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REVISED 04/26/2018 RETAIL MARIJUANA TESTING FACILITY LICENSE APPLICATION CHECKLIST A Zoning Verification Form must be approved by the City of Lafayette Director of Community Development before the application process begins. Applicants must first submit a Colorado Retail Marijuana Business License Application (DR 8548) along with required attachments to the Colorado Marijuana Enforcement Division for review, including Associated Person and Associated Key Marijuana License Applications. The State will forward approved applications to the City for local review. The following supplemental information must be submitted with the State application forms. City of Lafayette Marijuana Business License Application Cover Sheet Proof of possession of the premises (lease, lease assignment, deed) Authorization to use Property for a Marijuana Business Lawful Presence Affidavit (for sole proprietor) Proof of worker’s compensation insurance and public liability insurance in the minimum amounts of $150,000 for any injury to one person in any single occurrence and $600,000 for any injury to two or more persons in any such occurrence. City of Lafayette Sales Tax and Use Tax License Application The applicant must obtain two Sales and Use Tax Licenses (one for retail sales and one for medical sales) Application Fee ($500 Collected by the State) and License Fee ($2,000 Payable to the City). Cashiers check or money order made out to City of Lafayette. If the application is denied, the License Fee will be returned Operating Fee ($3,000) due upon issuance of license and paid annually thereafter. Background Investigation Fee ($750/person) Application fee includes one background investigation Mechanical ventilation plan, in accordance with Lafayette Municipal Code Section 56-266 Floor plan, drawn to scale, according to Lafayette Municipal Code, Section 56-266(b)(3)(ii). The co- located sales areas may share a common foyer but they must have separate entrances and exits. Description of products and/or services to be provided by the retail marijuana operation. Plan for disposal of waste marijuana Report from a State Certified Industrial Hygienist, according to Lafayette Municipal Code, Section 56-265 Copy of the Retail Marijuana Testing Facility Certification issued by the MED, following on-site inspection by state officials. Local background investigations will be conducted for each individual submitting an application (excepting support employees) On-site inspections will be conducted by police, fire, building and public works officials. ---PAGE BREAK--- 1290 S. Public Rd. Lafayette, Colorado 80026 (303) 665-5588 Fax (303) 665-2153 REVISED 04/24/18 ZONING VERIFICATION FORM MARIJUANA BUSINESS LICENSE APPLICATION YOU MUST OBTAIN AN APPROVED ZONING VERIFICATION FORM FOR THE PROPOSED LOCATION OF YOUR BUSINESS BEFORE PROCEEDING WITH THE APPLICATION PROCESS A $100 FEE MUST ACCOMPANY THIS FORM. PROPERTY Street Address: Lafayette, Colorado 80026 Lot Area (in Square Feet or Acres): Existing Zoning: Existing Use of Property: PROPOSED USE Trade Name of Establishment Description of proposed use: (include proposed use and summarize type of activity, as applicable): PREMISES Attach a site plan, indicating the lot, all existing and proposed buildings, and distances from the building(s) to all property lines. Attach a floor plan, drawn to scale indicating dimensions. Total square footage: USE CATEGORY Retail Marijuana Cultivation Medical Marijuana Cultivation Retail Marijuana Store Medical Marijuana Center Retail Products Manufacturer Medical Marijuana Products Manufacturer Marijuana Testing Facility CONTACT INFORMATION Name of Owner or Contact Person: Business Mailing Address: (if different from physical address) Business Phone: Email: I certify that the information and exhibits submitted are true and correct to the best of my knowledge and I understand that there may be additional reviews required to complete the planning process. Signature: Date: ---PAGE BREAK--- 1290 S. Public Rd. Lafayette, Colorado 80026 (303) 665-5588 Fax (303) 665-2153 ZONING VERIFICATION FORM MARIJUANA BUSINESS LICENSE APPLICATION Page 2 MAP REQUIRED Attach a street map that is drawn to scale. Indicate the proposed premise, at the center