At least 51% owned by socially and economically disadvantaged individual(s), as defined further by
regulations to be promulgated by the City Manager based off of the Small Business Association Section
8(a) regulations. (6 points)
Description of
qualification:
Supporting evidence
attached:
Staff Use Only:
☐
Qualifies ☐ Does not qualify
Notes:
☐ At least 51% owned by individual(s) who have been a Maine resident for at least five years. (5 points)
Description of
qualification:
Supporting evidence
attached:
Staff Use Only:
☐
Qualifies ☐ Does not qualify
Notes:
☐ Owned by individual(s) with experience running a business in a highly regulated industry, such as
marijuana, liquor, banking, etc. with no history of violations or license suspensions or revocations. (6
points)
Description of
qualification:
Supporting evidence
CITY OF PORTLAND
Permitting and Inspections Department
9
attached:
Staff Use Only:
☐
Qualifies ☐ Does not qualify
Notes:
☐ Owned by individual(s) who have previously been licensed by the State of Maine or a Maine municipality
for non-marijuana related business, with no history of violations or license suspensions or revocations for
a minimum of 5 years. (4 points)
Description of
qualification:
Supporting evidence
attached:
Staff Use Only:
☐
Qualifies ☐ Does not qualify
Notes:
☐ Owned by individual(s) who have been a registered caregiver in the State of Maine for at least two years.
(3 points)
Description of
qualification:
Supporting evidence
attached:
Staff Use Only:
☐
Qualifies ☐ Does not qualify
Notes:
☐ Ownership of proposed retail location by applicant; or at least five year lease for proposed retail location.
(4 points)
Description of
qualification:
Supporting evidence
attached:
CITY OF PORTLAND
Permitting and Inspections Department
10
Staff Use Only:
☐
Qualifies ☐ Does not qualify
Notes:
☐ Evidence of at least $150,000 in liquid assets. (2 points)
Description of
qualification:
Supporting evidence
attached:
Staff Use Only: ☐ Qualifies
☐
Does not qualify
Notes:
☐ Business plan committing to social and economic development, by including three or more of the
following: 1. Create at least five full-time jobs paying a minimum of $15/hr; 2. Provide PTO (or
vacation/sick time) and health benefits to employees; 3. Provide at least one annual training around
diversity, cultural awareness, sexual harassment, or workplace violence. Training must be in addition to
any required by the State or City; 4. Annual contribution of 1% net profits as a restricted donation to the
City for youth education on substance use education and prevention. (4 points)
Description of
qualification:
Supporting evidence
attached:
Staff Use Only:
☐
Qualifies ☐ Does not qualify
Notes:
Staff Use Only: Total Points:
REGULATIONS REGARDING POINTS FOR ALLOCATION OF
MARIJUANA RETAIL LICENSES PURSUANT TO § 35-14(f)(3)
I. In General.
A. Pursuant to § 35-14(f), the City Manager shall establish an opening date and a closing date
for applications in the initial year in which marijuana retail licenses become available.
B. After the closing date of that application window, the City shall evaluate all applications
for eligibility for the points outlined in § 35-14(f).
C. Once all applications have been evaluated, the City will send a notice to each applicant
containing the following information:
1. The points that the City has awarded to the applicant, and the factors in § 35-14(f)(3)
for which those points were awarded;
2. If the City does not award points for any of the factors in § 35-14(f)(3) for which the
applicant applied, the City will give a reason for declining to award those points; and
3. Whether, if all point values remain the same among applicants, the applicant will
receive tentative approval for one of the 20 marijuana retail licenses.
D. Upon specific request, the City will make available the notice described in subsection
(C)(3) above to any other applicant.
E. Each applicant will have ten days to request in writing that the City reconsider its position.
1. If an applicant requests that the City reconsider a decision to not award points for which
the applicant applied, that applicant must explain why it believes the City erred in its
determination. The applicant may not submit additional information, as all information
must be submitted with the original application.
2. If any party requests that the City reconsider a decision to award points, that party must
explain why the City erred in its determination and may provide evidence to support
its position that points awarded were not merited. The applicant whose points are being
challenged will be given a chance to rebut the position of the requesting party.
F. After the expiration of the ten days and/or the resolution of any disputes, the City will
finalize the points awarded and issue tentative approvals pursuant to § 35-14(f)(4).
