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CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION Please Note: This form is an application that is subject to approval or denial by the City of Barre, Vermont. No license application is considered approved until the Applicant receives approval from the City of Barre, Vermont. Cultivation and storage of marijuana at a residence or dwelling without license approval shall be grounds for a violation citation and / or denial of a subsequent license application or renewal. PLEASE SUBMIT THIS APPLICATION COMPLETELY AND LEGIBLY. INCOMPLETE AND / OR IILLEGIBLE APPLICATIONS WILL BE DENIED AS INCOMPLETE. YOU MUST ATTACH A CURRENT PHOTOGRAPH OF ANY OUTDOOR AND/OR INDOOR CULTIVATION AREA TO THIS APPLICATION. THIS APPLICATION IS (check one) A new license application A renewal of an existing license application. APPLICANT INFORMATION: NAME: _________________________________________________________________ First Middle Last SOCIAL SECURITY NUMBER: ______________________ DATE OF BIRTH: ____/_____/______ IN THE PREVIOUS TEN (10) YEARS, HAS THE APPLICANT USED ANY OTHER NAME(S) OR ALIASES? YES NO IF YES, PLEASE LIST ALL OTHER NAMES OF ALIASES USED IN THE LAST TEN (10) YEARS. OTHER NAMES OR ALIASES USED: _________________________________________ _________________________________________ First Middle Last First Middle Last _________________________________________ _________________________________________ First Middle Last First Middle Last ARE YOU CURRENTLY PROHIBITED FROM POSSESSING OR CONSUMING MARIJUANA? YES NO APPLICANT CONTACT INFORMATION: MAILING ADDRESS: ________________________________________________________________________ Street or PO Box City State Zip TELEPHONE: _____________________________ EMAIL: ____________________________________
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CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE ... · CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION APPLIANT CHECKLIST AND CERTIFICATION FEE: $250.00

Jun 27, 2020

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Page 1: CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE ... · CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION APPLIANT CHECKLIST AND CERTIFICATION FEE: $250.00

CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION Please Note: This form is an application that is subject to approval or denial by the City of Barre, Vermont. No license application is considered approved until the Applicant receives approval from the City of Barre, Vermont. Cultivation and storage of marijuana at a residence or dwelling without license approval shall be grounds for a violation citation and / or denial of a subsequent license application or renewal.

PLEASE SUBMIT THIS APPLICATION COMPLETELY AND LEGIBLY. INCOMPLETE

AND / OR IILLEGIBLE APPLICATIONS WILL BE DENIED AS INCOMPLETE.

YOU MUST ATTACH A CURRENT PHOTOGRAPH OF ANY OUTDOOR AND/OR INDOOR CULTIVATION AREA TO THIS APPLICATION.

THIS APPLICATION IS (check one) □ A new license application □ A renewal of an existing license application. APPLICANT INFORMATION: NAME: _________________________________________________________________ First Middle Last SOCIAL SECURITY NUMBER: ______________________ DATE OF BIRTH: ____/_____/______

IN THE PREVIOUS TEN (10) YEARS, HAS THE APPLICANT USED ANY OTHER NAME(S) OR ALIASES? □ YES □ NO IF YES, PLEASE LIST ALL OTHER NAMES OF ALIASES USED IN THE LAST TEN (10) YEARS. OTHER NAMES OR ALIASES USED: _________________________________________ _________________________________________ First Middle Last First Middle Last _________________________________________ _________________________________________ First Middle Last First Middle Last ARE YOU CURRENTLY PROHIBITED FROM POSSESSING OR CONSUMING MARIJUANA? □ YES □ NO APPLICANT CONTACT INFORMATION: MAILING ADDRESS: ________________________________________________________________________ Street or PO Box City State Zip TELEPHONE: _____________________________ EMAIL: ____________________________________

Page 2: CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE ... · CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION APPLIANT CHECKLIST AND CERTIFICATION FEE: $250.00

CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION LOCATION OF CULTIVATION AND STORAGE FACILITY: _________________________________________________ Barre, VT 05641

911 Address IS THIS YOUR RESIDENCE? □ YES □ NO IF NO, PLEASE BE ADVISED THAT YOU CANNOT LEGALLY CULTIVATE OR STORE MARIJUANA AT A LOCATION OTHER THAN YOUR LEGAL RESIDENCE AND THAT DOING SO MAY SUBJECT YOU TO CRIMINAL PROSECUTION. DO YOU RENT OR OWN YOUR RESIDENCE? □ OWN □ RENT IF YOU RENT YOUR RESIDENCE, YOU MUST ATTACH THE “LANDLORD CONSENT FORM” TO THIS APPLICATION. AN APPLICATION SEEKING LICENSURE AT A RENTED LOCATION THAT DOES NOT HAVE THIS FORM COMPLETED AND ATTACHED WILL BE DENIED AND RETURNED AS INCOMPLETE. DO YOU INTEND TO CULTIVATE MARIJUANA OUTDOORS AT THIS LOCATION? □ YES □ NO DO YOU INTEND TO CULTIVATE MARIJUANA INDOORS AT THIS LOCATION? □ YES □ NO IF YES, WILL YOU BE UTILIZING ELECTRICLY POWERED “GROW LIGHTS” OR ANY OTHER ELECTRICLY POWERED ARTIFICAL LIGHT SOURCE AT THIS LOCATION? □ YES □ NO IF YES, YOU MUST ATTACH THE “LICENSED ELECTRICIAN INSPECTION FORM” TO THIS APPLICATION. AN APPLICATION SEEKING INTERIOR CULTIVATION LICENSURE AT ANY LOCATION THAT DOES NOT HAVE THIS FORM COMPLETED AND ATTACHED WILL BE DENIED AND RETURNED AS INCOMPLETE. DO YOU INTEND TO STORE CULTIVATED MARIJUANA AT THIS LOCATION? □ YES □ NO IS YOUR EXTERIOR CULTIVATION AREA IN AN ENCLOSURE THAT IS SCREENED FROM PUBLIC VIEW? □ YES □ NO ARE ALL CULTIVATION AND STORAGE AREAS SECURE SO THAT ACCESS IS LIMITED TO YOU AND ONLY TO PERSONS TWENTY ONE YEARS OF AGE OR OLDER WHO HAVE YOUR PERMISSION TO ACCESS THE AREA(S)? □ YES □ NO HAVE YOU READ AND ARE YOU FAMILIAR WITH VERMONT’S STATUTES AS THEY RELATE TO THE POSSESSION, CULTIVATION AND STORAGE OF MARIJUANA? □ YES □ NO DO YOU UNDERSTAND THAT IT IS ILLEGAL TO SELL MARIJUANA TO ANY INDIVIDUAL? □ YES □ NO DO YOU UNDERSTAND THAT IT MAY BE ILLEGAL TO GIFT MARIJUANA TO ANY INDIVIDUAL? □ YES □ NO DO YOU UNDERSTAND THAT IT IS ILLEGAL TO CONSUME MARIJUANA IN PUBLIC PLACES? □ YES □ NO DO YOU UNDERSTAND THAT INDIVIDUALS UNDER THE AGE OF TWENTY ONE MAY NOT GROW, POSSESS OR CONSUME MARIJUANA IN VERMONT AND THAT ENABLING THEM TO DO IS A CRIME? □ YES □ NO

Page 3: CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE ... · CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION APPLIANT CHECKLIST AND CERTIFICATION FEE: $250.00

CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION

APPLIANT CHECKLIST AND CERTIFICATION

FEE: □ $250.00 for an ini�al or first �me applica�on. □ $100.00 for a renewable application. Licenses renew annually.

PHOTOGRAPH: □ A CURRENT PHOTOGRAPH OF ANY OUTDOOR OR INDOOR CULTIVATION AREA IS ATTACHED TO THIS APPLICATION.

