HomeMy WebLinkAboutMegan's Organic (300 Higuera) Application FormITY OF SAN LUIS OBISPO
d' Community Development Department
919 Palm Street, San Luis Obispo, CA 93401
805.781.7170
Commercial Cannabis Business Operators Permit Application
A. Business Information
Assessor Parcel Number: Zoning Designation:
B. Business Type
Cultivation - Specialty (Up to 5,000 Cultivation - Small (5,001 - 10,000 Cultivation - Nursery (Up to 10,000
Sq. Ft. Max) Sq. Ft. Max) Sq. Ft. Max)
Ll Manufacture (Non-volatile Raw El Manufacture (Cannabis Infusion) El Manufacture (Itinerant - No
Product Extraction) permanent facility)
Manufacturer (Research and Distributor Testing Laboratory
Development)
Retailer Storefront (Adult -use) Retailer Storefront (Medical) Retailer Storefront (Adult -use and
Medical
Retailer Non -storefront (Adult -use) Retail Non -Storefront (Medical) Retail Non -storefront (Adult -use and
Medical
Transporter Microbusiness (No more than 50% Microbusiness (More than 50% GR*
GR* from cultivation, distribution from cultivation, distribution and
and manufacturing) manufacturing)
GR -Gross Receipm
C. Definitions
Applicant - The entity petitioning for the Cannabis Business Operator Permit.
Principal(s) - The individual members of the applicant team.
Primary Principal - An individual who has a 10% or greater ownership stake of the applicant business, which
includes partners, officers, directors, and stockholders of every corporation, limited liability company, or general
limited partnership that owns at least 10% of the stock, capital, profits, voting rights, or membership interest of the
commercial cannabis business or that is one of the partners in the commercial cannabis business; the managers of
the commercial cannabis business.
Operator - An applicant that has been licensed and conducts or conducted active cannabis operations.
Majority - A greater number; more than half. An equal number does not constitute a majority.
D. Applicant Information
Name of Primary Responsible Party Completing the Application:
Social Security No:
t
If applicant is a not corporation, partnership or other business entity, please identify.,
Name of Business Entity:
Type of Ownership:
A
P-1.
Federal Tax Id: Start Date:
r
1 -10 -) 9
Mailing Address: [Hos
H. City Authorization
AI, the applicant, provide authorization and consent for the City Manager or his/her designee to seek verification
of he information contained on this application.
I. Indemnification
I, the applicant, agree to the fullest extent permitted by law, any actions taken by a public officer or employee
under the City of San Luis Obispo regulations for Commercial Cannabis Businesses, shall not become a personal liability
of any public officer or employee of the City. To the maximum extent permitted by law, the permittee shall defend
with counsel acceptable to the City), indemnify and hold harmless the City of San Luis Obispo, the San Luis Obispo
City Council, and its respective officials, officers, employees, representatives, agents and volunteers from any liability,
damages, actions, claims, demands, litigations, loss (direct or indirect), causes of action, proceedings, or judgments
including legal costs, attorneys' fees, expert witness or consultant fees, City Attorney or staff time, expenses or costs)
against the City to attach, set aside, void or annul, any cannabis -related approvals and actions and strictly comply
with the conditions under which such permit is granted, in any. The City may elect, in its sole discretion, to participate
in the defense of said action and the permittee shall reimburse the City for its reasonable legal costs and attorneys'
fees.
J. Nonrefundable Filing Fee
K, the applicant, understand and accept that the nonrefundable filling fee must be submitted with the competed
mercial Cannabis Business Operators Permit Application and will be retained by the City regardless of the out-
come of the application review.
K. Background — Request for Live Scan Services
kyI, the applicant, understand that a completed and processed Request for Live Scan Service, State of California
Form BCIA 8016, as determined by the City of San Luis Obispo, by a duly authorized business must be provided for
the applicant and all interested parties. All applicable fees and charges are the responsibility of the applicants and
interested parties.
L. Disqualification
Application was received late
Application is incomplete or inaccurate
Facility does not meet City business licensing standards
More than one application is received for the same cannabis business type on one property (stacking of
applications)
Primary Phone No: Alt. Phone No:
Email Address:
Preferred method of contact (check one) Mail Phone Email
E. Additional Responsible
Title:
Social Security No:
Mailing Address:
Primary Phone No: Alt. Phone No:
DOB:
Email Address:
Preferred method of contact (check one) Mail Phone Email
Please attach additional sheets if there are more than Z Responsible Parties.
F. Information on Property Owner or Landlord
Name: Sef fV J. O'C nnot
Mailing Address:
Primary Phone No: ($Alt. Phone No:
Email Address: NIA
Preferred method of contact (check one) Mail A Phone Email
If the applicant is not the legal owner of the property, the ,,ppiiration must be accompanied by a notarized Owners
Statement of Consent to operate a commercial rannabr. business on the property.