II. Social and Economic Disadvantage.
A. In order to qualify for the points for a business that is at least 51% owned by socially and
economically disadvantaged individuals, those qualifying individuals must show both:
1. Social disadvantage; AND
2. Economic disadvantage.
B. Social disadvantage. Social disadvantage can be shown in one of two ways:
1. Identification as an individual listed in 13 C.F.R. § 124.103(b)(1).
a. Individuals must identify the group the individual identifies as a member of.
b. Individuals must certify and/or demonstrate that they have held themselves out as
a member of that designated group.
2. Demonstration of individual social disadvantage.
a. In order to demonstrate individual social disadvantage, the person must:
(1) Identify a distinguishing feature that has contributed to social disadvantage,
such as race, ethnic origin, gender, physical or mental handicap, gender identity
or expression, sexual orientation, etc.; AND
(2) Identify how that individual has suffered social disadvantage as a result of that
distinguishing feature in the area of education, employment, and/or business
opportunities.
b. The City shall generally follow the requirements of 13 C.F.R. § 124.103(c) in
evaluating a claim of individual social disadvantage.
C. Economic Disadvantage. To show economic disadvantage, an applicant must
demonstrate the following as of the date of application:
1. Net worth of less than $250,000 as of the date of application;
2. Average personal income over the last three years of less than $250,000; and
3. Total assets of less than $4 million as of the date of application.
The City shall generally follow the requirements of 13 C.F.R. § 124.104 in evaluating a
claim of individual economic disadvantage, except that when the threshold levels for net
worth, income, and assets increase under that rule on July 15, 2020, the threshold levels
for purposes of this regulation shall remain the same.
III. Maine Residency.
In order to qualify for the points for an individual who has been a Maine resident for at least
five years, the individual may demonstrate residency through a variety of evidence, including
homestead exemptions, tax returns, historical drivers license records, voting records, etc.
IV. Highly Regulated Industry.
A. A highly regulated industry is one that is subject to a significant and complex set of
regulations with substantial oversight, such as marijuana, liquor, banking, etc. Simply
because an industry is “regulated” does not mean that it is “highly regulated.”
B. In order to qualify for the points for an individual with experience running a business in a
highly regulated industry, an applicant must demonstrate all of the following:
1. The individual holds a substantial ownership interest in the applicant business of at
least 26%.
2. The business for which the applicant is seeking points is in a highly regulated industry.
3. The individual is/was significantly responsible for the day-to-day operations and
compliance within that industry for a period of at least two years.
4. The business has no recent history of violations in the last seven years, and has no
history of license suspensions or revocations while the individual was associated with
that business.
C. A marijuana caregiver does not qualify as a business in a highly regulated industry for
purposes of these points.
V. State or Local Licensure.
A. In order to qualify for the points for an individual who has been previously licensed by the
State or a Maine municipality an applicant must demonstrate all of the following:
1. The individual holds a substantial ownership interest in the applicant business of at
least 26%.
2. The individual has either:
a. Been personally issued a business license by the State of Maine or a Maine
municipality (e.g. attorney, medical professional, barber, electrician); or
b. The individual is/was significantly responsible for the day-to-day operations and
compliance in a business that was issued a business license by the State of Maine
or a Maine municipality for at least two years.
3. The individual or business that was licensed has no history of violations or license
suspensions or revocations for the previous five years, and while the individual was
associated with that business.
B. An individual with experience in a licensed marijuana business does not qualify.
VI. Maine Registered Caregiver
In order to qualify for the points for an individual who has been a Maine registered caregiver
for at least five years, the applicant must demonstrate all of the following:
A. The individual holds a substantial ownership interest in the applicant business of at least
26%.
B. The individual has been a Maine registered caregiver for the required period of time.
C. The individual has no recent history of caregiver registration violations, suspensions, or
revocations.
VII. Long Term Investment in Location.
With respect to the points for business that owns the proposed retail location or has a five year
lease for the proposed retail location, the following apply:
A. To qualify for ownership or lease, the deed or lease to the retail location must be in the
same name as the applicant business.
B. To qualify for points for a five-year lease:
1. The lease must be for any five-year period that will encompass the projected opening
date of the retail location.
2. The lease may not have an option for the landlord to terminate the lease within the five-
year period, except for extreme circumstances.
3. An exclusive option to enter into a five-year lease shall be sufficient.
VIII. Liquid Assets
A. With respect to the points for a business that has at least $150,000 in liquid assets, an
applicant may demonstrate liquid assets through bank accounts, lines of credit, and
similarly liquid sources of cash.
B. The liquid assets must be in the name of the applicant business.
IX. Business Plan
A. In order to qualify for the points for a business plan committing to social and economic
development, the applicant must present a clear and detailed business plan with specific
commitments to at least three of the four options outlined in the ordinance.