BY SIGNING AND SUBMITTING THIS APPLICATION, THE APPLICANT UNDERSTANDS AND AGREES THAT:

The ability to hold a Marijuana Cultivation and Storage License in the City of Barre, Vermont is not a right. It may be suspended or revoked at any time for cause. All holders of a Marijuana Cultivation and Storage License are subject to reasonable compliance inspections by agents or designees of the City (including law enforcement). The refusal of an inspection shall be grounds for immediate revocation or suspension of a Marijuana Cultivation and Storage License. The Licensee shall be solely responsible for their education and knowledge of Vermont Statutes as they related to cultivation and storage of marijuana. Failure to adhere to Vermont Statues in all respects shall be grounds for immediate revocation or suspension of a Marijuana Cultivation and Storage License. The Licensee shall be solely responsible for their education and knowledge of Barre City Ordinances as they related to cultivation and storage of marijuana. Failure to adhere to Barre City Ordinances in all respects shall be grounds for immediate revocation or suspension of a Marijuana Cultivation and Storage License. The Licensee is solely responsible for the safe and secure cultivation and storage of marijuana, as well as the safe, secure and responsible disposition of any unwanted marijuana product or by-products. Any unwanted marijuana products or by-products may not be disposed of in garbage containers that are left unattended or in a manner that would allow said unwanted products or by-products to be accessed by a third party. The Licensee is responsible for the safe and code compliant operation of any indoor marijuana growing facility (with or without “grow lights”). If an indoor growing facility with growing assist devices is altered, it must be immediately re-inspected by a master electrician and the inspection results must be forwarded to the city on the prescribed form. The Licensee shall not knowingly or negligently enable the consumption or possession of marijuana by a person under 21 years of age. The Licensee shall not consume marijuana in public places within the State of Vermont. If the Licensee has been granted permission to cultivate and store marijuana at a residence or facility that is not owned by the Licensee, that permission may be revoked by the property own at any time. If permission of the property owner is revoked, the Licensee must ceased all cultivation and storage of marijuana on the premises immediately and arrange for the safe and responsible disposal of all marijuana and marijuana plants in a manner that will ensure that they are not accessed or possessed by any third party. Marijuana cultivated at an unauthorized or unlicensed facility or residence is subject to seizure by the City of Barre, Vermont or their designees (including law enforcement). ALL REPRESENTATIONS MADE ON THIS APPLICATION ARE TRUE AND COMPLETE, UNDER THE PAINS AND PENALTIES OF PERJURY. _______________________________________________ APPLIANT SIGNATURE DATE

Page 4: CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE ... · CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION APPLIANT CHECKLIST AND CERTIFICATION FEE: $250.00

CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION

LANDLORD CONSENT FORM

IF YOU OWN THE CULTIVATION FACILITY, DO NOT COMPLETE THIS FORM APPLICANT NAME: _________________________________________________________________ First Middle Last

THIS SECTION MUST BE COMPLETED BY THE OWNER(S) OF THE PROPERTY PROPERTY OWNER: NAME(S): ____________________________________________________________________________

First Middle Last NAME(S): ____________________________________________________________________________ First Middle Last MAILING ADDRESS:: ___________________________________________________________________ Street or PO Box City/Town State Zip TELEPHONE NUMBER: _________________________ EMAIL ADDRESS: ________________________ LOCATION OF CULTIVATION AND STORAGE FACILITY: _________________________________________________ Barre, VT 05641

911 Address IS THIS A MULTI-UNIT PROPERTY? □ YES □ NO IF YES, HOW MANY UNITS? _____________ DO YOU CURRENTLY HAVE ANY OUTSTANDING OR UNRESOLVED CODE VIOLATIONS? □ YES □ NO HAVE YOU GIVEN SPECIFIC PERMISSION FOR THE APPLICANT TO SET UP OR MAINTAIN INTERIOR “GROW LIGHTS” AT YOUR PROPERTY? □ YES □ NO

