Marijuana Establishment License Application Page 1 Application Date: This application is for: New License Renewal of Existing License Transfer/Change of Ownership Change of Location If this application is for a change of ownership or location, describe the proposed changes Attach additional information: *This application is for the following Premises Location License Type: Retail Marijuana Store Retail Marijuana Cultivation Facility-Limited Retail Marijuana Products Manufacturing Facility Retail Marijuana Testing Facility Retail Marijuana Cultivation Facility * If more than one type applicant must fill out a separate application for each type. *Applicant* shall mean an applicant for a license and shall include all members, shareholders, officers, directors, partners, and managers in the case of a corporate entity or partnership. Applicant is applying as: Corporation Limited Liability Company Sole Proprietor Partnership Association or Other Attach relevant organizational documents: First Name: Last Name: Phone: Email: Address: City: State: Please select...ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Trade Name of Establishment/ DBA: Page 2 Business Information Business. Phone: Emergency Phone: Business Email: Website: Premises Location: Address: City: State: Please select...ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Is Business Mailing Address Different from Premises: YesNo Business Mailing Address Address: City: State: Please select...ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Will the Applicant have legal possession of the premises for at least one (1) year from the date that this license will be issued by virtue of ownership, lease or other arrangement? YesNo Is building leased? YesNo Landlord: First Name: Last Name: Phone: Cell Phone: Address: City: State: Please select...ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Tenant First Name: Last Name: Lease Expires: Premises Is this proposed premises to be licensed within 400 feet of any existing public or private school facility where classes are held for children aged kindergarten through 12th grade? This distance shall be computed by a straight line measurement from the nearest property line of the school property to the nearest property line of the premises housing the retail marijuana establishment. YesNo Page 3 To complete this application attach the following documents Complete Copy of State License Application Proof of ownership, lease rental agreement or other arrangement for possession of the proposed Licensed Premises A diagram showing the configuration of the proposed Licensed Premises, including a statement of total floor space occupied by the business, and designating the use of each room or other areas of the premises. The diagram shall designate those rooms or other areas of the premises where patrons are not permitted. The diagram shall designate the place at which the License will be conspicuously posted as required by this Chapter. Sign, security, odor and lighting plans indicating how the applicant will comply with the requirements of the Colorado Retail Marijuana Code, this Chapter and application provisions of the Municipal Code. An area map, drawn to scale, indicating the boundaries of the property upon which the Retail Marijuana Establishment is located, and indicating the proximity, measured per the standards as set forth below, of the proposed License premises to any kindergarten through 12th grade public or private school and indicating the proximity to any other licensed Retail Marijuana Establishment. The diagram need not be professionally prepared but must be drawn to a designated scale of drawn with marked dimensions of the interior of the premises to an accuracy of plus or minus six inches (+/_6"). A diagram using the Mesa County GIS mapping System is acceptable. Authorization By its signature below applicant attests and affirmed that the information contained in this application is true, correct, and valid. Applicants have an affirmative ongoing duty to update the information contained herein. Signature: Date: Need assistance with this form?
