MANAGEMENT AND OPERATIONS PROFILE

Request for a Certificate of Registration to

Operate a Registered Marijuana Dispensary

INSTRUCTIONS

This application form is to be completed by an entity that wishes to apply for a Certificate of Registration to operate a Registered Marijuana Dispensary (“RMD”) in Massachusetts, and has been invited by the Department of Public Health (“Department”) to submit a Management and Operations Profile (“applicant”).

Once invited by the Department to submit a Management and Operations Profile, the applicant must submit the Management and Operations Profile within 45 days from the date of the invitation letter, or the applicant must submit a new Application of Intent and fee.

If invited by the Department to submit more than one Management and Operations Profile, the applicant must submit a separate Management and Operations Profile, attachments, and application fee for each proposed RMD. Please identify each application of multiple applications by designating it as Application 1, 2 or 3 in the header of each application page. Please note that no executive, member, or any entity owned or controlled by such an executive or member, may directly or indirectly control more than three RMDs.

However, even if submitting a Management and Operations Profile for more than one RMD, an applicant need only submit one Employment and Education Form, Character and Competency Form and background check packet, including authorization forms for all required individuals and entities, and fee associated with the background checks.

Unless indicated otherwise, all responses must be typed into the application forms. Handwritten responses will not be accepted. Please note that character limits include spaces.

Attachments should be labeled or marked so as to identify the question to which it relates.

Each submitted application must be a complete, collated response, printed single-sided on 8 ½” x 11” paper, and secured with a binder clip (no ring binders, spiral binding, staples, or folders).

Mail or hand-deliver the Management and Operations Profile, with all required attachments, the $30,000 application fee, and completed Remittance Form to:

Department of Public Health

Medical Use of Marijuana Program

RMD Applications

99 Chauncy Street, 11th Floor

Boston, MA 02111

All fees are non-refundable and non-transferable.

REVIEW

Applications are reviewed in the order they are received.

After a completed application packet and fee is received by the Department, the Department will review the information and will contact the applicant if clarifications or updates to the submitted application materials are needed. The Department will notify the applicant whether it has met the standards necessary to be invited to submit a Siting Profile.

Applicants must receive an invitation from the Department to submit a Siting Profile within 1 year of the date of submission of the Management and Operations Profile, or the applicant must submit a new Application of Intent and fee in order to proceed in the application process.

PROVISIONAL CERTIFICATE OF REGISTRATION

Applicants must receive a Provisional Certificate of Registration from the Department within 1 year of the date of the invitation letter from the Department to submit a Siting Profile. If the applicant does not meet this deadline, the application will be considered to have expired. Should the applicant wish to proceed with obtaining a Certificate of Registration, a new application must be submitted, beginning with an Application of Intent, together with the associated fee.

REGULATIONS

For complete information regarding registration of an RMD, please refer to 105 CMR 725.100, as well as materials posted on the Medical Use of Marijuana Program website: www.mass.gov/medicalmarijuana.

It is the applicant’s responsibility to ensure that all responses are consistent with the requirements of 105 CMR 725.000, et seq., and any requirements specified by the Department, as applicable.

PUBLIC RECORDS

Please note that all application responses, including all attachments, will be subject to release pursuant to a public records request, as redacted pursuant to the requirements at M.G.L. c. 4, § 7(26).

QUESTIONS

If additional information is needed regarding the RMD application process, please contact the Medical Use of Marijuana Program at 617-660-5370 or RMDapplication@state.ma.us.

CHECKLIST

The forms and documents listed below must accompany each application, and be submitted as outlined above:

A fully and properly completed Management and Operations Profile, signed by an authorized signatory of

the applicant

A completed Remittance Form (use template provided)

A bank or cashier’s check made payable to the Commonwealth of Massachusetts for $30,000

A copy of the applicant’s Articles of Organization (as outlined in Section B)

A copy of the applicant’s Certificate of Good Standing (as outlined in Section B)

A copy of the applicant’s bylaws or operating agreement (as outlined in Section B)

An Employment and Education Form for each required individual (as outlined in Section D)

A completed and signed Character and Competency Form for each required actor (as outlined in Section G)

