LIC-977-CNB Cannabis License Application Page 1 of 66
¿ THE CITY OF
O BARSTOW
CHOSSROADS DE OPPORTUNITY
Planning and Building Agency
Cannabis Division
CANNABIS LICENSE APPLICATION
ALL FEES ARE NON-REFUNDABLE - THIS APPLICATION IS A PUBLIC RECORD Application Number 000a Date 12 - 1-2021
-
To be filled out by City To be filled out by City
Check each that applies:
Cannabis Application Fee
Initial • $18,644.85
Quarterly Compliance Inspection $550.00
Annual Renewal*** $14,107.85
Entity Transfer or Modification** П
TOTAL FEES $18,644.85
For Manufacturing, circle one: Volatile Non-Volatile
**For a transfer of one person or entity to another, original permit holder must submit a signed and dated letter on professional letterhead detailing his/her intention to be removed from the business and permit.
*** Annual Regulatory Fee included. For an Annual Renewal Permit submit the following: Completed Application; Updated Live Scans; Proof that Business License taxes and Cannabis taxes have been paid and are up-to-date; One, 8.5" × 11" Site Plan and Floor Plan identifying the location of cannabis activities and showing the exact square footage of each cannabis activity. Include permit numbers.
An inspection by City Staff is required prior to issuance of the Annual Renewal. 220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB Cannabis License Application Page 2 of 66
Please print the following information and attach the conditions of approval for each permit you list:
Conditional Use Permit Application Number (required before operation):
N/A
Other related permits (previous cannabis applications, location development plan, etc.):
N/A
I.
Application Information
Name of Business: Shryne Barstow LLC
Applicant entity structure:
• Corporation
• Unincorporated Association
J Other (described): Limited Liability Company
I1.
Applicant (Entity Name) Shryne Barstow LLC
Applicant Representative & Title: Tak Sato President
(this is the person who will be listed on the permit when it is issued, and whom the planning department will contact regarding this application)
Address: 728 E Commercial St.
City: Los Angeles State: CA Zip: 90012
Telephone: (310)488-5707 Email: [email protected] Cellphone: (310)488-5707
Ill.
Location / Property Information
Facility address (issued by City of Barstow, If there are multiple addresses, list them all):
2560 High Point Pkwy, Ste. A-2 and A-3
Assessor's Parcel Number (Issued by San Bernardino County Assessor): 042821148 Zip Code: 92311
Total square-Feet of each structure on site: Bidg A: 4,922 saft and Bldg B: 3,560 sqft IV.
Property Owner information
Recorded Owner: JC Investments LLC
Address: 2560 High Point Pkwy
City: Barstow State: CA Zip: 92311
Telephone: (702)493-6669 Cellphone: (702)493-6669
V.
Criminal Convictions
220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB Cannabis License Application Page 3 of 66
Please list any felony criminal convictions or misdemeanor convictions involving moral turpitude, or the illegal use, possession, transportation, distribution, or similar activities related to controlled substances. Please list offense, date of offense, date of conviction, and City in which conviction occurred:
1. N/A
2. 3.
VI.
Unfair Business Practices
For any Applicant or Managing Member, please list all unlawful, fraudulent, unfair, or deceptive business acts or practices:
1. N/A
2. 3.
Business Entity Information
Appropriate Entity: • Nonprofit • Not-for-profit For-Profit Name of Corporation or LLC Shryne Barstow LLC
Cal. Sec. of State Corp. ID No: 202131410228
Federal Tax ID No: N/A
Date of Incorporation: November 11, 2021
Place of Incorporation: California
Location of Corporation Headquarters: 728 E Commercial St, Los Angeles, CA 90012 Is this a Mutual Benefit Corporation? •YES DINO
Are all members of the corporation Qualified Patients and Designated Primary Caregivers •YES ZNO
of the Qualified Patient members?
220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB Cannabis License Application Page 4 of 66
Corporate Officers:
Please provide the following information for each cannabis permit applicant Corporate Officer. Attach additional pages to the application if necessary. Those listed will be authorized to discuss matters of this application with the Planning Department. Corporate Officers and Delivery Drivers must be recorded by the California Secretary of State.
All corporate officers and non-store front delivery drivers shall submit a live scan, failure to do so may result in delayed processing of this application.
Name (First, MI, Last) Title Phone
James ST Kim Managing Director 1(562)833-0842
Tak Sato President (310)488-5707
Jonathan Avidor I CEO |(917)740-3695
220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB Page 5
BARSTOW PROPERTY OWNER / LANDLORD USE DISCLOSURE & AUTHORIZATION FOR
A CANNABIS FACILITY
If the applicant is the owner of the property on which this activity is located, the applicant shall provide a copy of the title or deed to the property. If the applicant is not the owner of the property, this form shall be filled out and a copy of the contractual agreement between applicant and owner included. ¡ James Chen of JC Investments LLC _ am the legal Owner Landlord / Lessor or real (Name of Property Owner / Landlord) (Circle Appropnate Term) Property located at 2560 High Point Pkwy, Ste. A-2 and A-3 _ in Barstow, California. (Address of Property)
I hereby authorize the Cannabis Applicant entitled
Shryne Barstow LLC _ to use this property as a
(Name of Corporation, Individual, or Business)
cannabis facility, as that term is defined in state law and by the City of Barstow Municipal Code, for the specific use of a cannabis facility.
