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Rhode Island Department of Business Regulation

Application for Medical Marijuana Cultivator License

Publication Release Date:December 30, 2016

Application Response Deadline:End of Application Period: April 30, 2017

Business Days: M–F, 8:30 am–4:00 pm

For additional information regarding the Application process, please visit the Department’s website at: http://www.dbr.state.ri.us/

.Questions about the Application and the Application process must be submitted to the Department by email only to [email protected]. See Section K of this

Application for further instructions

Rhode Island Department of Business RegulationApplication for Medical Marijuana Cultivator License

APPLICATION INFORMATION SHEET*1 COMPANY NAME

(legal name, and any d/b/a name(s), if applicable)

Company Name

2 STREET ADDRESS Street Address3 CITY, STATE, ZIP City, State, Zip

4 STREET ADDRESS OF PROPOSED LICENSED PREMISES

Street Address

5 CITY, STATE, ZIP City, State, Zip6 PLAT/LOT # OF

PROPOSED LICENSED PREMISES

7 SQUARE FOOTAGE OF PROPOSED FACILITY

7A License Class(select one):

☐ Micro-license☐ Class A☐ Class B

8 TELEPHONE NUMBERAREA CODE

Area CodeNUMBER:Number

EXTENSION:Extension

9 FAX NUMBERAREA CODE


EXTENSION:Extension

10

TOLL FREE NUMBERAREA CODE


EXTENSION:Extension

11

Contact Person for providing information, notices, signing documents, or ensuring actions are taken per the Act and Regulations

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Name: NameTitle: TitleAddress: AddressEmail Address: Email Address

12

TELEPHONE NUMBER AND FAX FOR CONTACT PERSON

AREA CODEArea Code

TELEPHONE NUMBER:Number

EXTENSION:Extension

AREA CODEArea Code

FAX NUMBER:Number

13

CONTACT PERSON SIGNATURE

SIGNATURE: DATE:Click here to enter a date.

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TABLE OF CONTENTSSECTION SECTION TITLE PAGE

NUMBERA Introduction 6B Cultivator License Restrictions 6C Cultivator License Limitations 6D Cultivator Licensee Possession Limits 7E Cultivator Licensee Medical Marijuana Tracking and Testing 7F Terms and Definitions 7G Application Timeline 8H Evaluation Criteria 9I Evaluation Procedures 11J Important Notices/Disclaimers 11K Communications with the Department of Business Regulation 12L How to Apply 13M License Index 16N Denial or Disqualification of Application 17Form 1 Affirmation Section 18Form 2 Disclosure of Owners, Investors, Managers and Controlling

Parties22

Form 3 Business License Identification Form 24Form 4 Tax Payer Status Affidavit / Identity Form 25Form 5 Investors, Owners, Managers and Controlling Parties

Certification Statement 26

Form 6 Mandatory Questions 29

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FORMS/DOCUMENTS CHECKLISTFORM/Exhibit # Name/Description of Exhibit Included

Yes Not

Included

Form 1 Affirmation Section ☐ ☐Form 2 Disclosure of Owners,

Investors, Managers and Controlling Parties

☐ ☐

Form 3 Business Interest Identification Form

☐ ☐

Form 4 Tax Payer Status Affidavit / Identity Form

☐ ☐

Form 5 Investors, Owners, Managers and Controlling Parties Certification Statement

☐ ☐

Form 6 Mandatory Questions ☐ ☐Supporting Documents The Applicant should include a

list of any supporting documents, which the Applicant submits with their Application (the “Supporting Documents”)

☐ ☐

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Medical Marijuana Cultivator License Application

SECTION A: Introduction

The Rhode Island Department of Business Regulation (the “Department”) is accepting Applications from qualified Applicants interested in receiving a Medical Marijuana Cultivator License.

Pursuant to The Edward O. Hawkins and Thomas C. Slater Medical Marijuana Act, Rhode Island General Laws § 21-28.6-1 et seq., as amended by Rhode Island Public Laws 2016, ch. 142, Article 14 (as so amended, the “Act”), the Department of Business Regulation is responsible for licensing cultivators of medical marijuana. The Medical Marijuana Program allows a qualifying patient, authorized purchaser or caregiver who is registered with the Department of Health to purchase medical marijuana from a registered compassion center. Licensed cultivators may sell medical marijuana and medical marijuana products to registered compassion centers in accordance with the Act and Rules and Regulations Related to the Medical Marijuana Program Administered by the Department of Business Regulation, 161-RICR-300-35-1 (the “Regulations”). Please thoroughly review the Regulations which can be found on the Department’s website accessible at the following link: http://www.dbr.state.ri.us/.

SECTION B: Cultivator License Restrictions

During the initial application period ending April 30, 2017, the Department will only receive for consideration applications for Micro-license, Class A, and Class B Cultivator Licenses. For this period, licensed cultivator applications may be submitted to the Department until April 30, 2017. The application period will be re-opened each subsequent year during the months of January, February, and March, provided that the Department may modify the re-opening period based on patient and program need. Any Applicant to whom a Micro-license, Class A, or Class B Cultivator License is issued during the initial application period may apply during a subsequent application period to expand into a larger license class in accordance with the Regulations. With respect to application periods commencing after April 30, 2017, the Department may hereafter issue regulations limiting the number and/or classes of new licenses available for application based on the projected needs of the Rhode Island Medical Marijuana Program population.

SECTION C: Cultivator License Limitations

Pursuant to the Act and the Regulations, Licensed Cultivators cannot serve as caregivers or provide medical marijuana directly to registered patients, caregivers, or authorized purchasers. Licensed Cultivators must surrender any caregiver registration card in their possession and may

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only supply medical marijuana to registered compassion centers. A Licensed Cultivator may not have any material financial interest or control in another Licensed Cultivator, in a compassion center or a licensed cooperative cultivation or in a Rhode Island Department of Health approved third party testing provider and vice versa.

