HomeMy WebLinkAboutSLOCal Roots Application FormCITY OF SAN LUIS OBISPO
Community Development Department
919 Palm Street, San Luis Obispo, CA 93401
805.781.7170
Commercial Cannabis Business Operators Permit Application
Business Name: ! Lo (f-nA-L**..e
Property Address:
Assessor Parcel Number: (,'IS *3 — 2,.S 6— 407 Zoning Designation:
B. Business p- pp
7]—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)
Manufacture (Non-volatile Raw Manufacture (Cannabis Infusion) Manufacture (Itinerant — No
Product Extractionpermanent facility)
Manufacturer (Research and Distributor Testing Laboratory
Development)
4A.Retailer Storefront (Adult -use) tailer 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)
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:
Title: ! ' DOB:
Social Security No:
Ifapplicant is anot for profit, corporation, partnership or other business entity, please identify.-
Name of Business Entity: 6/0 p, t rg-boof5 p lw j LPL
Type of Ownership: G,;n. 7 G ,,lil,j i 7j LOB,,, I Ay
Federal Tax Id: Start Date: 10
Mailing Address: S 9 oa i - ; 6 P C ? 'z/D
rimaryPhoneNo: Alt. Phone No:
Email Address:
Preferred method of contact (check one) Mail Phone (%Email
E. Additional Responsible Party Information
Title: DOB:
Social Security No:
Mailing Address:
Primary Phone No: Alt. Phone
Email Address:
Preferred met contact (check one) Mail Phone Email
attach additional sheets if there are more than 2 Responsible Partles,
Email Address:
Preferred method of contact (check one) Mail PhoneEmail
If the applicant is not the legal owner of the property, the application must be accompanied by a notarized Owners
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.
E.Yes E] No (If yes, please provide the following information)
A
Name: i-116+cn OWn G li...
City or County:S Start Date: End Date:%-75-
Business Name:Business Type: ifyM }:„Cefii._
Or
Please attach additional sheets if necessary.
N
i • • • • •
Please attach all applicable documents listed below as part of your application as they pertain to your business type.
For any items that do not apply to your business type, please provide a brief explanation as to why they do not
apply.
Business Operations Plan
Business Plan: A plan describing how the commercial cannabis business will operate in accordance with City
code, state law, and other applicable regulations. The business plan must include plans for handling cash and
transporting cannabis and cannabis products to and from the site.
Community Relations Plan: A plan describing who is designated as being responsible for outreach and
communication with the surrounding community, including the neighborhood and businesses, and how the
designee can be contacted.
State Licenses: Copies of the state licenses relating to the commercial cannabis business licenses, the applicant
holds (when available).
Tax Compliance: A current copy of the applicant's city business operations tax certificate, state sales tax seller's
permit, and the applicant's most recent year's financial statement and tax returns (for first time applicants, the
business operations tax account will be set up in-house after the application has been submitted).
Insurance: The applicant's certificate of commercial general liability insurance and endorsements and
certificates of all other insurance related to the operation of the cannabis business.
Budget: A copy of the applicant's most recent annual budget for operations (If available)
Financial Capacity: Financial information such as bank balances, available loans and other sources of funding
the enterprise.
Products and Services: A list/description of the general products and services the business will provide.
Community Benefit: The applicant shall demonstrate to the satisfaction of the City of its intent to local hiring
and community support.
Education Plan: A plan describing the type of cannabis education and prevention efforts that will be provided by
the business to the community.
Security Plan: A detailed security plan outlining the measures that will be taken to ensure the safety of persons
and property on the business site. The security plan must be prepared by a qualified professional.
Lighting Plan: A detailed lighting plan showing existing and proposed exterior and interior lights that will provide
adequate security lighting for the business site.
Site and Floor Plans: A dimensioned site plan of the business site, including all buildings, structures, driveways,
parking lots, landscape areas and boundaries. Also provide dimensioned floor plans for each level of each building
that makes up the business site, including the entrances, exits, walls and cultivation areas, if applicable. The plans
shall also include the following information about the site: current zoning, parking requirements, consistency with
development standards for the zone, if new development planned for the site, and any other site development
information.
Water Efficiency Plan: The applicant shall demonstrate to the satisfaction of the City that sufficient water supply
exists for the use.
Odor Control Plan: A detailed plan describing how the applicant will prevent all odors generated from the
cultivation, manufacturing and storage of cannabis from escaping from the buildings on the business site, such
that the odor cannot be detected by a reasonable person of normal sensitivity outside the buildings.
Hazardous Materials Plan: To the extent that the applicant intends to use any hazardous materials in its
operations, the applicant shall provide a hazardous materials management plan that complies with all federal,
state and local requirements for management of such substances.
Energy Efficiency Plan: Documentation that the applicant has identified the best way, including carbon free
power sources to provide reliable and efficient energy solutions for their business.
I, the applicant, provide authorization and consent for the City Manager or his/her designee to seek verification
of the information contained on this application.
Is Indemnification
FI, 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.
J0 Nonrefundable Filing 'Fee
I, the applicant, understand and accept that the nonrefundable filling fee must be submitted with the competed
omm4ercial Cannabis Business Operators Permit Application and will be retained by the City regardless of the out- come
of the application review. VJ
I, 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)
bnlicant's Certificati
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 this application hat the information contained herein is true and correct.
Signature: Date: e?-
The information contained on this document is subject to disclosure under the Public Records Act,
Applicants pro viding 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
ii) 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
TVT
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 owners 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-, C) Q.
Mailing Address- --'3 5,
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 applicable law. The subject property
is located at,, k e Assessor"s Parcel
Number: 4(1 46) 0 See Attached Certificate
10W 1 44 Z k,dA1
1111iol57
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
County of
A
On before me Dote
Here Insert Name and Title of the Officer e
4, personallyappearedName(
s) c'Signer(s) who
proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon
behalf of which the person(s) acted, executed the instrument. M.
AM- ML All Imi Mir
Cox California
NotaryPub'ic San
Luis Obispo County Commission
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My r dm;m. Expitres Oct 29, 2022 In,
I- MWI- I Place
Notary Seal andlor Stamp Above I
certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct. WITNESS
my hand and official seal. Signature
Signature
of Notary Public Completing
this information can deter alteration of the document or fraudulent
reattachment of this form to an unintended document Description
of Attached Document Title
or Type of Document: Document
Date: Signer(
s) Other Than Named Above: Capacity(
les) Claimed by Signer(s) Signer'
s Name: 11
Corporate Officer — Title(s): 0
Partner — n Limited El General El
Individual El Attorney in Fact n
Trustee n Guardian of Conservator 11
Other: Signer
is Representing: 02017
National Notary Association Number
of Pages: Signer'
s Name: o
Corporate Officer — Title(s): El
Partner — 11 Limited n General 1:
1 Individual 0 Attorney in Fact r-
1 Trustee o Guardian of Conservator El
Other: Signer
is Representing: