For Official City Use ONLY Date Stamp Office of the City Manager 555 Santa Clara Street Vallejo CA 94590 707.648.4576 MEDICAL MARIJUANA REGULATORY PERMIT APPLICATION NEW APPLICATION ONLY The purpose of this application is to request a permit to operate a facility as described in the City of Vallejo Emergency Ordinances amending Chapter 7.100, amending Title 16 and adding Chapter 7.200, to establish requirements for medical marijuana cultivation, distribution, manufacturing and dispensing. The permit requested and facilities described in this application are for marijuana related facilities only. All requested items and authorizations listed on this form must be completed and submitted or the application will be rejected. All applications shall be submitted to the City of Vallejo City Manager s office. A checklist is included in the application packet to assist all applicants and help ensure complete applications. Only businesses issued a permit pursuant to Chapter 7.100.050 to operate a Medical Marijuana Dispensary (P-MMD) in Vallejo may apply for and receive one permit to conduct Medical Marijuana Manufacturing (P-MFG), Distribution (P-DST) and/or Cultivation (P-CLT). Each Medical Marijuana Dispensary that has a permit to operate (P-MMD) is limited to one location in addition to the MMD location. Copy of current permit to operate (P-MMD) attached (attach and label #1). The applicant must meet any additional standard criteria and fulfill any additional standard requirements typically associated with obtaining a business permit in the City. Permit fees, application fees, annual regulatory fees and any other fees are adopted by the City Council and are non-refundable. This application is valid for one year from the date of issuance unless otherwise revoked, abandoned or deemed invalid. All renewal applications are due by June 30, each year and must be submitted to the City Manager or designee at least 60 calendar days before expiration of the current permit or the permittee shall be required to submit a new application and pay fees associated with submission of a new application. Section 1- Specific Activity Requested The facility must be proposed in the allowable zone in order for the application to be filed. It is the applicant s responsibility to confirm that the location selected is in the correct zone (see below for Zoning Verification Letter (ZVL) information). Please select all that apply: Medical Marijuana Distribution, P-DST Medical Marijuana Manufacturing, P-MFG (non-volatile only) Medical Marijuana Cultivation, P-CLT (limited to 10,000 s/f) 1
Section 2 Site Plan Including Zoning and Sensitive Buffer Verification 1. Using a separate sheet of 18 X 24 plain white paper, submit a scaled premises diagram indicating the boundaries of the property and proposed premises with all boundaries, dimensions, entrances and exits, interior partitions, walls, rooms, windows and common or shared entryways. If the proposed premise consists of only a portion of the property, the diagram shall be labeled indicating which part of the property is the proposed premises and in what way the remaining property is used. (attach and label #2.1) A. The plan shall include the assessor s parcel number and shall be to scale and include all the following: i. Designated holding area for marijuana designated for destruction. ii. Designated processing area(s) if licensee will process on site. iii. Designated packaging area(s) if licensee will package on site. iv. Designated composting area if licensee will compost plant waste on site. v. Designated refuse areas. vi. Designated area(s) for harvested marijuana storage. vii. Designated parking spaces. viii. Photographs of the exterior of the building including the entrance(s), exit(s), street frontage(s) and parking area. 2. Zoning Verification from the City of Vallejo Planning Department either a Zoning Verification Letter (ZVL) or a receipt showing payment for a Use Permit. (attach and label #2.2) 3. Evidence of appropriate buffer from sensitive uses in accordance with the Vallejo Municipal Code. (attach and label #2.3) Section 3 Additional Documentation Note: Please attach to this application Section 3 items and label accordingly. 1. Attach photocopy of: A. Seller s Permit issued by the appropriate State of California Agency. B. Proof of Bond ($5,000) for destruction of product. C. Proof of General Liability Policy. D. A list of types and numbers of marijuana licenses already received by the applicant from the State of California, including the date the license was obtained and the licensing authority that issues the license. 2