James Chen, Managing Member
(Printed Name & Title)
Joe de
(702)493-6669 2560 High Point Pkwy, Barstow, CA 92311
(Phone Number) (Address)
Nov. 25/2021
(Copy and attach additional pages of this form if necessary to include multiple Owners) All Signatures must be original, no electronic signatures, or copies will be accepted. 1, Tak Sato on behalf of Shryne Barstow LLC • declare under penalty of perjury that the foregoing (Applicant)
Information is true and correct. Executed this_ 24 day of 11 202L.
Allo
220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB Cannabls License Application Page 6 of 66
ACKNOWLEDGEMENT OF CANNABIS OPERATING STANDARDS AS SET FORTH IN
BARSTOW'S MOST RECENT CANNABIS ORDINANCE
The undersigned Management Members, on behalf of the herein Cannabis Operation I, permit applicant, Tak Sato on behalf of Shryne Barstow LLC → declare under penalty of perjury that I have read and understand the provisions of Barstow's most recent cannabis ordinance, and shall, collectively and individually, ensure that the Cannabis Applicant, its Members, and Management Members shall not engage in activity that violates the Operational Requirements set forth in Barstow's most recent cannabis ordinance, which states in relevant part that the Cannabis Applicant shall:
(A) Only Operate on a property located within the zoning districts specified by Barstow Municipal Code sections 19.16.030 and 19.18.030, as applicable.
(B) Not be located within a 1,000-foot radius of any public or private school providing instruction in kindergarten or any grades one through twelve, public park, public day care center or youth center, or church or other religious land use that in in existence at the time the Cannabis Business applies for its initial Permit.
(C) Not be located within 1,000-foot radius of any residentially zoned district of the City (Districts ER, LDP, SFR, MDR or any other newly created residential zoning district) that is so zoned at the time the Cannabis Business applies for its initial Permit.
(D) Comply with all City laws and all other applicable laws. (E) Comply with all applicable provisions of Business & Professions Code Section 26000, et seq. and all applicable rules and regulations promulgated by the State Licensing Agencies. (F) Designate one of its Owners or full-time employee as its Community Relations Liaison and who shall be responsible for receiving and responding to all concerns and complaints made to the City regarding the Cannabis Business and for making a good faith attempt to promptly address all concerns and resolve all complaints. The Community Relations Liaison's name, phone number, and email address shall be posted prominently on the exterior of the Cannabis Business's Business Premises. (G) Individuals under 21 years of age shall not be allowed on the Business Premises of any Cannabis Business, except as pertaining to the sale of cannabis for medicinal use by a Storefront Retail Cannabis Business to a medical patient or primary caregiver who is at least 18 years of age. (H) A Retail Storefront Cannabis Business shall only be open to the public between the hours of 6 a.m. and 10 p.m. A Delivery Cannabis Business shall only deliver Cannabis or Cannabis Products between the hours of 6 a.m. and 10 p.m. The City Manager may adjust these default hours by regulation. 220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB Cannabls License Application Page 7 of 66
(1) Implement sufficient security measures to deter and prevent the unauthorized entrance into areas containing Cannabis or Cannabis Products, and to deter and prevent the theft of Cannabis or Cannabis Products. These security measures shall include, but may not be limited to the following:
1) Alarm system (perimeter, fire, and panic buttons)
2) Remote monitoring of alarm systems by licensed security professionals 3) Perimeter lighting systems (including motion sensors) for after-hours security 4) Perimeter security and lighting
5) Establishing limited access areas accessible only to authorized Cannabis Business personnel 6) All Cannabis and Cannabis Products shall be stored and secured in accordance with the requirements specified by the State of California. All Cannabis and Cannabis Products, including live plants that are being cultivated, shall be kept in a manner as to prevent diversion, theft, and loss.
7) 24-hour security surveillance cameras to monitor all entrances and exits to and from the Business Premises, all interior spaces within the Cannabis Business which are open and accessible to the public, all interior spaces where Cannabis, cash or currency, is being stored for any period of time on a regular basis and all interior spaces where diversion of Cannabis could reasonably occur. Live feed and video recording shall be maintained for a minimum of 90 days. (J) Take reasonable steps to discourage persons on or around its Business Premises, including any parking areas under its control from engaging in illegal, criminal, or nuisance activities, including, but not limited to, disturbances of the peace, public intoxication, drinking alcoholic beverages, smoking or ingesting Cannabis Products, illegal drug activity, vandalism, obstruction of the operation of another business, harassment of passersby, gambling, prostitution, loitering, public urination, lewd conduct, drug trafficking, excessive loud noise, or any other behavior that adversely affects or detracts from the quality of life for adjoining residents, property owners, or businesses. (K) Provide immediate access to its Business Premises and all areas therein to employees or agents of the City performing their official duties.