SECTION D: Cultivator Licensee Possession Limits

Pursuant to the Act and the Regulations, Licensed Cultivators are limited to the amount of marijuana that they may possess as follows:

1. The amount of usable marijuana a Licensed Cultivator may possess is specified in the Regulations and in the license index in Section M below.

2. The number of marijuana plants and the amount of wet marijuana that a Cultivator Licensee may possess is specified in the Regulations.

SECTION E: Cultivator Licensee Medical Marijuana Tracking and Testing

Upon direction by the Department, all licensed cultivators shall be required to use the state approved Medical Marijuana Program Tracking System (as defined and described in the Regulations). Licensed Cultivators may be required to pay costs associated with use of the Medical Marijuana Program Tracking System, which may be assessed on an annual, monthly, per use, or per volume basis and payable to the state or to its approved vendor.

Compassion centers and Licensed Cultivators will be required to comply with the DOH Testing Regulations (as defined in the Regulations) to be hereafter promulgated by the Rhode Island Department of Health (“DOH”). The DOH Testing Regulations may require compassion centers and/or Licensed Cultivators to pay the costs associated with testing their products.

SECTION F: Terms and Definitions

Please refer to the “Definitions and References” in the Regulations, which are applicable to all Cultivator License Applications. The Regulations are posted on the Rhode Island Department of Business Regulation’s website at http://www.dbr.state.ri.us/.

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SECTION G: Application Timeline

The following represents the estimated timeline for the initial application period ending April 30, 2017. The timeline is subject to change by the Department in its discretion.

TASK DATE/TIMEApplication Form Posted on Department Website

Week commencing October 28, 2016

Deadline for Submission of Applications (hard copies, including all Forms, Supporting Documents and payment) to the Department of Business Regulation

Initial application period

Subsequent application periods

By April 30, 2017

From January 1st through March 31st of each year commencing January 1, 2018

Application Evaluation

Initial application period

Subsequent application periods

The Department anticipates that all applications submitted by the close of the initial application period will be evaluated by July 1, 2017

The Department anticipates that all applications submitted by the close of subsequent application period will be evaluated by June 1st of the applicable year

Application Decision Following completion of evaluation and determination by the Department

Issuance of license by the Department of Business Regulation

Following request of an approved Applicant for final inspection and Applicant’s satisfaction of all terms and conditions for license issuance as set forth in the Regulations

Decision Notification: The Department will notify an Applicant in writing of the Department’s approval or rejection of their Application. The Department’s decision to approve or reject an Application for a cultivator

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license shall be final. The Department may require an initial inspection of the proposed licensed premises before approving an Application in order to verify information contained in an Application.

Final Inspection, Requirements and Deadlines: Approved Applicants must schedule and receive a final pre-license inspection prior to the Department’s issuance of a cultivator license. Additionally, all registry identification card requirements, including completion of national criminal background checks, payment of the licensing fee, and all other licensing conditions and requirements under the Act and Regulations must be satisfied prior to the Department’s issuance of a license. Approved Applicants will have nine (9) months from the date of Application approval to complete the pre-requisites for issuance of the license as described in the Regulations. Licensees will have six (6) months to commence “licensed cultivator activities” as defined in the Regulations. If an approved Applicant or cultivator licensee is unable to meet these deadlines, the Department of Business Regulation may rescind its approval or revoke the license as described in the Regulations.

SECTION H: Evaluation CriteriaThe Department of Business Regulation shall review the submitted Applications based upon the following criteria.

Experience, Knowledge and Training Applicant’s demonstrated experience in the Rhode Island Medical Marijuana Program or

lawful marijuana production in another state, including, to the extent applicable:o History supplying medical marijuana to Rhode Island compassion centers or

other state’s dispensaries or retail distributors;o History supplying medical marijuana to Rhode Island registered patients or

another state’s qualified patient population;o Currently cultivating medical marijuana in Rhode Island (specify patient grow,

caregiver grow, cooperative cultivation, and local zoning permit/authorization, if applicable);

o Horticultural production; or o Agricultural production.

Demonstrated experience using seed to sale or other inventory tracking systems, to the extent applicable

Demonstrated experience with marijuana testing and third party testing facilities, to the extent applicable

Relevant training

Operational Factors Applicant’s detailed responses in its Application and Supporting Documents

demonstrating the ability of the Applicant to satisfy the operational requirements set forth in the Regulations and including:

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o Summaries of policies and procedures for the following activities, as applicable: Cultivation; Growth; Processing; Packaging and labeling; Odor control; and Recordkeeping.

Safety and Security Factors Applicant’s detailed responses in its Application and Supporting Documents

demonstrating the Applicant’s ability to satisfy the safety and security requirements under the Regulations, including:

o Detailed plan or information describing the security systems and procedures;o Detailed plan describing how the Applicant will prevent diversion; ando Detailed plan describing safety procedures, including safety procedures

regarding the use of pesticides and extraction methods.

Production Control FactorsApplicant’s detailed responses in its Application and Supporting Documents demonstrating Applicant’s:

Quality control plan; Inventory control plan; and Medical marijuana waste disposal plan. Demonstrated ability to fill unmet patient needs by producing medical marijuana not

regularly available from compassion centers o A list of proposed medical marijuana varieties and products proposed to be

grown with proposed cannabinoid profiles, including:o Varieties with high cannabidiol content; ando Whether the strain has any demonstrated success in alleviating symptoms of

specific diseases or conditions.

Business and Economic Factors Applicant’s business plan demonstrating a likelihood of success, a sufficient business

ability and experience on the part of the Applicant, and providing for appropiate employee working conditions, benefits and training;

Demonstration of adequate capitalization and/or deployed assets and infrastructure; Ability to quickly and effectively enter the market.

General Suitability Factors Applicant’s demonstrated suitability to hold a license of this type including evidence of

good character, honesty and integrity and satisfaction of all registry identification card requirements, including national criminal background checks.