LANDLORD CONSENT I (We) understand that the above reference applicant has applied for a “Marijuana Cultivation and Storage License” with the City of Barre, Vermont. We hereby consent to granting of said License and give our specific permission for marijuana cultivation and storage to occur at our property. We further understand that this consent may be revoked at any time. We understand that if consent is revoked, we have an obligation to so notify the City of Barre, Vermont. The City of Barre, Vermont has offered no opinion or advice regarding the effect of marijuana cultivation at this property with regard to compliance with any mortgage, insurance or code provision(s). ____________________________________________ ____________________________________________ Landlord Signature Date Landlord Signature Date

Page 5: CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE ... · CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION APPLIANT CHECKLIST AND CERTIFICATION FEE: $250.00

CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION

LICENSED ELECTRICIAN INSPECTION FORM

THIS FORM MUST BE COMPLETED FOR ANY LOCATION SEEKING INDOOR MARIJUANA CULTIVATION WHERE “GROW LIGHTS” OR ANY OTHER ARTIFICAL LIGHT SOURCE WILL BE UTILIZED

APPLICANT NAME: _________________________________________________________________ First Middle Last APPLICANT CERTIFICATION. I understand that I am responsible for the safe and code compliant operation of my indoor marijuana cultivation facility. I understand that if the fixtures, devices or wiring are changed in any respect (other than routine maintenance, such as bulb changing), I must have the facility immediately re- inspected □ YES □ NO

THIS SECTION MUST BE COMPLETED A LICENSED MASTER ELECTRICIAN INSPECTING MASTER ELECTRICIAN: NAME(S): ____________________________________________________________________________

First Middle Last MAILING ADDRESS:: ___________________________________________________________________ Street or PO Box City/Town State Zip TELEPHONE NUMBER: ______________________ EMAIL ADDRESS: ________________________ LOCATION OF CULTIVATION AND STORAGE FACILITY: _________________________________________________ Barre, VT 05641

911 Address DATE OF INSPECTION: ________/_______/________ ARE ALL ELECTRICAL DEVICES INSPECTED UL APPROVED? □ YES □ NO DID YOU OBSERVE ANY CODE VIOLATIONS DURING YOUR INSPECTION? □ YES □ NO ARE ALL ELECTRICAL DEVICES, SOURCES OF POWER AND RELATED DEVICES, PANELS AND WIRING CODE COMPLIANT AND FREE OF OBSTRUCTIONS OR DEFICIENCIES THAT COULD RESULT IN COMBUSION? □ YES □ NO

INSPECTION CERTIFCATION I have inspected the above referenced electrified indoor grow facility and all related electrical fixtures, devices and wiring. I certify them to be code compliant and safe if property used. I have instructed the applicant in the safe use and operation of all electrical devices and fixtures. ____________________________________________ ___________________________________ Master Electrician Signature Date Vermont Master Electrician License Number

Page 6: CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE ... · CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE APPLICATION APPLIANT CHECKLIST AND CERTIFICATION FEE: $250.00

CITY OF BARRE, VERMONT MARIJUANA CULTIVATION AND STORAGE LICENSE

LICENSE NUMBER: MCSL 0000001 DATE OF ISSUANCE: 07/01/2018 EXPIRATION DATE: 06/30/2019 LICENSEE: JOE SAMPLE LOCATION: 1 SAMPLE STREET APT 1

*One will be noted* THIS LOCATION IS APPROVED FOR OUTDOOR CULTIVATION ONLY.

THIS LOCATION IS APPROVED FOR INDOOR CULTIVATION ONLY.

THIS LOCATION IS APPROVED FOR BOTH OUTDOOR AND INDOOR CULTIVATION.

THIS LICENSE MUST BE DISPLAYED AT THE LICENSED PREMISES

THIS LICENSE MUST BE RENEWED ANNUALLY