(L) The City Manager or its designee may develop other operational requirements or regulations as are determined to be necessary to protect the public health, safety, and welfare. (M) Cannabis growing, manufacturing, and testing shall be in appealing and discreet facilities that do not openly advertise the presence of any cannabis products or operations on site and subject to City's Design Guidelines.
220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB Page 8
We, James Chen of JC Investment LLC and Tak Sato of Shryne Barstow LLC (Printed Name of Property Owner) (Printed Name of Operator) Collectively acknowledge that we have been provided a copy of the cannabis facility operating standards listed on the City of Barstow's most recent cannabis ordinance. We further acknowledge that we have read, understand, and shall ensure compliance with the aforementioned operation standards and all applicable provisions of the City of Barstow's most recent cannabis ordinance at the time cannabis facility entitled Shryne Barstow LLC
(Name of facility listed on the application)
We certify under penalty of perjury that the foregoing information is true and correct.
Executed this _ 24 day of 20_2 L in Barstow, California. (Day) (Month) (Year)
Latche James Chen, Managing Member
Signature of Property Owner | Printed Name & Title
* ти Tak Sato, President
Signature of Operator Printed Name & Title
220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB
Cannabis License Application Page 9 of 66
INFORMATION AND RELEASE FORM
The undersigned, on behalf of Shryne Barstow LLC hereby authorize the City of Barstow, by and (Name of Corporation)
Through its appropriate Officers, Agents, and Employees to verify and confirm the information contained in this application, and to conduct such other investigations as may be reasonably required by the City of Barstow, its Officers, Agents, and Employees for the purpose of determining the capability, fitness, and capacity of the above named Corporation to obtain the Cannabis Permit.
The Applicant by signing this Information Release Form consents to service of any notice required or provided for by the laws, rules, regulations, or ordinances of the City of Barstow upon the person(s) at the address listed for Applicant, will constitute sufficient and legal notice, unless said Applicant listed an Attorney of Record and/or Agent for service of process, with sufficient contact information.
The Applicant consents and agrees that full compliance will be made with all applicable State laws and City ordinances governing the conduct of the particular type of activity for which the Cannabis Permit re requested.
The Applicant by signing this Information Release Form understand that any complete or false information may constitute grounds for denial.
This form MUST be signed by each Applicant Management Member.
James Kim, Managing Director 1/30/2021
Signature of Management Member Printed Name & Title Date Tak Sato, President 11/30/2021
Signature of Management Member Printed Name & Title Date Jon Avidor 11/30/2021
signature of Management Member Printed Name & Title Date This release may be executed in two or more counterparts, each of which shall be deemed an original, and all of which taken together shall constitute one and the same instrument. All Signatures must be originals; no electronic signatures or copies will be accepted.
I declare under penalty of perjury that I have read the forgoing application and all information, statements, verifications, declarations, and authorizations made, attached to and contained herein, and that I have personal knowledge of the information contained in the application, and that the information contained and the application is true and correct, and that the application was completed under supervision of the Management Members.
Executed this 30T dayof November20_202/n Barstow, California. 220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home LIC-977-CNB Cannabis License Application Page 10 of 66
BARSTOW CANNABIS FACILITY
ON-SITE MEMBER CONTACT STATEMENT
The undersigned, on behalf of Shryne Barstow LLC
(Name of Corporation)
hereby designates Tak Sato® as the on-site
(Name of On-Site Manager)
Community Relation's Representative to whom the Public or City can provide notice to fi there are operating problems or issues relating to the Barstow Cannabis Facility. The Cannabis Facility shall make every good faith effort to encourage residents to call this person to try to solve operating problems, if any, before any calls or complaints are made to the Police or Planning Departments.
Tak Sato, President*
Signature of On-Site Manager | Printed Name & Title
728 E Commercial St, Los Angeles, CA 90012* (310)488-5707* Address Phone Number
N/A [email protected]*
Fax Number Email
I declare under penalty of perjury that I have read the forgoing application and all information, statements, verifications, declarations, and authorizations made, attached to and contained herein, and that I have personal knowledge of the information contained in the application, and that the information contained and the application is true and correct, and that the application was completed under supervision of the Management Members.
24 Executed this 11 20_2 L in Barstow, California.
(Month)
*Subject to change after approval of license.
220 E Mountain View St. Ste A • Barstow, CA 92311 • (760) 255-5161 • https://www.barstowca.org/home