CITY OF PALM SPRINGS Application for MCCC Medical Cannabis Cooperative or Collective Please submit one original and fifteen copies of this completed Application and all required materials to the Office of the City Clerk, 3200 E. Tahquitz Canyon Way, Palm Springs, California, 92262. The submission deadline is 2:00 PM on Monday, October 19, 2015. Applications will not be considered complete until all submittal requirements are met. GENERAL INFORMATION MCCC : Tax ID Number: California Sellers Permit Number: Projected Days/Hours of Operation: If awarded a permit estimated number of days to begin operations: Estimated number of qualified patients and/or primary caregivers who will be served: Number of Qualified Patients: Number of Primary Caregivers: and contact information of applicant: APPLICANT INFORMATION Residence Business Cell Facsimile
and contact information of the on-site, community relations, or staff person or other representative to whom one can provide notice, if there are operating problems associated with the MCCC: Residence Business Cell Facsimile Residence Business Cell Facsimile LOCATION AND PROPERTY INFORMATION Please note the site location restrictions contained in Section 93.23.15 of the Palm Springs Zoning Code. of the MCCC: Assessor s Parcel Number: Zoning: General Plan: Gross Square Footage of the Proposed Business Space: Page 2
CANNABIS OPERATIONS What percentage of the cannabis will be cultivated on site: % What percentage of the cannabis will be cultivated at a permitted MCCC grow facility operated by the MCCC: % If less than 100% of the cannabis will be grown on site, or at a grow facility operated by the MCCC, please provide the name and contact information of the person(s) who will be cultivating the cannabis: YES NO YES NO YES NO YES NO Page 3
Will edible cannabis products be provided on site: YES NO Will 100% of edible products be made on site: YES NO If no, or less than 100% of the edible cannabis products will be made on site, please provide the name and contact information of the person(s) who will be the source of the edible products: YES NO YES NO YES NO YES NO Please note if edible cannabis products are provided, a County of Riverside Health permit will be required as a condition of approval and submitted prior to operations. Page 4
Will cannabis lotions or ointments, etc. be provided on site: YES NO Will 100% of such products be made on site: YES NO If no, or less than 100% of other cannabis products will be made on site, please provide the name and contact information of the person(s) who will be the source of such products: YES NO YES NO YES NO YES NO Page 5
The City Council recently modified the regulations to allow permitted MCCC to provide delivery services. Will delivery service be provided: YES NO If yes, please describe the extent of the delivery service: Please describe any other service that will be available at the site: Page 6
CERTIFICATIONS AND DECLARATIONS Must be signed by Applicant and all Officers/Directors 1. I declare under penalty of perjury, under the laws of the State of California, that all statements contained in this application and any accompanying documents is true and correct, with full knowledge that all statements made in this application are subject to investigation and that any false or dishonest answer to any question may be grounds for denial of the application or subsequent revocation of the permit. 2. I expressly authorize the City Manager of the City of Palm Springs to seek verification of the information contained within this application, including but not limited to, a comprehensive review of my background. I understand that this review may include verification of my personal social security number, credit reports, current and previous residences, employment history, education background, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions, driving records, birth records, and any other public records. Page 7
3. I have received, read, reviewed, and understand all of the requirements of the City of Palm Springs regarding the operation and management of medical cannabis cooperatives or collective in the City, including without limitation the provisions of Chapters 3.35 and 5.35 and Section 93.23.15 of the Palm Springs Municipal Code, and I acknowledge that I am required to fully comply with these provisions. I also acknowledge that ability to comply with any of these requirements may subject me to administrative fines, criminal sanctions, and other penalties as provided in the Palm Springs Municipal Code, including suspension or termination of my permit to operate a medical cannabis cooperative or collective in the City. All applications must include a deposit of $7,500 toward the cost of the City s review of the application. In the event this amount is insufficient to cover the City s costs, the applicant will be required to post additional funds to cover City costs. Make checks payable to the CITY OF PALM SPRINGS. Page 8
ATTACHMENT 1 PROPERTY OWNERSHIP AND DOCUMENTS Is the Property owned by the MCCC Applicant: YES NO Property Owner and Contact Information: Residence Business Cell Facsimile Is the MCCC in a multi-tenant building: YES NO If yes please list other businesses in the building: Business Business Type Insert behind the Attachment 1 Cover Sheet either: Evidence of property ownership by the MCCC applicant. Current Lease Agreement and notarized acknowledgement from the owner of the property that approves an MCCC will be operated on his/her property. Page 9