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SECTION I: Evaluation Procedures

The Department will review each Application to ensure that it meets the three following points:1. All sections, questions and forms of the Application that are marked as mandatory with

an asterisk (*) are completed;2. The checkboxes in Form 1 below are marked with an affirmation to all questions posed;

and3. The Applicant has submitted each of the following:

(a) A signed, paper copy of the completed Application with all completed Forms and the Supporting Documents that the Applicant has determined to submit (the “Supporting Documents”),(b) A paper copy of completed Forms 5 and 6 and the Supporting Documents, redacted as described below, (c) Two photocopies of item (a), (d) Two photocopies of item (b),(e) The nonrefundable application fee described in Section L, and(f) The completed Tax Payer Status Affidavit/Identity Form (use Form 4 attached hereto).

As indicated above, the Applicant must submit a redacted version of completed Forms 5 and 6 and the Supporting Documents as follows. The redacted version of Forms 5 and 6 and the Supporting Documents described in 3(b) above must be redacted so that it is devoid of any identifying information in Forms 5 and 6 and in the Supporting Documents attached thereto, including the Applicant’s name, the company name of the Applicant (if applicable), and the names of any owners, investors, officers and directors or managers/members, employees, and managers or agents with operational control. Upon initial review, only the redacted version of Forms 5 and 6 and the Supporting Documents will be reviewed to determine if the Application meets the qualification criteria to the Department’s satisfaction. If this information adequately displays the Applicant’s qualifications and their ability to meet the license requirements under the Act and the Regulations, then the Department will review the rest of the Application. If the entire Application is approved, the Applicant will then be notified by the Department. Any Application that does not meet the qualification criteria to the Department’s satisfaction will be removed from the Application process and will not be evaluated.

SECTION J: Important Notices/Disclaimers This Application form is an OFFICIAL DOCUMENT of the Rhode Island Department of Business Regulation. It MAY NOT be altered or changed in any fashion except to fill-in the areas provided with the information that is required. Should any alteration or revision of a question occur, the

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Department reserves the right to deny the Application in its entirety, or the Department may deem void that specific response and treat that section as unanswered.

The burden of proving an Applicant’s qualifications at all times rests on the Applicant. The Applicant accepts any and all risk of adverse public notice, criticism, emotional distress, or financial loss that may result from any action with respect to this Application. The Applicant expressly waives any and all claims for damages as a result thereof.

The Department may deny an Application that contains a misstatement, omission, misrepresentation, or untruth.

An Application must be completed in every material detail, including all of the mandatory sections that are marked with an asterisk (*).

The Department of Business Regulation may request any additional information that it determines is necessary to process and fully vet an Application including inspection of existing grow facilities. The Applicant shall provide all information, documents, materials, and certifications at the Applicant’s own expense.

Should the Department request any additional information that it determines is necessary to process and fully vet an Application, the Applicant shall provide the additional information within the time prescribed. If the Applicant does not provide the requested information within the prescribed time period, the Department will remove the Application from the evaluation process.

The Applicant is not able to contribute additional information after the Application is submitted, unless the Department requests more information.

The Applicant is under a continuing duty to promptly disclose to the Department any changes in owners, investors, officers and directors or managers/members, employees, and managers or agents with operational control. The duty to make such additional disclosures shall continue throughout any period of any license that may be granted by the Department.

All notices regarding an Application submission will be sent to the Applicant’s email address provided on this form. The Applicant must immediately notify the Department if the Applicant’s email address changes.

An Applicant who applies for and obtains a license from the Department will be required to submit to inspection as stated in the Act and Regulations.

After the Application has been submitted, the Applicant may withdraw the submitted Application after written notice to the Department. An Applicant who withdraws their Application forfeits the Application fee which is nonrefundable.

All submissions with and for this Application become the property of the Department and will not be returned.

The Department of Business Regulation’s decision to approve or deny an Application is final.

SECTION K: Communications with the Department of Business Regulation

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All questions about the Application or Application process must be forwarded to the Department of Business Regulation by email only at [email protected] with the subject line “Medical Marijuana Cultivator Application Question.”

Questions and answers of a general nature may be posted on the Department of Business Regulation website so that all Applicants will have access to the same information.

For questions received after 4:00 pm Monday, April 17, 2017, the Department of Business Regulation may not respond prior to the first application period submission deadline. Applicants are therefore encouraged to identify and raise any questions as soon as possible.

All questions must be sent to the Department of Business Regulation email address only. Violation of this guideline may result in disqualification.

SECTION L: How to Apply

It is recommended that all potential Applicants thoroughly review the Act and the Regulations governing Cultivator License application procedures and licensee requirements for the Medical Marijuana Program. The Act and Regulations are available on the Department’s website at: http://www.dbr.state.ri.us/.

Applicants should use the definitions and descriptive sections of those documents to assist in preparing their Application. The burden of proving an Applicant’s qualifications rests solely on the Applicant.

Applicants must submit a complete Application package by the application period deadline outlined in Section G. The Application package will consist of the following:

1. A signed, hard copy of the Applicant’s completed Application with all completed Forms and the Supporting Documents (as outlined in Section I (3)(a)),

2. A paper copy of completed Forms 5 and 6 and the Supporting Documents, redacted as described in Section I,

3. Two photocopies of item 1,4. Two photocopies of item 2, 5. The Application fee of five-thousand dollars ($5,000) payable to the General Treasurer,

State of Rhode Island, in the form of a cashier's check or money order only. The Application fee will be retained and will not be refunded under any circumstances, and

PLEASE NOTE: If an Application is approved, there will be an additional annual license fee which is based upon the class of license issued. License classes are defined in the Regulations according to the square footage of the licensed facility. License fees are in addition to the Application fee and range from five-thousand dollars ($5,000) to eighty-thousand dollars ($80,000). Please refer to the chart of license fees in the license index in Section M.

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6. Completed Taxpayer Status Affidavit/Identity Form (use Form 4 attached hereto).