A sealed envelope with the name of the applicant and marked “authorization forms,” that contains the

background check authorization forms (use forms provided) and fee, for each of the following actors:

The Chief Executive Officer; Chief Operating Officer; Chief Financial Officer; individual/entity responsible for marijuana for medical use cultivation operations; individual/entity responsible for the RMD security plan and security operations; each individual performing onsite services on behalf of a consulting or contracted company as Cultivation or Security Manager or the equivalent, if known during the application process; each member of the Board of Directors; each Member of the Corporation, if any; and each person and entity known to date that is committed to contributing 5% or more of initial capital to operate the proposed RMD. If the applicant does not have a Chief Executive Officer, Chief Operating Officer, or Chief Financial Officer, it must identify the individuals performing the equivalent duties for the applicant and submit these forms for each said individual.

For entities contributing 5% or more of initial capital to operate the proposed RMD, the forms must be completed by the entity’s Chief Executive Officer or Executive Director and President or Chair of the Board of Directors. If the entity does not have a Chief Executive Officer or Executive Director or President or Chair of the Board of Directors, it must identify the individuals performing the equivalent duties for the entity and submit these forms for each said individual.

SECTION A. APPLICANT INFORMATION

Legal name of Applicant Corporation

Name of Applicant Corporation’s Chief Executive Officer

Mailing address of Applicant Corporation (Street, City/Town, Zip Code)

Applicant Corporation’s point of contact (name of person Department should contact regarding this application)

Point of contact’s telephone number

Point of contact’s e-mail address

Number of applications: How many Management and Operations Profiles does the applicant intend to submit?

SECTION B. INCORPORATION

Attach a copy of the applicant’s Articles of Organization, documenting that the applicant is an entity incorporated in Massachusetts.

Attach a copy of the applicant’s Certificate of Good Standing from the Massachusetts Secretary of the Commonwealth. The Certificate of Good Standing must be dated no earlier than 90 days prior to the date the Management and Operations Profile is received by the Department.

Attach a copy of the applicant’s bylaws (if a non-profit or domestic business corporation) or operating agreement (if a limited liability company).

SECTION C. NON-PROFIT COMPLIANCE

If the applicant is a non-profit corporation, answer each of the questions in Section C to explain how the corporation will remain in compliance with the non-profit requirements of Ch. 369 of the Acts of 2012, the regulations at 105 CMR 725.000, and “Guidance for Registered Marijuana Dispensaries Regarding Non-Profit Compliance.” Please refer to the “Guidance for Registered Marijuana Dispensaries Regarding Non-Profit Compliance” document in completing this Section.

Please identify any management company that the applicant intends to utilize and summarize the terms of any agreement or contract, executed or proposed, with the management company.

Please identify any agreements or contracts, executed or proposed, in which the applicant will engage in a Related Party Transaction and summarize the terms of each such agreement.

Please identify whether any members of the Board of Directors are also serving as employees of the proposed RMD and, if so, their title and role with the proposed RMD.

Please identify whether any members of the Board of Directors are serving as officials, executives, corporate members or board members for any management company, investor or other third party proposed to contract or otherwise conduct business with the proposed RMD.

Please identify any contract or agreement, executed or proposed, under which a percentage or portion of the applicant’s revenue will be distributed to a third party and summarize the terms of any such agreement or contract.

ATTESTATION

The applicant agrees and attests that it will operate in compliance with the “Guidance for Registered Marijuana Dispensaries Regarding Non-Profit Compliance.”

____________________________	Click here to enter a date.

Signature of Authorized Signatory	Date Signed

Print Name of Authorized Signatory

Title of Authorized Signatory

SECTION D. EXPERIENCE

16.	Attach a completed and signed Employment and Education Form (use template provided) for each required individual (as outlined in the Employment and Education Form)

17. Describe the experience, and length of experience, of the applicant’s Chief Executive Officer, Chief Operating Officer, and Chief Financial Officer, or their equivalent, with running a business.

Describe the experience, and length of experience, of the applicant’s Chief Executive Officer, Chief Operating Officer, and Chief Financial Officer, or their equivalent, with providing health care services.

