County RMJ License # (for Staff Use Only): License Type, Fees and Contact Information Applicant's Name (please print) Trade Name (DBA) Application is for: (Circle One) New License Change of Location Type of Retail Marijuana Application: (Circle One) Store Cultivation Facility Products Manufacturing Facility Testing Facility Website Address Primary Contact for Business Title Primary Contact Phone # Primary Contact Address (city, state, ZIP) Primary Contact Fax # Federal Taxpayer ID Colorado State Tax License # Email Address Physical Address Street Address of Proposed Retail Marijuana Business (include city, state, ZIP) Parcel # Business Phone Number ( ) Home Phone Number ( ) Email Address Mailing Address (if different from Business Address) Address City State Zip Application Checklist 1) A Building Plan on 24 x 24 (or larger) paper, including compliance with all other requirements of section 53(1)(b), Chapter 7, Article III, Retail Marijuana Code. Please follow the model and instructions provided with this application form. Questions regarding Floor Plan preparation should be directed to the Code Enforcement Officer in the Building Department. 2) Proof of the right to possess the proposed premises, per section 53(1)(a), Chapter 7, Article III, Retail Marijuana Code 3) A Location Plan/Plot Plan showing compliance with all requirements of section 53(1)(c), Chapter 7, Article III, Retail Marijuana Code. 4) Fingerprints on forms provided by the State, per section 53(1)(e), Chapter 7, Article III, Retail Marijuana Code. Please follow instructions provided with this application form. 5) Corporate formation documents for the proposed license, per section 53(1)(f), Chapter 7, Article III, Retail Marijuana Code. 6) Material Safety Data Sheets for all proposed chemicals and proposed chemical mixtures must be provided, per section 53(1)(g), Chapter 7, Article III, Retail Marijuana Code. 7) Off-Premises Storage facilities to be associated with the proposed Retail Marijuana Facility must provide documents as set forth in section 53(1)(h), Chapter 7, Article III, Retail Marijuana Code. Please follow the instructions provided with this application form. 8) A copy of the applicable State Retail Marijuana License Application (a copy of the application you submitted to the State MED Office). Please be advised that La Plata County may not, in its sole discretion, process your application for a County License until the State has determined the application is complete and forwarded said determination to the County. 9) Fees in the form of a check or money order, made payable to La Plata County, for operating fees of $ 3,500.00, per section 53(1)(d), Chapter 7, Article III, Retail Marijuana Code. 10) During the County s review of the application Additional Information may be required in order to process and fully investigate the application per section 53(1)(i), Chapter 7, Article III, Retail Marijuana Code. Additional Information for this application is outlined on a separate sheet included with this application form. Application Tracking Information (for Staff Use Only) Application Submittal Initial Review State License #: Application Deemed Complete Land Use Approval License Final Determination Approval Local License Expiration LLA Preliminary Determination Hearing Approved: License Denied: {4900:2913 00018685.DOCX 2}Page 1 of 7
General Restrictions You must answer all of the questions in this Section for the applicant and each person listed in the Ownership Structure section of the applicant s State application. Are, or have you: Under 21 years of age? Delinquent on the payment of County property taxes? Discharged a sentence for a conviction of a felony in the five (5) years immediately preceding the application date? Discharged a sentence for a conviction of a felony pursuant to any state or federal law regarding the possession, distribution, manufacturing, cultivation, or use of a controlled substance in the ten (10) years immediately preceding the application date or five (5) years from May 28, 2013, whichever is longer other than for a state felony conviction based on possession or use of marijuana or marijuana concentrate that would not be a felony on the application date? A La Plata County Sheriff s Office employee, police officer, prosecuting officer, or a local jurisdiction employee? A person who has not been a resident of Colorado for at least two years prior to the application date? A person who employs another person at a retail marijuana establishment who has not submitted fingerprints for a criminal history record check or whose criminal history record check reveals that the person is ineligible? A person who is not in possession of the licensed premises throughout the duration of the license period? If you answer Yes to any of the questions in this Section, you must include a written explanation on a separate sheet of paper. Good Moral Character You must answer all of the questions in this Section for the applicant and each person listed in the Ownership Structure section of the applicant s State application. Have you ever: Been a party to a civil lawsuit that involved claims of fraud, forgery, or other dishonest conduct or a lack of respect for legal obligations? Had any professional or business license denied, suspended or revoked? Violated the rules of the Colorado Marijuana Enforcement Division? Had a criminal conviction, including misdemeanor convictions, on the premises to be licensed? Had more than one misdemeanor conviction in one year or three or more misdemeanor convictions in the last five (5) years from the application date? Had any felony conviction within the past fifteen (15) years or a drug-related felony at any time, unless such felony is no longer a criminal offense? Had more than one DUI offense in the last five (5) years and/or lack of follow through on Court-ordered requirements related to a DUI charge? If you answer Yes to any of the questions in this Section, you must include a written explanation on a separate sheet of paper. Yes No {4900:2913 00018685.DOCX 2}Page 2 of 7