The Application is only considered complete if all of these components are submitted. The Applicant is responsible for delivery of all of the Application materials to the Department on or before the application period deadline indicated in Section G. Only applications which the Department has determined to be complete shall be eligible for review. An applicant who submits an incomplete Application shall receive written notification from the Department regarding the specific deficiencies and shall be allowed to resubmit additional material to address these deficiencies within a reasonable timeframe.

Other than the redacted material, the information provided in Forms 5 and 6 of the signed, hard copy version of the Application and the Supporting Documents and in the redacted version of Forms 5 and 6 and the Supporting Documents should be identical.

To ensure the integrity of the evaluation process, the redacted version of Forms 5 and 6 and the Supporting Documents will be reviewed for the initial evaluation. It is the responsibility of the Applicant to redact this information in the redacted version of Forms 5 and 6 and the Supporting Documents. Further details on what information should be redacted are outlined in Section I.

GENERAL APPLICATION INSTRUCTIONS

Read each question carefully. Answer each question completely. Do not leave blank spaces. If a question does not apply, write “Does Not Apply” or “N/A.” If the correct answer to a particular question is “None,” write “None.” If a question has an asterisk (*), it is mandatory and must be completed. Answering a mandatory question with “Does Not Apply” or “N/A” is insufficient. Failure to submit an Application with all of the mandatory questions completed may result in the removal of the Application from the evaluation process.

All entries on the Application should be single spaced and typed in 12-point Calibri or Times New Roman font. Signatures on the hard copy Application must be in handwriting, unless otherwise stated by the Department, by the individual providing the information. Do not misstate or omit any material fact(s).

All Supporting Documents, such as business formation papers, tax returns and appendices, as well as the Application forms that comprise an Application package for a license, as listed above, must be submitted at the time of filing this Application. Further, the Applicant is under a continuing duty to promptly notify the Department of Business Regulation if there is a change in the information provided to the Department.

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APPLICATION CONTENTS

A complete Application package must include:

1. A signed, hard copy of the Applicant’s completed Application with all completed Forms and the Supporting Documents (as outlined in Section I (3)(a)),

2. A hard copy of completed Forms 5 and 6 and the Supporting Documents, redacted as described in Section I,

3. Two photocopies of item 1,4. Two photocopies of item 2, 5. The Application fee of five-thousand dollars ($5,000) payable to the

General Treasurer, State of Rhode Island, in the form of a cashier's check or money order only. The Application fee will be retained and will not be refunded under any circumstances,

6. The completed Tax Payer Status Affidavit/Identity Form (use Form 4 attached hereto).

The submittal of an Application constitutes acceptance of the requirements, administrative stipulations, and all of the terms and conditions of this Application. All costs and expenses incurred in submitting an Application in response to this Application will be borne by the Applicant.

APPLICATION DELIVERY

It is the Applicant’s responsibility to allow sufficient time to address potential delays. Sole responsibility rests with the Applicant to ensure that their Application is received by

Department of Business Regulation on or before the application period submission deadline.

Late Applications will not be accepted.

Department of Business Regulation Delivery Address:

Attn: Medical Marijuana Compliance ProgramRhode Island Department of Business Regulation

1511 Pontiac Avenue, Building 68-1Cranston, RI 02920

401-462-9500

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SECTION M: License Index1. Cultivator licenses shall be divided into the following categories:

License Class Size of Facility*

Micro-license 0 – 2,500 sq. ft.

Class A 0 – 5,000 sq. ft.

Class B 5,001 – 10,000 sq. ft.

Class C 10,001 – 15,000 sq. ft.

Class D 15,001 – 20,000 sq. ft.

* Only Micro-license, Class A, and Class B licenses will we awarded during the first year of licensing. Please refer to the Regulations to review the process to request a change to the class of an issued license.

2. The annual license fee shall be determined by the below table and must be paid in full before the license will be issued.

License Class Annual License Fee

Micro-license $5,000.00

Class A $20,000.00

Class B $35,000.00

Class C $50,000.00

Class D $80,000.00

3. Usable Marijuana Inventory.

Pursuant to its authority under R.I. Gen. Laws § 21-28.6-16(d), DBR establishes limits on the amount of “uncommitted inventory” of usable marijuana a licensed cultivator may possess based on licensed facility size as provided in the below table. “Uncommitted inventory” shall refer to marijuana and marijuana product not under formal agreement to be purchased by a compassion center.

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License Class

By Size per Section 1.5(C)

Pounds of dried usable marijuana

OR Equivalent # 10 mg edible units**

OR Equivalent grams

of concentrate**

OR any combination thereof that does not equate to more than the maximum limit of dried usable marijuana in pounds

Micro-license

2.5 max OR 3,320 max OR 308 max OR ̋

Class A 5 max OR 6,640 max OR 616 max OR ̋

Class B 10 max OR 13,280 max OR 1,232 max OR ̋

Class C 15 max OR 19,920 max OR 1,848 max OR ̋

Class D 20 max OR 26,560 max OR 2,464 max OR ̋

Applicants should review the Regulations for further information regarding usable marijuana possession limits for cultivator licensees.

SECTION N: Denial or Disqualification of Application

The Department of Business Regulation may deny any Application or decline to issue a license under any of the following circumstances:

The Application contains a misstatement, omission, misrepresentation, or untruth. The Applicant fails to submit the Application by the submission deadline. The Applicant fails to pay the Application fee prior to the submission deadline. The payment of taxes due in any jurisdiction is in arrears. The Application fails to demonstrate to the Department’s satisfaction that it adequately

meets the qualifications outlined in this document, including Section H, and that it will satisfy all requirements under the Regulations and the Act.

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FORM 1*Affirmation Section The Applicant understands the following:

YES NO

1. The burden of proving an Applicant’s qualifications rests on the party applying for the license.

☐ ☐

2. The Department of Business Regulation may deny an Application that contains a misstatement, omission, misrepresentation, or untruth.