B. The City will audit any retail store within one year of opening to ensure compliance with
the business plan. Failure to comply may result in revocation of the applicant’s license.
1
SOCIAL AND ECONOMIC DISADVANTAGE
Directions: You must complete Sections A, B and C. If all three sections are not
completed fully and accurately, then you will not be considered for eligibility for the points
for social and economic disadvantage. Please use additional sheets as required. Please
attach all relevant documents and evidence to support your assertion of social and
economic disadvantage.
A. BACKGROUND INFORMATION
Applicant business: __________________________________________________________________
Owner asserting social and economic disadvantage: ______________________________________
Percentage ownership in applicant business: ______________________________________________
B. SOCIAL DISADVANTAGE
Directions: You must complete either Option 1 or Option 2. Please attach any relevant
documents or other evidence that support your position.
Option 1 – Presumptive Social Disadvantage
I am a member of a group that has a rebuttable presumption of social disadvantage
pursuant to 13 C.F.R. § 124.103. Specifically, I identify as a:
☐ Black American
☐ Hispanic American
☐ Native American (Alaska Native, Native Hawaiian, or enrolled member of a
Federally or State recognized Indian Tribe)
☐ Asian Pacific American (person with origins from Burma, Thailand, Malaysia,
Indonesia, Singapore, Brunei, Japan, China (including Hong Kong), Taiwan,
Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust
Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall
Islands, Federated States of Micronesia, the Commonwealth of the Northern
Mariana Islands, Guam, Samoa, Macao, Fiji, Tonga, Kiribati, Tuvalu, or Nauru)
☐ Subcontinent Asian American (person with origins from India, Pakistan,
Bangladesh, Sri Lanka, Bhutan, the Maldives Islands or Nepal).
2
I have held myself out as a member of the above group. This is evidenced in part by the
following:
Option 2 – Other Social Disadvantage
I have experienced social disadvantage as a result of the following distinguishing feature
or membership in a protected class: ______________________________________________________.
The following is an incident of bias or discriminatory conduct that I experienced based on
the distinguishing feature or membership in the protected class identified above:
1
That incident negatively impacted me in the following area(s):
☐ Education
☐ Employment
☐ Business history
☐ Other impact on advancement in the business world (describe)
Specifically, the incident negatively impacted me in the entry into or advancement in the
business world as follows:
1
Please use additional sheets to identify multiple instances of bias or discriminatory conduct and how that impacted
your entry into or advancement in the business world.
3
I believe this shows a chronic and substantial social disadvantage for the following
reasons:
C. ECONOMIC DISADVANTAGE
Directions: Please complete the following information, including totals.
• Cells with $ are positive values to be added to your total.
• Cells with –- need not be filled out, and should not be included in your
calculations, but are simply there for your reference.
• Cells with ($ ) are negative amounts that should be subtracted from your total.
**You must include any assets you have transferred in the previous two years for less than
fair market value, other than bona fide gifts to family members.**
1. Amount in personal checking accounts
$
$
2. Amount in personal savings accounts
$
$
3. Amount in retirement accounts with NO penalty for
early withdrawal
$
$
4. Retirement accounts with penalty for early withdrawal
--
--
4
5. Amount of accounts and notes receivable (debts owed
TO you)
$
$
6. Life insurance cash surrender value
$
$
7. Value of stocks, bonds, mutual funds
$
$
8. Value of ownership in the applicant business
$
--
9. Value of primary residence
$
--
10. Value of other real estate
$
$
11. Value of automobiles
$
$
12.
Value of other personal property (furniture, electronics,
art, etc.)
$
$
13. Value of other assets (boats, ATVs, other financial
accounts)
$
$
14. Value of HELOC on primary residence
--
--
15. Notes payable (debts you owe to a bank or other
lender)
--
($ )
16. Other installment accounts (credit card debt)
--
($ )
17. Auto installment accounts (loans and leases)
--
($ )
18. Loan on life insurance
--
($ )
19. Mortgage on primary residence
--
--
20. Mortgage on other real estate
--
($ )
21. Unpaid taxes
--
($ )
22. Other liabilities (loans, payments, etc.)
--
($ )
TOTAL
$
$
Total
Assets
Adjusted
Net Worth
Please submit the following supporting documents:
☐ Three years of personal tax returns
☐ Three years of applicant business tax returns
☐ Other documents as requested by the City to evaluate social and economic
disadvantage
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Retail Marijuana Business Application Process The application must (City of Portland, Maine)

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Completed 14 July 2020

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