of a circle with a labled 1,000-foot radius, such that the setback restrictions below may be verified by the Planning and Building Department. STAFF USE ONLY According to the map provided by the applicant, the proposed premise complies with the following setback restrictions: 500 feet from a commercially licensed day care facility 500 feet from an existing licensed medical marijuana center or retail marijuana store 1,000 feet from a public or private school 1,000 feet from a hospital 500 feet from Public Road, north of South Boulder Road 500 feet from a residential subdivision, residentially zoned property or property with residential as the principal use 500 feet from East Simpson Street east of Public Road to 500-501 East Simpson Street 500 feet from 120th and 119th Streets north of Emma Street to US Hwy 7 800 feet from US Hwy 287 and US Hwy 7 Zoning District: Use Category: Previous Reviews: Approved Denied Reason for denial: Further Discretionary Review Required: Application reviewed by: Date: ---PAGE BREAK--- REVISED 04/24/18 MARIJUANA BUSINESS LICENSE APPLICATION COVER SHEET Applicant Trade Name (d/b/a) Address of Licensed Premise Mailing Address (if different) Contact Person Telephone E-mail address BUSINESS STRUCTURE Corporation Partnership Limited Liability Corporation Individual (Sole Proprietor) Association or Other TYPE OF LICENSE Retail Marijuana Cultivation Medical Marijuana Cultivation Retail Marijuana Store Medical Marijuana Center Retail Marijuana Products Manufacturer Medical Marijuana Products Manufacture Testing Facility TYPE OF APPLICATION New License Change of Ownership License Renewal Late License Renewal Change of Location Pending Application Modification Modification of Premises Change in Corporate Structure Change in Business Manager Change Corp. or Trade Name License Modification Change of Financier FEES AND SUPPLEMENTAL INFORMATION Fees must be submitted with application in the form of a cashiers check or money order. See attached Fee Schedule. Attach supplemental information according to instructions for type of application. AFFIRMATION AND CONSENT I affirm that I have reviewed this application and all associated documents and that the contents and statements made therein are true and correct to the best of my knowledge and belief. I understand that any misrepresentation or failure to disclose information requested or pertinent information may be deemed good cause to deny, withhold, or revoke a license. Furthermore, I understand that any misrepresentations or omissions may subject me to civil or criminal liability. Date: Applicant Signature Date: Registered Agent (if applicable) ---PAGE BREAK--- MEDICAL AND RETAIL MARIJUANA LICENSING FEES 4/24/2018 STORE (RETAIL) APPLICATION FEE / LICENSE FEE New Application $3,000 $2,000 Transfer Ownership $3,000 $2,000 Renewal $1,500 $2,000 Operating Fee $3,000 CENTER (MEDICAL) APPLICATION FEE / LICENSE FEE New Application $3,000 $2,000 Transfer Ownership $3,000 $2,000 Renewal $1,500 $2,000 Operating Fee $3,000 CULTIVATION APPLICATION FEE / LICENSE FEE New Application $3,000 $2,000 Transfer Ownership $3,000 $2,000 Renewal $1,500 $2,000 Operating Fee $3,000 PRODUCT MFG APPLICATION FEE / LICENSE FEE New Application $3,000 $2,000 Transfer Ownership $3,000 $2,000 Renewal $1,500 $2,000 Operating Fee $3,000 TESTING FACILITY APPLICATION FEE / LICENSE FEE New Application $3,000 $2,000 Transfer Ownership $3,000 $2,000 Renewal $1,500 $2,000 Operating Fee $3,000 ADMINISTRATIVE SERVICES FEES CONVERSION MMJ TO RMJ $250 (established by the State) BACKGROUND $750/per person INVESTIGATION CHANGE BUSINESS $200 MANAGER PROCESSING FEE / SUPPORT $100/person EMPLOYEE APPLICATION MODIFICATION OF $500 PREMISES CHANGE OF $2,000 LOCATION PENDING APPLICATION $500 MODIFICATION LATE RENEWAL FEE $750 ---PAGE BREAK--- MEDICAL AND RETAIL MARIJUANA LICENSING FEES 4/24/2018 LICENSE MODIFICATION $500 CHANGE OF CORPORATE $200/person STRUCTURE CHANGE OF FINANCIER $1,500 ZONING VERIFICATION $100 DUPLICATE LICENSE $50 TEMPORARY PERMIT (TRANSFER) $2,500 CHANGE IN CLASS OF LICENSE $200 CHANGE OF TRADE NAME $50 LOTTERY APPLICATION $100 ---PAGE BREAK--- REVISED 04/24/18 AUTHORIZATION TO USE PROPERTY FOR A MARIJUANA BUSINESS Property Address: Lafayette, CO 80026 Name of Lessee: Lessee’s Business