☐ ☐

3. An Application shall be complete in every material detail. ☐ ☐

4. The Department of Business Regulation may rescind its approval of a Cultivator License if the Cultivator has not completed the pre-requisites for issuance of the license as described in the Regulations within 9 months of their approval.

☐ ☐

5. In regards to the location of the licensed premises, the Licensee commits to the following:

a. The premises and operations of a Licensee shall conform to local zoning requirements.

☐ ☐

b. The Cultivator License shall be conspicuously displayed at the licensed premises.

☐ ☐

6. In regards to manufacturing, the licensee commits to having any form of manufacturing that uses a heat source or flammable/combustible material approved by the State Fire Marshall and/or the local fire department.

☐ ☐

7. The licensee commits to not using any compressed, flammable gas as a solvent in any solvent extraction process, manufacturing or for any other purpose.

☐ ☐

8. The licensee commits to not supplying medical marijuana to anyone other than a registered compassion center in accordance with the Act and the Regulations.

☐ ☐

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YES NO

9. The licensee commits to the limitations set forth in the Act and the Regulations and understands that they are limited to possessing marijuana only as permitted in the Act and the Regulations.

☐ ☐

10. The licensee understands that the licensed premises may not be within 1,000 feet of the property line of a preexisting public or private school.

☐ ☐

11. The licensee understands that a licensed cultivator may not have any material financial interest or control in another licensed cultivator, in a compassion center or a licensed cooperative cultivation or in a Rhode Island Department of Health approved third party testing provider and vice versa.

☐ ☐

The undersigned attests that the Applicant organization understands and will adhere to the all requirements of the Act and the Regulations, including but not limited to those listed above, and that they have the authority to bind the Applicant organization to all requirements.

Click here to enter a date. Authorized Signatory Date

Printed NamePrinted Name

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Notice Pertaining to Testing:

Compassion centers and licensed cultivators will be required to comply with the DOH Testing Regulations (as defined in the Regulations) to be hereafter promulgated by the Rhode Island Department of Health. The DOH Testing Regulations may require compassion centers and/or licensed cultivators to pay the costs associated with testing their products. I understand that medical marijuana testing will be required under the DOH Regulations and that this testing may come at an additional expense.



Notice Pertaining to the Use of an Inventory Tracking System:

Upon direction by the Department of Business Regulation, all licensed cultivators shall be required to use the state approved Medical Marijuana Program Tracking System (as defined and described in the Regulations). Licensed cultivators may be required to pay costs associated with use of the Medical Marijuana Program Tracking System, which may be assessed on an annual, monthly, per use, or per volume basis and payable to the state or to its approved vendor.

I understand that I will be required to use the state approved Medical Marijuana Program Tracking System in accordance with the Regulations and that access to and use of this system may come at an additional expense.


Printed Name Printed Name

Notice Pertaining to Criminal Background Checks

If an Application is approved, all officers, directors, managers/members, employees, and agents of the Licensed Cultivator Applicant (“Applicant”) must apply for a registry identification card and submit to a national criminal background check. Such individuals may be hired, appointed, or retained prior to receiving a registry identification card, but may not begin engagement in

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medical marijuana cultivation, storage, processing, packaging, manufacturing, transport, or other medical marijuana activities requiring a licensed cultivator license pursuant to the Edward O. Hawkins and Thomas C. Slater Medical Marijuana Act until receipt of the card. Upon review of the cultivator application, DBR may also require that any other persons who have authority to make decisions concerning the operation of, exercise control over, or are otherwise involved in the management of, and/or have an ownership interest in the cultivator Applicant or proposed cultivator activities (“key persons”) apply for a registry identification card and submit to a national background check.

The undersigned attests that the Applicant organization understands that all relevant parties must apply for a registry identification card and pass a criminal background check in accordance with the Act and the Regulations before engaging in cultivator activities.



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FORM 2*Disclosure of Owners, Investors, Managers and Controlling Parties

Part I: Ownership Structure List all persons and/or entities with any ownership interest, and all officers and directors or members/managers, whether they have ownership interest or not and anyone with managing or operational control of the cultivator license or licensed facility (collectively, “Key Persons”). If an entity (corporation, partnership, LLC, etc.) has interest, list all persons associated with such entity, their ownership in the entity, and their effective ownership in the license. List all parent, holding or other intermediary business interest. Attach a separate sheet if necessary.

Name

Title

SSN/FEIN

DOB

App submitted?☐Yes ☐No

Address

City

State

ZIP

Phone Number( )

Business Associated with (Parent business or sub-entity)

Own. % Business Associated with

Effective Own. % in Applicant

Name

Title

SSN/FEIN

DOB


Address

City

State

ZIP

Phone Number( )




Name

Title

SSN/FEIN

DOB


Address

City

State

ZIP

Phone Number( )




Name

Title

SSN/FEIN

DOB


Address

City

State

ZIP

Phone Number( )




Name

Title

SSN/FEIN

DOB


Address

City

State

ZIP

Phone Number( )




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Name

Title

SSN/FEIN

DOB


Address

City

State

ZIP

Phone Number( )




Name

Title

SSN/FEIN

DOB


Address

City

State

ZIP

Phone Number( )




Part II: Who, besides the owners and other Key Persons listed in this application (including persons, firms, partnerships, corporations, limited liability companies, trusts), will loan or give money, inventory, furniture or equipment to or for use in this business, or hold a security interest therein; or who will receive money or profits from this business. Attach a separate sheet if necessary.

Name Date of Birth SSN/FEIN Interest



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FORM 3*

BUSINESS LICENSE IDENTIFICATION FORMI/We, on behalf of the undersigned Applicant, hereby state(s) as follows:

With respect to the Applicant and the Key Persons described in Form 2, Part I, such persons have either applied for or are currently or have been previously licensed or authorized to produce or otherwise deal in the manufacture or distribution of Marijuana in any form, in the following States or jurisdiction and corresponding agency or authority:

State & Name of Agency Type of License Name of Licensee License or Registration #

I/we have disclosed and provided any and all denial, suspension, revocation or other sanction of the license or authorization listed above as instructed in FORM 5.