G. Related License Information
The applicant and/or responsible parties has been associated with a commercial cannabis business permit In the
past 10 years.
Yes No If yes, please provide the followings information)
Name:
City or County: Start Date: End Date:
Business Name: Business Type:
Please attach addwi i jl sheets if necessary.
rimary Phone No: Alt. Phone No;
Email Address:
Preferred method of contact (check one) Mail Phone §4 Email
AdditionalE. ..
Name: ec
Title: pag;
Social Security No:
Mailing Address: , ( ( ,
Phone No: t- ' Phone No: Email
Address: i
method of contact (check one) Mail Phone Email Please
attach additional sheets if there are more than 2 Responsible Parties. Name: ,
CI -
PLvef'/`r ! Mailing
Address: 1
Phone No: vgwAlt.
Preferred method
of contact (check one) Mail Phone Email If the
applicant is not the legal owner of the property, the application must be accompanied by a notarized Owner's Statement of
Consent to operate a commercial cannabis business on the property. G. Related
License Information The applicant
and/or responsible parties has been associated with a commercial cannabis business permit in the past 10
years. Yes No
If yes, please provide the following information) Name: vo
e City or
County: Start Date: 1a SL I • .2 o IB End Date: Business Name:
I Please attach
additional sheets ifnecessary`. Business Type: L_
L1 ' -
nnlicant's Certificatir
I agree to abide by and conform to the conditions of the permit and all provisions of the San Luis Obispo Municipal
Code pertaining to the establishment and operation of the commercial cannabis business. I acknowledge that the
approval of the Commercial Cannabis Business Operators Permit shall, in no way, permit any activity contrary to the
San Luis Obispo Municipal Code, or any activity which is in violation of any applicable law.
I certify under penalty of perjury under the laws of the State of California, that I have personal knowledge of the
information contained in this application, and that the information contained herein is true and correct.
Signature: ` Date:
The information contained on this document is subject to disclosure under the Public Records Act.
Applicants providing false or misleading information in the permitting process will result in rejection of the application
and/or nullification or revocation of any issued permit All commercial cannabis permits must be approved by the
City Council. The City may attach conditions to the permit. A commercial cannabis permit may be denied if any of
the following findings are made:
i) The application does not meet all requirements of the commercial cannabis ordinance; or
Approval would very likely result in harm to public safety, health, or welfare; or
iii) Potential negative impacts of the use cannot be mitigated with conditions or through the ordinance
requirements.
Applicants will be notified regarding application completeness
OMMERCIAL CANNABIS BUSINESS OPERATORS PERMIT APPLICATION
OWNER'S STATEMENT OF CONSENT
If the applicant is not the owner of record of the subject site, the following Statement of Consent must be completed
by the owner or the owner's authorized representative, granting the applicant permission to apply for a cannabis
business operator permit.
I, the undersigned legal owner of record, hereby grant permission to:
Applicant: A 0M ` Sc— O ( Lj,_— Phone:_
Mailing Address: Gk+
To operate a commercial cannabis business on the property described below. I agree to abide by and conform to the
conditions of the permit and all provisions of the San Luis Obispo Municipal Code pertaining to the establishment and
operation of the commercial cannabis business, I acknowledge that the approval of the Commercial Cannabis
Business Operator Permit shall, in no way, permit any activity contrary to the San Luis Obispo Municipal Code, or any
activity which is In violation of any appllcable law,
2g6 -
The subject property Is located at: 3 V I
Assessor's Parcel Number: 41r-10.-)— - a - C. 1 /nn
Printed Name of Owner of Record: 'b_gJfV J • nn>O
Address of Owner of Record:
Phone: (Email address: - N/A
Signature of Owner of Record: Date:
Attorney -In -Fact (Agent) for Owner ofpepord R. Michael Tpwi 4 oate: Janus 24 201Q
Signature of Attorney -In -Fact: ) ate: •j0AWKY 29, W M
NOTARY AC'KNOWLEDGMEN'I
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or validity
of that document.
State of California }
Ss.
County of San Luis Obispo j
TITLE OF DOCUMENT:
COMMERCIAL CANNABIS BUSINESS OPERATORS PERMIT APPLICATION
OWNER'S STATEMENT OF CONSENT
On January 29, 2019, before me, TREVOR C. LUENSER, a Notary Public, personally
appeared R. MICHAEL DEVITT, who proved to me on the basis of satisfactory evidence to be
the person whose name is subscribed to the within instrument and acknowledged to me that she
executed the same in her authorized capacity, and that by her signature on the instrument the
person, or the entity upon behalf of which the person acted, executed the instrument.
1 certify under PENALTY OF PERJURY under the laws of State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal.
f1V '. LUFNSER, Notary Public.
LUIS
LUENSER
2420
uRNMA
COUNTY
13, 2022
Seal)