ATTACHMENT 2 FINANCIAL INTEREST INFORMATION Please provide the names and contact information of every person(s) who has a financial interest in the MCCC: Percentage Interest in MCCC Percentage Interest in MCCC Percentage Interest in MCCC Percentage Interest in MCCC Insert behind the Attachment 2 Cover Sheet: Copy of current Driver License and/or California Identification Card for each individual who has a financial interest in the MCCC. Page 10
ATTACHMENT 3 PRINCIPAL OFFICERS AND DIRECTORS INFORMATION Please provide the names and contact information of every principal officer, director and operator of the MCCC: Insert behind the Attachment 3 Cover Sheet: Copy of current Driver License and/or California Identification Card for each principal officer, director, and operator of the MCCC. Page 11
ATTACHMENT 4 OPERATIONS AND MANAGEMENT INFORMATION Please provide the names and contact information of every person who is managing or responsible for the MCCC activities: Insert behind the Attachment 4 Cover Sheet: Copy of current Driver License and/or California Identification Card for every person who is managing or responsible for the MCCC activities. Page 12
ATTACHMENT 5 EMPLOYEE INFORMATION Please provide the names and contact information of every employee, and a statement as to whether such person(s) has or have been convicted of a crime(s), the nature of the offense(s) and the sentence(s) received for such convictions(s): Offense Type (if any) Sentence Offense Type (if any) Sentence Offense Type (if any) Sentence Offense Type (if any) Sentence Insert behind the Attachment 5 Cover Sheet: Copy of current Driver License and/or California Identification Card for every Employee. Page 13
ATTACHMENT 6 ARTICLES OF INCORPORATION Pursuant to State and local law, all medical cannabis cooperatives and collectives shall be non-profit, mutual-benefit corporations: Designed agent for service of process: Insert behind the Attachment 6 Cover Sheet ALL of the following: Copy of Articles of Incorporation filed with the California Secretary of State. Copy of filed California Secretary of State Statement of Information. Copy of Internal Revenue Service Letter of Determination you are an approved tax-exempt entity. Evidence of proof of lawful presence or residence in the City of Palm Springs. Examples of this may include a copy of the applicant s driver s license or a combination of other documents such as a utility bill, etc. Page 14
All Applicants must submit a security plan. A security plan that includes the following: ATTACHMENT 7 SECURITY PLAN a. Security cameras that have been installed and maintained in good working condition, and used in an on-going manner with at least 240 continuous hours of digitally-recorded documentation in a format approved by the City Manager. Please provide the number of security cameras and list the areas covered by each. The areas to be covered by the security cameras include, but are not limited to (1) the storage areas (2) cultivation areas (3) all doors (4) all windows, and (5) any other areas as determined by the City Manager. b. A reliable and commercial alarm system that is operated and monitored by a lawfully-operating security company or alarm business. Please provide the name and contact information of the security camera monitoring company. c. Properly illuminated windows and doors that are in compliance with the City s lighting standards regarding fixture type, wattage, illumination levels, shielding, etc. (Applicants may be required to secure the necessary approvals and permits.) Insert behind the Attachment 7 Cover Sheet ALL of the following: Security Plan that meets requirements. Valid current agreement with licensed alarm monitoring company. Page 15
ATTACHMENT 8 SITE PHOTOGRAPHS All Applicants must submit photographs of the existing site that show the front, back and sides of the building, lighting, parking, etc. Insert behind the Attachment 8 Cover Sheet ALL of the following: Photos of front of building. Photos of rear of building. Photos of sides of building. Photos of exterior lighting. Photos of parking. Page 16
ATTACHMENT 9 SITE AND FLOOR PLANS All Applicants must submit on one sheet of white paper no less than 11 X 17 inches and no larger than 24 X 36 inches an accurate detailed site plan and floor plan of the premises that clearly labels all the uses of areas on the premises, including: 1) doors; 2) entrances; 3) windows; 4) use of each area including 5) storage area(s), 6) cultivation area(s), 7) exterior lighting fixtures, 8) security cameras, 9) restrooms, 10) signage and 11) parking (including other tenant spaces if the MCCC is proposed for a multi-tenant building site). The project shall be required to provide secure bicycle parking facilities on site for use by residents and commercial/retail patrons and owners. Location and design shall be approved by the Director of Planning. Insert behind the Attachment 9 Cover Sheet the following: Site Plan. Floor Plan. Bicycle parking facilities. Page 17
ATTACHMENT 10 ADDITIONAL MATERIALS List and insert behind the Attachment 10 Cover Sheet any additional materials you would like to submit with your application to be considered by the City Council and City Staff. List of Additional Materials: Page 18