I/we hereby authorize the Rhode Island Department of Business Regulation to contact the state agencies indicated above for information regarding the Applicant and the licenses/registrations listed above and by our signature below, authorize such state agencies to provide any and all information requested by the Department regarding the licenses/registrations. If hereafter requested by the Department, I/we will provide any additional authorization required by any of the state agencies in order to provide information requested by the Department.

Click here to enter a date. Name- Authorized Signatory Date

Name- PrintedName- Printed

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FORM 4*T A X P A Y ER ST A T U S A FF I DAV IT / IDE N TITY F O R M

All persons applying for or renewing any license, registration, permit or other authority (hereinafter called “licensee”) to conduct a business or occupation in the state of Rhode Island are required to file all applicable tax returns and pay all taxes owed to the state prior to receiving a license as mandated by state law (RIGL 5-76) except as noted below.

In order to verify that the state is not owed taxes, licensees are required to provide their Social Security Number or Federal Tax Identification Number as appropriate. These numbers will be transmitted to the Division of Taxation to verify tax status prior to the issuance of a license. This declaration must be made prior to the issuance of a license.

LICENSEE DECLARATION

PLEASE CHECK ONE BOX BELOW OR APPLICATION WILL BE CONSIDERED INCOMPLETE

☐I hereby declare, under penalty of perjury, that I have filed all required state tax returns and have paid all taxes owed.

☐I have entered a written installment agreement to pay delinquent taxes that is satisfactory to the Tax Administrator.

☐I am currently pursuing administrative review of taxes owed to the state.

☐I am in federal bankruptcy. (Case # )

☐I am in state receivership. (Case # )

☐I have been discharged from Bankruptcy. (Case # )

Type of License you’re applying for:

Print Full Name Social Security or Federal Tax Identification Number

Click here to enter a date.

Signature Date

FORM 5*

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Investors, Owners, Managers & Controlling Parties Certification Statement Form

On behalf of the Applicant, and with respect to the Applicant and each of the Key Persons described in Form 2, Part I, the undersigned certifies as follows:

1. I certify that none of the Applicant, any Key Person and any Marijuana business entity or its equivalent in which such persons hold or have held an interest, has had a registration or license, suspended, revoked, placed on probationary status or subject to any disciplinary action. If no, provide an explanation.

Yes☐

No☐

4. Neither the Applicant or any Key Person is delinquent on the filing of State or Federal taxes. If delinquent, provide an explanation.

Yes☐

No☐

5. If the Applicant or any Key Person or any Marijuana business entity or its equivalent in which such persons hold or have held an interest holds or has held a medical Marijuana or medical marijuana license or registration in another State, have any such person(s) been disciplined (including, but not limited to restricted, suspended, or terminated) by any State? If yes, provide a brief explanation.

Yes☐

No☐

6. I certify that none of the Applicant and any Key Person has been denied a professional license, privilege of taking an examination, or had a professional license or permit disciplined by a licensing authority in Rhode Island or other State. If no, provide a brief explanation.

Yes☐

No☐

7. Is any Key Person employed by the State of Rhode Island? If no, skip next question.

Yes☐

No☐

8. If any Key Person is employed by the State, please state the name, agency and position:

9. Does any Key Person have any “material financial interest or control” (as defined in Section 1.5(E)(5) of the Regulations) in another licensed cultivator, a compassion center, a licensed cooperative cultivation, or a Rhode Island DOH-approved third party testing provider or vice versa. If

Yes☐

No☐

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no, skip the next question.10. If any Key Person has such “material financial interest or control” or vice versa, please describe below.

11. I acknowledge that I fully understand that:

Marijuana is a Schedule I controlled substance under the Controlled Substances Act of 1970 (21 U.S.C. 801 et seq.);

Manufacture, distribution, cultivation, processing, possession, or possession with intent to distribute a Schedule I controlled substance, or conspiring or attempting to do so, are offenses subject to harsh penalties under federal law and could result in arrest, prosecution, conviction, incarceration, fine, seizure of property, and loss of licenses or other privileges; and

Any activity regarding Marijuana that does not comply with Rhode Island law or regulations is a violation of State law and could result in arrest, prosecution, conviction, incarceration, fine, seizure of property, and loss of licenses or other privileges.

Yes☐

Yes☐

Yes☐

No☐

No☐

No☐

12. I certify my acknowledgement that Application Fees are non-refundable.

Yes☐

No☐

13. I acknowledge that in filing an Application for a license, the following:a. The Department of Business Regulation is vested with broad

discretion to select the Applicants to be approved for a Cultivator License; and

b. The Department of Business Regulation’s decision in approving or denying an Application shall be final.

Yes☐

No☐

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Dated this __________day of ________________, 20______

____________________________________ Authorized SignatoryPrinted Name: Title:

Sworn to and subscribed before me on this ________day of ______________, 20________.

(SEAL) ___________________________________ Notary Public

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FORM 6*

Mandatory Questions1. Please provide a biography for the Applicant including experience, knowledge and training

as it relates to (a) the marijuana industry in Rhode Island or any other state, (b) current role or participation in the Rhode Island Medical Marijuana Program, (c) horticultural production and agricultural production, (d) familiarity with product testing and the use of seed to sale inventory tracking, (e) any other background information or documentation the Applicant believes demonstrates their qualifications to hold a cultivator license. If the Applicant is currently a caregiver or part of a cooperative cultivation in Rhode Island they must include their registration ID number, how long they have been a caregiver or operating as a cooperative cultivation, how many plants they are currently growing, how much medicine they currently produce and what marijuana products, if any, they manufacture or produce. *

Click here to enter text.