Name: As owner of the property described above, I hereby consent to the use of said property for the purpose(s) of conducting a marijuana business as follows, so long as said use is authorized under and in accordance with applicable state and local laws: Retail Marijuana Cultivation Medical Marijuana Center Cultivation Retail Marijuana Store Medical Marijuana Center Retail Products Manufacturer Medical Marijuana Products Manufacturer Marijuana Testing Facility Term of Approval: (examples: indefinitely; to coincide with term of lease; specific date to specific date; certain amount of time from issuance of license, etc.) I understand that the lessee must operate the business on the property described above according to the provisions of Chapter 56 (as may be amended) of the Code of Ordinances of the City of Lafayette. I further understand that in issuing a marijuana business license, the City of Lafayette assumes no legal liability or duty of care regarding the licensee’s business operation or possession of the property. I hereby release the City, its officers, elected officials, employees, attorneys and agents from all liability for claims of damages of any kind whatsoever, present or future, in any way relating to or arising from the conduct of the lessee/licensee’s business operation on said property. Signature of Property Owner or Authorized Agent Printed Name / Property Owner or Authorized Agent Date Company Name State of Colorado Address County of Boulder Telephone Subscribed before me on this ____day of Name of Signatory Notary Public [SEAL] My Commission Expires: ---PAGE BREAK--- REVISED 05/26/15 LAWFUL PRESENCE AFFIDAVIT FOR INDIVIDUALS (SOLE PROPRIETORS) APPLYING FOR A MARIJUANA BUSINESS LICENSE New License Transfer License I, dba swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen, or I am a Permanent Resident of the United States, or I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8- 503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date Form of ID Presented: Valid Colorado Driver’s License, Colorado ID card, Military ID, Coast Guard Mariner, or Native American Tribal Documents are acceptable forms of identification STATE OF COLORADO COUNTY OF BOULDER I, Public in and for said County and State, do hereby certify that on this day of appeared before me in person and executed the above instrument. IN WITNESS THEREOF, I have hereunto set my hand and seal. Notary Public [SEAL] My commission expires: ---PAGE BREAK--- Finance Dept APPLICATION FOR SALES AND USE TAX LICENSE NO FEE REQUIRED Owner’s or Corporate Name Name of Business (DBA) Business Address (Street, City, State, Zip) Mailing Address (Street, City, State, Zip) Nature of Business (Type of sales/service) Does your business acquire, possess, cultivate, manufacture, produce, use, sell, distribute, dispense, or transport marijuana? Yes No Ownership Individual Partner Corporation Other (Explain) Federal Employer Identification Number (FEIN) or Social Security Number (SSN) – Application will NOT be processed if missing State of Colorado Sales Tax Account Number – Application will NOT be processed if missing Filing Period Quarterly Annual Will you be printing your own returns? Yes No If you have software or a company who will be printing your returns, you would mark Yes, everyone else should mark No. By marking No, the City will mail you the returns for the year. Returns are not available on–line. Date business will begin in Lafayette If business was purchased, list name of former owner and business name (if name listed above is new) Sales Tax Contact Name and Title Sales Tax Contact Email Address Business phone number Business fax number I, DECLARE,UNDER PENALTY OF PERJURY THAT THIS APPLICATION HAS BEEN EXAMINED BY ME AND THE STATEMENTS MADE HEREIN ARE MADE IN GOOD FAITH PURSUANT TO THE CITY OF LAFAYETTE TAX LAWS AND REGULATION AND, TO THE BEST OF MY KNOWLEDGE AND BELIEF ARE TRUE, CORRECT, AND COMPLETE. Printed Name Title Signature Date Please mail or fax the application to: City of Lafayette – Sales Tax PO Box 250 Fax (303) 604-4334 Lafayette, CO 80026 Phone (303) 665-5588 NOTE: If the average for remittance is $40 or greater, filing is required. If less than $40 per year or fewer than two sales transactions are expected, annual filing is desired.