Describe the experience, and length of experience, of the applicant’s Chief Executive Officer, Chief Operating Officer, and Chief Financial Officer, or their equivalent, with providing services for marijuana for medical purposes.

Describe the experience, and length of experience, of the applicant’s individual/entity responsible for marijuana for medical use cultivation operations and individual/entity responsible for the RMD security plan and security operations with providing services for marijuana for medical purposes.

SECTION E. OPERATIONS

Provide a summary of the applicant’s operating procedures for the cultivation of marijuana for medical use.

Describe the types and forms of Marijuana Infused Products (“MIPs”) that the applicant intends to produce, if any.

Provide a summary of the applicant’s methods of producing MIPs, if the applicant intends to produce MIPs.

Provide a summary of the applicant’s operating procedures for the provision of security at the proposed RMD.

Provide a summary of the applicant’s operating procedures for the prevention of the diversion of marijuana.

Provide a summary of the applicant’s operating procedures for the storage of marijuana for medical use.

Provide a summary of the applicant’s operating procedures for the transportation of marijuana for medical use.

Provide a summary of the applicant’s operating procedures for inventory management.

Provide a summary of the applicant’s operating procedures for quality control and testing of product for potential contaminants.

Provide a summary of the applicant’s operating procedures for maintaining confidentiality of registered qualifying patients, personal caregivers, and dispensary agents, as required by law.

Provide a summary of the applicant’s personnel policies.

Provide a summary of the applicant’s operating procedures for the dispensing of marijuana for medical use.

Provide a summary of the applicant’s operating procedures for record keeping.

Provide a summary of the applicant’s plans for providing patient education.

Provide a summary of the applicant’s operating procedures for patient or personal caregiver home-delivery, if the applicant plans to provide home-delivery services.

Provide a summary of the applicant’s policies and procedures for the provision of marijuana for medical use to registered qualifying patients with verified financial hardship without charge or at less than the market price.

Provide a summary of the training(s) that the applicant intends to provide to Dispensary Agents.

Will the applicant provide worker’s compensation coverage to its Dispensary Agents?

Yes No

Will the applicant obtain professional and commercial insurance coverage?

Yes No

Describe the applicant’s plan to obtain liability insurance or place in escrow the required amount to be expended for the coverage of liabilities.

SECTION F. CAPITAL CONTRIBUTORS

List all persons and entities known to date that are committed to contributing 5% or more of initial capital to operate the proposed RMD. For entities contributing initial capital to operate the proposed RMD, list the entity’s Chief Executive Officer or Executive Director and President or Chair of the Board of Directors, or their equivalent.

Attach additional tables if needed.

Individual Name	Amount of Initial Capital Committed	% of Initial Capital Committed
$
$
$
$
$

Entity Name	Leadership Names	Amount of Initial Capital Committed	% of Initial Capital Committed
Entity CEO or ED Entity Pres or Chair	$
Entity CEO or ED Entity Pres or Chair	$
Entity CEO or ED Entity Pres or Chair	$

SECTION G. CHARACTER AND COMPETENCY FORMS

Attach a completed and signed Character and Competency Form (use templates provided) for each required actor (as outlined in the Character and Competency Forms). Please note that there is a “Form for an Individual” and a “Form for an Entity.”

ATTESTATIONS

Signed under the pains and penalties of perjury, I, the authorized signatory of the applicant, agree and attest that all information included in this application is complete and accurate and that I have an ongoing obligation to submit updated information to the Department if the information presented within this application has changed.

____________________________	Click here to enter a date.

Signature of Authorized Signatory	Date Signed

Print Name of Authorized Signatory

Title of Authorized Signatory

The applicant agrees and attests that it will operate in compliance with all applicable state laws and regulations, including, but not limited to, laws regarding child support and taxation.

____________________________	Click here to enter a date.

Signature of Authorized Signatory	Date Signed

Print Name of Authorized Signatory

Title of Authorized Signatory

I, the authorized signatory for the applicant, hereby attest that if the applicant is allowed to proceed to submit a Siting Profile, the applicant is prepared to comply with all Siting Profile requirements.

_____________________________	Click here to enter a date.

Signature of Authorized Signatory	Date Signed

Print Name of Authorized Signatory

Title of Authorized Signatory