Fillable Small Scale Marijuana Caregiver Business Application Process The (City of Portland, Maine)

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Small Scale Marijuana Caregiver Business Application Process The (City of Portland, Maine)

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CITY OF PORTLAND
Permitting and Inspections Department
1
Small Scale Marijuana Caregiver 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 (§ 35-27). Details to include:
1. Total square footage dedicated to the small scale caregiver use
2. Amount of plant canopy to be grown
3. Floor plans including:
Location of mature, immature and seedling plants
Storage areas
Office areas
Quality control plan (§ 35-27). Detailing the testing protocols and schedules to ensure the safety of the
marijuana being cultivated.
Operations plan (§ 35-27). Details to include:
1. Overview of policies and procedures
To prevent unauthorized sale to minors
To ensure that operation does not exceed five patients in one calendar month
Security plan (§ 35-36). Details to include:
1. Lighting
2. Alarm system
3. Locks
4. Security cameras interior & exterior
5. Securing of cash and marijuana products
6. 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).
FSE License (Ch. 11). If manufacturing food, must provide copy of FSE license.
Ventilation plan (§ 14-411). Ensuring adequate ventilation to prevent the release or dispersal beyond
the premises of pesticides, insecticides, or other chemicals.
Distance from school (§ 14-411). Distance from nearest public school, private school and/or public
preschool.
Payment of application fee
Copy of State license
After you submit your application to the Business Licensing Office:
• 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 Small Scale Marijuana Caregiver License
Application Fee $50 SBI $21.00 each owner \License $250
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:
State in which you were formed: _______________
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 Marijuna 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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Small Scale Marijuana Caregiver Business Application Process The (City of Portland, Maine)

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Completed 14 July 2020

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