Property Owner Acknowledgement and Consent: I,, am the property owner of record of the property subject to this application to operate a retail marijuana facility. Furthermore, I consent to and authorize the local licensing authority, its investigators and designees to enter my property to perform inspections and investigations as authorized by the County's retail marijuana regulations and law. I have read this application and acknowledge that there may be unique risks associated with operation of a retail marijuana facility on my property and have considered such risks. I understand that by signing this Acknowledgement and Consent that I am not entering into a contract and that my signature does not create any legal obligation. Signature: Affirmation and Consent I affirm that I have reviewed this application and all associated documents and that the contents and statements made therein are true and correct to the best of my knowledge and belief. I understand that any misrepresentations or failure to disclose information requested or pertinent information may be deemed good cause to deny, withhold, or revoke a license. Furthermore, I understand that any misrepresentations or omissions may subject me to civil and/or criminal liability. I consent to all required and necessary investigations and inspections permitted by law; I affirm that I have read, understand and agree to abide by the license requirements and restrictions set forth in Article III, Chapter 7 of the La Plata County Code, as amended from time to time, as well as all applicable statutory and regulatory requirements and restrictions set forth in the Colorado Retail Marijuana Code, rules promulgated pursuant to the Colorado Retail Marijuana Code and the La Plata County Code, as amended from time to time. I affirm that violation(s) of any applicable local or state statute, regulation, rule and/or code may result in the suspension, revocation of the license or the issuance of a fine in lieu of suspension. Signature: Release and Indemnification If granted a license by the County, the applicant agrees to release the County, its elected officials, employees, officers, attorneys, and agents from any and all liability for any and all known, unknown or unforeseen damages, injuries, losses and liabilities directly or indirectly related to the applicant's retail marijuana operations, including but not limited to any claim that results from any arrest or prosecution of the applicant, its employees, clients or customers, for a violation of state or federal law, rules, or regulations. Furthermore, by accepting a license issued by the County the applicant, jointly and severally, if more than one, indemnifies and holds harmless the County, its employees, officers, elected officials, insurers, attorneys and agents from any and all suits, actions, claims, judgments, obligations or liabilities of every nature and description which arise out of or in any manner are connected with the operation of the retail marijuana operation that is the subject of the license. Furthermore, the applicant agrees to investigate, handle, respond to, and provide defense for and defend against, any such liability, claims, or demands at its expense, and to bear all other costs and expenses related thereto, including court costs and attorney fees; however, such agreement does not make the applicant an agent or employee of the County. Signature: {4900:2913 00018685.DOCX 2}Page 3 of 7
Additional Information The information requested above is required for the processing of the application. Please contact the County s Code Enforcement Officer Marianna Spishock at 970-382-6253 if you have any questions regarding the additional information requested. This list may not be complete. Additional items may be requested during review of the application. Application Checklist Instructions Building Plan Plans for the interior of the building including a detailed floor plan layout drawn to scale (1/4 = 1 ft.) which clearly reflects the uses functions, and operations within the building. The plan shall show mechanical functions (i.e. cooling systems, ventilation systems, filters, discharge systems, heating systems) and locations, and all grow light configurations. Marijuana product preparation area shall include a detailed plan for food preparation area broken out separately. Marijuana facilities located in a multi-occupancy building must also provide detailed drawings showing the wall construction that separates the ownerships or occupancies. All drawings must be submitted on 24 x 24 paper or larger. See model included with this application (to be used as a guide for preparing the Building Plan). Proof of the right to possess premises - Documents that demonstrate proof of possession of the proposed premises may include a copy of a deed, lease, or contract that governs the terms and conditions of the occupancy of the premises for the period of the license. Location Plan/Plot Plan - The Location Plan shall show all uses within 50 feet of the licensed premises and any of following uses that are located within 1,500 feet of the licensed premises: (i) any public or private preschool or elementary, middle, junior high, or high school; (ii) the campus of any college, university, or seminary, or a residential child care facility; or (iii) a drug or alcohol rehabilitation treatment center. The measurement shall be a direct line between the closest point of the project boundary and the closest boundary point on the neighboring lots or parcels. If the premises is within 3.5 miles of the municipal boundaries of either the towns of Ignacio or Bayfield, the Location Plan shall also show the distance to the nearest incorporated portions of such town. The measurement shall be a direct line between the closest point of the licensed premises and the boundary of the closest parcel within the incorporated area of the towns of Ignacio or Bayfield. The Location Plan shall be submitted on paper 24 x 24 or larger. The Plot Plan shall show the location of the building containing the proposed licensed premises and provide distances from the building to adjacent buildings and occupancies, property lines, and physical land features, such as streams, driveways, and roadways. The Plot Plan shall be submitted