2. Please provide a business plan that demonstrates the likelihood of success, a sufficient business ability and experience on the part of the Applicant. The business plan should also include (a) a description of the size of the cultivation (desired square footage/license class, number of mature plants to be grown, number of employees to be hired), (b) scope of proposed activities (cultivation, manufacturing methods, products to be produced, packaging/labeling), (c) budget and resource narratives, (d) timeline for initiating operations, (e) a description of the Applicant’s plan to ensure appropriate employee working conditions, benefits and training, and (f) any other information or documentation showing the Applicant’s ability to quickly and successfully enter the market as a licensed cultivator. If the Applicant proposes to have a management agreement in place, attach a copy of the management agreement or management agreement proposal.*


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3. Attach a diagram of the proposed facility to be licensed and outline or designate the area (including dimensions) which shows where marijuana will be cultivated, stored, processed and/or manufactured, the limited access areas, walls, partitions, entrances, exits and security alarms, cameras and surveillance recording equipment locations. This diagram must also show or describe the location and distance of the facility relative to streets and other public areas and proposed measures (such as black-out window shades) to ensure that marijuana at the premises will not be visible from the street or public areas. This diagram should be no larger than 8 1/2" X 11" (It does not have to be to scale). Include the proposed physical location of the licensed cultivator (by plat and lot number, mailing address, etc.), if a precise location has been determined. Attach evidence of ownership or, if the property is leased, agreement of the owner to allow the operation of a licensed cultivator on the property. If a precise physical location has not been determined, a description of the general location(s) where it may be sited, if approved, and the expected schedule for purchasing or leasing said location(s). Attach evidence of the location’s compliance or preliminary determination of compatibility with the local zoning laws. This should be in the form of a signed letter from an authorized municipal zoning official, if possible. If you are currently operating in location that has been approved/inspected/permitted for marijuana cultivation please include copies of documentation to this effect. *


4. Please describe adequate capitalization and/or deployed assets and infrastructure and attach relevant documentation. This may include bank statements, loan agreements, valuable assets and infrastructure already in place (grow rooms, grow lights, equipment already in place which will be used in the licensed cultivation facility). *


5. Please certify that the applicant is eligible to do business in Rhode Island and attach relevant documentation. Attach the Applicant’s certificate of incorporation or organization in Rhode Island or certificate of authority to transact business in Rhode Island, articles of incorporation or organization, and bylaws or operating agreement. *


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6. Please certify that the Applicant is not in arrears regarding any tax obligation in Rhode Island and other jurisdictions and attach relevant documentation. *


7. Please provide a list of proposed medical Marijuana varieties and products proposed to be grown and/or manufactured. *


8. Please explain how the Applicant would train all employees and registered Cultivator agents on Federal and State medical Marijuana laws and regulations, as well as other laws and regulations pertinent to the Cultivator agent’s responsibilities. *


9. Please explain how the Applicant would train all employees and registered Cultivator agents on standard operating procedures. *


10. Please explain how the Applicant would train all employees and registered Cultivator agents on detection and prevention of diversion of medical Marijuana. *


11. Please explain how the Applicant would train all employees and registered Cultivator agents on security procedures. *


12. Please explain how the Applicant would train all employees and registered Cultivator agents on safety procedures, including responding to a (1) medical emergency, (2) a fire, and (3) a chemical spill. *

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13. Please explain how the Applicant would train all employees and registered Cultivator agents on safety procedures, including responding to threatening events including an armed robbery, an invasion, a burglary, and any other criminal incident. *


14. Please explain how the Applicant would secure the licensed premises and facility for cultivation of medical Marijuana to prevent unauthorized entry in accordance with the Regulations. *


15. Please describe how the premises and facility will be equipped with a security alarm system that (1) covers the entire perimeter, (2) is continuously monitored, and (3) is capable of detecting power loss/interruption in accordance with the Regulations. *


16. Please describe how the premises and facility will be protected by a video surveillance recording system to ensure surveillance of the entire perimeter of the area of cultivation, manufacturing and storage and adherence to the video surveillance requirements in accordance with the Regulations. *


17. Please explain how a video surveillance system will be supported by adequate security lighting in accordance with the Regulations. *


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18. Please describe how the Applicant would maintain a security alarm system that covers all perimeter entry points and portals at all premises. *


19. Please describe how the security system will be (1) continuously monitored, (2) capable of detecting smoke and fire, and accessible via remote feed to the Department of Business Regulation in accordance with the Regulations. *


20. Please describe how a security footage will be stored and secured in accordance with the Regulations. *


21. Please describe how the Applicant will maintain a video surveillance recording system at all premises that (1) records all activity in images of high quality and high resolution capable of clearly revealing facial detail, (2) operates 24-hours a day, 365 days a year without interruption, and (3) provides a date and time stamp for every recorded frame. *


22. Please explain how the surveillance camera(s) will be located and operated to capture each exit from the premises. *


23. Please explain how the surveillance camera(s) will capture activity at each entrance to an area where medical Marijuana is grown, tested, cured, manufactured, processed, or stored. *


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24. Please describe how the any recording of security video surveillance shall be made available to the Department of Business Regulation or law enforcement in accordance with the Regulations. *


25. Please explain how Applicant will, when visitors are admitted to a non-public area of the licensed premises (1) log the visitor in and out, (2) continuously visually supervise the visitor while on the premises, and (3) ensure that the visitor does not touch any plant or medical Marijuana. *


26. Please explain how the Applicant will maintain a log of all visitors *


27. Please describe how the Applicant would establish written standard operating procedures to promote good growing and handling practices including all aspects of the (1) irrigation, propagation, cultivation, and fertilization, (2) harvesting, drying, and curing, (3) processing or manufacturing, (4) packaging, labeling, and handling of medical Marijuana byproduct, and (5) waste products, and the control thereof, to promote good growing and handling practices. *


28. Please describe how the Applicant would establish written standard operating procedures to promote good growing and handling practices including requiring that each individual engaged in the cultivation, manufacturing, handling, and packaging, of medical Marijuana has the training, education, or experience necessary to perform assigned functions. *