E. A copy of all documents filed with the California Secretary of State including but not limited to: business formation documents. If applicant is a foreign corporation, a certificate of qualification issued by the California Secretary of State pursuant to Section 2105 of the Corporations Code. Section 4 - Security and Operating Conditions Note: Please respond to Section 4 items 1 through 13 on an additional piece of paper, labeled accordingly and attached to this application with any appropriate supporting documentation. 1. A description of applicant s practice for transfer of marijuana products to and from premises. 2. Where inventory will be kept and how records will be maintained and reconciled. 3. A description of all security practices including but not limited to any panic buttons, dyes, bulletproof windows, or other. 4. Description of applicant s video surveillance system including camera placement and practices for maintenance of video surveillance equipment. 5. How applicant will ensure that all access points to the premises will be secured including the use of security personnel if applicable. 6. A description of the applicant s security alarm system. 7. A description of how inventory will be stored. 8. A description of the operating hours of the facility for each activity. 9. A description of the Track and Trace system the applicant will employ. 10. A description of the Point of Sale system the applicant will employ and how it will be integrated with the other permitted business activities. Identify the brand name and how the software tracks validity of identification cards, tracks and provides inventory reports, provides daily, monthly and annual sales reports, provides user security, tracks and provides reports to regulatory agencies, and supports a fully-integrated business model. Include a valid license agreement or other evidence of use, if applicable. 11. Method(s) that will be used to dispose of unused marijuana. 12. The year, make, model, license plate number, and numerical vehicle identification number for all commercial vehicles that will be used under the P-DST to transport marijuana goods and update the information within 30 calendar days of any changes. 13. Proof of ownership or a valid lease for all commercial vehicles that will be used to transport all marijuana goods. 3
Section 5 Manager s Certification, Live Scan and Contact Information Under penalty of perjury, each Medical Marijuana Dispensary Manager who has signed this application has read, understands and shall ensure compliance with the City of Vallejo Prohibited Activities Checklist. For each Manager include a completed Live Scan check or receipt from Live Scan check completed within the last 14 calendar days. Note: Please attach to this application Section 5 items and label accordingly. Business Applicant Address: MMD Manager Signature: Print MMD Manager Name: Phone Number Title: Date: Live Scan Date: Identification Type: Expires: MMD Manager Signature: Print MMD Manager Name: Phone Number Title: Date: Live Scan Date: Identification Type: Expires: 4
Section 6 Property Owner Affidavit I,, authorize the Marijuana Business entitled to use this property as a Marijuana facility, as those terms are defined in the City of Vallejo Municipal Code, should this facility obtain the appropriate permit. I further understand that I am responsible for, and also subject to, enforcement actions regarding any violations and/or nuisance activity which may occur at this property. Legal Property Owner (print name) Legal Property Owner (signature) Date: If different from above: Legal Building Owner (print name) Legal Building Owner (signature) Date: Note: Please attach to this application proof of possession of the premises and approval of use (deed, lease, lease assignment) and label accordingly. Please complete the following information: A complete list of every person with over 20% interest in the proposed business including the full name, title within the entity, birthdate and place of birth, social security or tax identification number, phone number, e-mail, the date owner acquired interest in entity, the percentage of ownership interest, and if applicable the number of shares owned, any financial interest in any other marijuana business licensed by the State of California. For each owner a completed Live Scan check or receipt from Live Scan check done within the last 14 days. (Attach additional documentation and label #6.1) Name Title DOB SS#/Tax ID# Contact Phone Number Date of acquired interest Percent of ownership Date of Live Scan Check 5
Section 7 - Applicant Certification Under penalty of perjury, I hereby declare that the information contained within and attached to this application is complete true, and accurate. I understand that a misrepresentation of fact is cause for rejection of this application, denial of the permit or revocation of a permit issued. By submitting this application, I certify that I have read and understand the requirements of the application process and that I may be disqualified for failure to meet the requirements of state law or City ordinance, or for incomplete, late or inaccurate applications/attachments, and that all fees paid in connection with this application are non-refundable. Signature of Applicant: Date: Print Name: Date and Initials Received by the City of Vallejo COV use only: Application Complete COV use only: Application Incomplete 6