on paper 24 x 24 or larger. Upon approval by the Building Department Director, the Plot Plan and Location Plan requirements may be satisfied through the submittal of one plan on paper 24 x 24 or larger. Fingerprints The La Plata County Sheriff s Office (LPCSO) charges $10 per fingerprint card. Fingerprinting at the LPCSO occurs on Tues. from 9-11 am, and 1-3:30 pm with no appointment necessary. You will need to bring the fingerprint card (supplied to you with the Retail Marijuana License Application Form) along with $10 per card (cash), and a photo ID. Please return the completed fingerprint card with your application at the time of application submittal along with a cashier s Check, money order, or pre-printed business check made out to CBI for $39.50. Corporate Formation Documents - This includes all formation documents filed with the Colorado Secretary of State, including a certificate of good standing issued by the Secretary of State s office. Material Safety Data Sheets - MSDS sheets for all proposed chemicals and proposed chemical mixtures to be stored or used on the premises. Off-Premises Storage - If you are seeking approval of an off-premises storage facility, include a copy of the completed State forms. In addition, include documents demonstrating the right to possess the off-premises storage facility along with a building, location and plat plan specific to the off-premises storage facility, as described in section 53(1)(a), (1)(b) and (1)(c), Chapter 7, Article III, Retail Marijuana Code. State Retail Marijuana License Application Please provide a copy of the application you submitted to the State for your Retail Marijuana License facility. Fees Provide a check or money order, made payable to La Plata County, for operating fees of $ 3,500.00. Additional Information If applicable, the required information is outlined in the box at the top of this page. {4900:2913 00018685.DOCX 2}Page 4 of 7
Dual Licenses The dual operation of a medical marijuana establishment licensed under Article I or II of Chapter 7 with its retail marijuana equivalent is permitted so long as all applicable state and local licenses have been issued; remain valid and active for both operations; and, both operations are in compliance with all applicable state and local requirements. If a retail marijuana store is dually located with a medical marijuana center that allows medical marijuana patients under the age of 21 years to be on the premises, the retail marijuana store and the medical marijuana center must maintain complete and distinct physical separation of the licensed premises, including but not limited to separate sales and storage areas, separate entrances and exits, separate inventories, separate point-of-sale operations, and separate record-keeping. If a retail marijuana cultivation facility is dually located with a medical marijuana optional premises, the licensee shall maintain visual and operational separation of the two licensed operations, including marijuana plants and marijuana inventory. If a retail marijuana products manufacturing facility is dually located with a medical marijuana-infused products manufacturing facility, the licensee shall maintain visual and operational separation of the two licensed operations, including marijuana product ingredients and product inventory. In addition to the instructions provided on the Application Checklist Instructions sheet for developing a Building Plan, Retail Marijuana Facilities that propose to share a location with a proposed or duly approved Medical Marijuana Facility must clearly delineate the physical or virtual separation between the two operations on the Building Plan. A narrative or other descriptive documentation may be required to support the information provided on the Building Plan. Modification Application and Fee. Retail Marijuana Facilities that propose to share a location with a duly approved Medical Marijuana Facility must comply with section 10 of Article I of Chapter 7 of the La Plata County Code. If applicable, you must submit a completed Modification Application, and it s associated Fee, with this application. Medical Marijuana Business License Application and Fee. Retail Marijuana Facilities that propose to share a location with a proposed Medical Marijuana Facility must comply with Article I of Chapter 7 of the La Plata County Code. You must also submit a completed Medical Marijuana Business License Application, and it s associated Fee, with this application. {4900:2913 00018685.DOCX 2}Page 5 of 7
CRIMES DISCLOSURE FORM Pursuant to La Plata Count Code, Chapter 7, any person of a licensed entity has continuing obligation to make written notification to the local licensing authority of any criminal conviction, summons or charge. Failure to disclose a criminal conviction, summons or charge may result in a denial of your application. Please list each arrest, summons or conviction separately, and use additional sheets if necessary. Date of Offense: Place of Offense: Arresting Agency: Original Charge: Disposition Narrative Must also provide official documentation (except for minor traffic offenses) Date of Offense: Place of Offense: Arresting Agency: Original Charge: Disposition Narrative Must also provide official documentation (except for minor traffic offenses) Date of Offense: Place of Offense: Arresting Agency: Original Charge: Disposition Narrative Must also provide official documentation (except for minor traffic offenses) {4900:2913 00018685.DOCX 2}Page 6 of 7
MED VIOLATIONS DISCLOSURE FORM Please list any investigation and/or enforcement action taken by the Colorado Marijuana Enforcement Division below. Use additional sheets if necessary. Date of Violation(s): Place of Violation(s): MED Investigator(s): Original Violation(s): Disposition Narrative Must also provide official documentation Date of Violation(s): Place of Violation(s): MED Investigator(s): Original Violation(s): Disposition Narrative Must also provide official documentation Date of Violations: Place of Violations: MED Investigator(s): Original Violation(s): Disposition Narrative Must also provide official documentation {4900:2913 00018685.DOCX 2}Page 7 of 7