29. Please describe how the Applicant would establish written standard operating procedures to promote good growing and handling practices including requiring that all registered

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Cultivator agents practice good hygiene and wear protective clothing as necessary to protect the products as well as themselves from exposure to potential contaminants. *


30. Please describe how the Applicant would establish written standard operating procedures to promote good growing and handling practices including requirements for receipt of material, including how the Applicant will inspect material for defects, contamination, and compliance with Regulations. *


31. Please describe how the Applicant would establish written standard operating procedures to promote good growing and maintain records of the type and amounts of, pesticides, fertilizer and any growth additives used. *


32. Please describe how the Applicant plans to use pesticides in accordance with the Regulations and how the Applicant would establish written standard operating procedures to ensure their safe use in accordance with regulation and other applicable state law. *


33. Please describe how the Applicant will seal or screen the premises to exclude contaminants. *


34. Please explain how sanitation will be maintained through the facility in accordance with the Regulations. *


35. Please describe how the Applicant will use a perpetual inventory control system that identifies and tracks the Applicant’s stock of medical Marijuana from the time the medical

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Marijuana is propagated from seed or cutting to the time it is delivered to a registered compassion center in accordance with the Regulations. Please address the situation in which the Applicant has access to the state approved Medical Marijuana Program Tracking System, and the situation in which the Applicant does not have access to the System (as specified in the Regulations). *


36. Please describe how as soon as is practical, if the Applicant does not have access to the state approved Medical Marijuana Program Tracking System, the Applicant will, for each plant, (1) create a unique identifier for each plant, (2) assign each plant to a batch, (3) enter information regarding the plant into an alternate inventory control system, (4) create a label with the unique identifier and batch number, and (5) securely attach the label to a plant container, plant or plant material. *


37. Please describe how the Applicant will notify the Department of Business Regulation of a meaningful discrepancy, if the Applicant discerns a discrepancy between the inventory of stock and inventory control outside of normal weight loss due to moisture loss and handling. *


38. Please describe the process the Applicant will follow in reporting a theft or diversion to the (1) Department of Business Regulation and (2) Rhode Island State Police in accordance with the Regulations. *


39. Please describe how the Applicant will ensure that the Applicant or a registered Cultivator agent thereof will not distribute any medical marijuana to any person if the licensee or registered Cultivator agent knows, or may have reason to know, that the distribution does not comply with the Act or the Regulations.*


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40. Please describe how the Applicant will record and execute the transfer of medical marijuana to and/or from compassion centers in accordance with the Regulations. *


41. Please describe how the Applicant will record the cultivation process to ensure (1) consistency of the batch with the variety and (2) accuracy of the day-to-day production. *


42. Please describe how the Applicant will not release any batch of medical Marijuana if the batch fails to meet all criteria for production or patient consumption in accordance with the Regulations. *


43. Please describe how the Applicant will, during the process of cultivation, regularly inspect each plant to ensure proper growth and absence of pests and disease. *


44. Please describe how the Applicant will hold medical marijuana in secure, segregated storage until released for distribution. *


45. Please describe how the Applicant will create and implement an odor control and mitigation plan which shall be in compliance with the odor control and mitigation requirements set forth in the Regulations.*


46. Please describe how the Applicant, as a Licensed Cultivator shall establish a procedure to receive, organize, store and respond to all oral, written, electronic or other complaints regarding medical marijuana and adverse events. *

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47. Please describe how the Applicant will ensure it does not transport medical marijuana to or receive any medical marijuana from any place outside of Rhode Island. *


48. Please describe how an Applicant will have a standard operating procedure to require an employee or cultivator agent to report any personal health condition that might compromise the cleanliness or quality of the medical marijuana the employee/agent might handle. *


49. Please describe how an Applicant procedure will provide for disposal and segregated storage of any medical marijuana that is outdated, damaged, deteriorated, misbranded, or adulterated. *


MORE ON FOLLOWING PAGE

QUESTIONS 50-57 BELOW NEED ONLY BE COMPLETED BY APPLICANT’S WHOSE CULTIVATOR OPERATIONS WOULD INCLUDE MANUFACTURING, PROCESSING AND/OR PACKAGING

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50. Please describe how the Applicant will require that any person involved in processing medical marijuana concentrates and medical marijuana-infused products is (1) appropriately trained in accordance to their job description to safely operate and maintain the system used for processing and attendance records are retained, (2) has direct access to applicable material safety sheets and labels, and (3) follows protocols for handling and storage of all chemicals.


51. Please describe how, if the state approved Medical Marijuana Program Tracking System is not available, the Applicant will assign a unique lot number to each lot of medical marijuana concentrate or medical marijuana-infused product.


52. Please describe how the Applicant will establish a standard operating procedure for the methods, equipment, solvents, and gases when processing medical marijuana concentrates and medical marijuana-infused products.


53. If the Applicant uses solvent extraction, please describe how the standard operating procedure of Applicant will use best practices to ensure worker and product safety.


54. Please describe how, if the Applicant uses solvent extraction, the standard operating procedure of Applicant will require following all applicable federal, state, and local fire, safety, and building codes in the processing and storages of the solvents.


55. Please describe how the packaging and labeling of medical marijuana finished products will be in compliance with all applicable Regulations.


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56. Please describe how a package of medical marijuana finished product will bear any allergen warning required by law.


57. Please describe how the Applicant will assure that a package of medical marijuana finished product does not bear any resemblance to the trademarked, characteristic, or product-specialized packaging of any commercially available candy, snack, baked good, or beverage.


58. Please describe how the Applicant will assure that a package of medical marijuana finished product does not bear any statement, artwork, or design that could be reasonably mislead any person to believe that the package contains anything other than a medical marijuana finished product.


59. Please describe how the Applicant will assure that a package of medical marijuana finished product does not bear any cartoon, color scheme, image, graphic, or feature that might make the package attractive to children.


_ __ Click here to enter a date. Authorized Signatory Date


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