MANTECA COMMERCIAL CANNABIS BUSINESS APPLICATION Page 1 of 3
COMMERCIAL CANNABIS
BUSINESS APPLICATION
(Cannabis Retailer)
APPLICANT (ENTITY) INFORMATION
APPLICANT (ENTITY) NAME: DBA:
Physical Address: City: State: Zip:
PRIMARY CONTACT:
Title:
Mailing Address: City: State: Zip:
Phone: Email:
HAS ANY INDIVIDUAL IN THIS APPLICATION APPLIED FOR ANY OTHER CANNABIS PERMIT IN THE CITY OF MANTECA: ☐ Yes ☐ No Select one or more of the following categories. For each category, indicate whether you are applying for Adult-Use (“A”) or/and Medicinal (“M”) or both.
☐ Adult Use ☐ Medicinal Use
Indicate whether you are applying for Retail (Storefront), Retail (Non-Storefront) or Retail (Storefront with Delivery). ☐ Retail (Storefront) ☐ Retail (Non-Storefront) ☐ Retail (Storefront with Delivery) Business Formation Documentation: Describe how the business is organized (attach to Business Plan). ☐ Sole Partnership ☐ Corporation ☐ S-Corporation ☐ Limited Liability Company ☐ Limited Partnership ☐ Other:__________
PROPOSED LOCATION
Applications failing to submit any of the following will be deemed incomplete unless otherwise noted by an asterisk for special deadlines, and will not move forward in the application process:
✓ One (1) printed hard copy of a complete and signed Commercial Cannabis Initial Application form (Pages 1-3). ✓ All Evaluation Criteria outlined in Appendix A (Sections A-H) saved in PDF format on a single USB flash drive. (This section shall not ✓ exceed 125 pages).(¹)
✓ Commercial General Liability Insurance with $2,000,000 minimum limit per occurrence and $4,000,000 general aggregate limit.
Worker’s Compensation as required by the State of California and Employer’s Liability Insurance. Commercial General Liability Additional Insured Endorsement naming the following as insured: “City of Manteca, its officers, officials, employees, agents, and volunteers”. ✓ Agency that the cannabis business is insurable.(²)
✓ A signed and notarized Property Consent form.
✓ A signed Financial Responsibility, Indemnity and Consent to Inspect Terms Agreement form (Pages F1-F3). ✓ A signed Limitations of City Liability and Indemnification to City form (Pages F4-F6). ✓ Proof of Background Check receipt.
✓ Application Zoning Verification Letter (ZVL).
✓ Proof of Capitalization.
(¹) Background and Proof of Capitalization documents are not part of the 125-page limitation. (²) The only information that can be submitted after the initial application is proof of insurance prior to the City awarding a Cannabis Permit. However, at a minimum, proof of insurability must be provided with the initial application package.
Property Owner Name:
Address: City: State: Zip:
Phone: Email:
Zoning Verification Letter (Please attach): ☐ Yes ☐ No
Assessor’s Parcel Number (APN):
Proposed Location Square Footage:
CITY MANAGER OFFICE
1001 West Center Street
Manteca, CA 95337
Ph: (209) 456-8011
Email:[email protected]
APPLICATION SUBMITTAL CHECKLIST
ATTACHMENT 3
MANTECA COMMERCIAL CANNABIS BUSINESS APPLICATION Page 2 of 3
SUPPORTING INFORMATION
I hereby certify, under penalty of perjury, on behalf of myself and all owners, managers and supervisors identified in this application that the statements and information furnished in this application and the attached exhibits present the data and information required for this initial evaluation to the best of my ability, and that the facts, statements, and information presented are true and correctto the best ofmy knowledge and belief. I understand that a misrepresentation offactis cause forrejection ofthis application, denial of the permit, or revocation of a permit issued.
In addition, I understand that the filing of this application grants the City of Manteca permission to reproduce submitted materials for distribution to staff, Commissions, Boards and City Council Members, and other Agencies to process the application. Nothing in this consent, however, shall entitle any person to make use of the intellectual property in plans, exhibits, and photographs for any purpose unrelated to the City's consideration of this application.
Furthermore, by submitting this application, I understand and agree that any business resulting from an approval shall be maintained and operated in accordance with requirements of the City of Manteca Municipal Code and State law.
Under penalty of perjury, I hereby declare that the information contained in within and submitted with the application is true, complete, and accurate. I understand that a misrepresentation on the facts is cause for rejection of this application, denial of a license or revocation of an issued license.
Name Signature
Title Date
For details about the information required as part of the application process, see the Application Procedures & Guidelines, City of Manteca Municipal Code Chapter 5.64, and Title 17 or any additional requirements to complete the application process. All documents can be found online at https://www.ci.manteca.ca.us/Pages/Cannabis.aspx. For questions, please contact the City Manager’s Office at (209) 456-8011 or https://www.manteca.gov.
List all fictitious business names the applicant is operating under including the address where each business is located:
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Has the Applicant or any of its owners been the subject of any administrative action, including but not limited to suspension, denial, or revocation of a cannabis business license at any time during the past five (5) years? If so, please list and explain:
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Is the Applicant or any of its owners currently involved in an application process in any other jurisdiction? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
APPLICATION CERTIFICATION
ATTACHMENT 3
MANTECA COMMERCIAL CANNABIS BUSINESS APPLICATION Page 3 of 3
OWNER INFORMATION
Owner Information must be completed by all owners with a 10% ownership or more. The total ownership percentage should equal 100%. Exception: If the business is a Publicly Traded Company (PTC), they will only be required to list all the Board of Directors and/or any person with an ownership interest of 10% or more. Please provide supporting documentation if you are claiming the PTC Waiver.
For all other business organizations, if any individual(s) own(s) less than 10%, list the number of individuals who own less than 10% and the total percentage in order to reach 100%. For example, If John Doe owns 9%, Joe Smith owns 8%, and Mary Jones owns 9% state at the bottom of this form that three individuals own 26% so that the total will equal 100% once you individually include all those who own 10% or more.
Add more pages as necessary to accommodate all Commercial Cannabis Business Owners I declare under the penalty of perjury that the information provided on this disclosure form is true and accurate to the best of my knowledge.
Ownership %
Name: Title:
Address: City: State: Zip:
Background Information Included as required? ☐ Yes ☐ No Signature: Date:
I declare under the penalty of perjury that the information provided on this disclosure form is true and accurate to the best of my knowledge.
Ownership %
Name: Title:
Address: City: State: Zip:
Background Information Included as required? ☐ Yes ☐ No Signature: Date:
I declare under the penalty of perjury that the information provided on this disclosure form is true and accurate to the best of my knowledge.
Ownership %
Name: Title:
Address: City: State: Zip:
Background Information Included as required? ☐ Yes ☐ No Signature: Date:
I declare under the penalty of perjury that the information provided on this disclosure form is true and accurate to the best of my knowledge.
Ownership %
Name: Title:
Address: City: State: Zip:
Background Information Included as required? ☐ Yes ☐ No Signature: Date:
ATTACHMENT 3