Application for Medical Marijuana Treatment Center ...

STATE OF FLORIDA DEPARTMENT OF HEALTH

Application for Medical Marijuana Treatment Center Registration

This application for Medical Marijuana Treatment Center Registration (Application) is designed to allow the Florida Department of Health, Office of Medical Marijuana Use (OMMU) to select Medical Marijuana Treatment Centers (MMTC).

This application is divided into three parts:

I. Part I requires the applicant to provide basic information about the applicant and application. II. Part II requires the applicant to provide the OMMU with detailed items to demonstrate the

ability to operate as a MMTC as set forth below in sections 1-16.

Section 1 2 3 4 5 6 7 8 9 10 11

12

13 14 15 16

Title Technical Ability: Cultivation Knowledge and Experience Technical Ability: Medical Marijuana Cultivation Infrastructure: Cultivation Technical Ability: Processing Infrastructure: Processing Technical Ability: Dispensing Operations Technical Ability: Medical Marijuana Dispensing Infrastructure: Dispensing Accountability: Premises Accountability: Operations Personnel: Medical Director Personnel: Cultivation, Processing, Dispensing and Delivery Staff Diversity Plan Financials: Certified Financial Documents Financials: Business Structure Infrastructure: Facilities

Points 50 50 50 100 50 50 50 100 100 100 50

50

100 100 100 50

Page Limit 4 7 4 7 4 5 7 8 4 7 6

4

4 No limit

8 8

III. Part III provides information on application submittal, the required application fee, and includes the applicant signature page.

Rule 64-4.002, F.A.C. Effective: 04/2018 Form DH8013-OMMU-04/2018

Application Instructions

APPLICATIONS MUST BE SAVED AS OPTICAL CHARACTER RECOGNITION PORTABLE DOCUMENT FORMAT (OCR PDF) FILES AND BE SUBMITTED ON A USB FLASH DRIVE.

1. Organization: When submitting an application for MMTC registration, applicants must organize the application so that each document submitted with the application is labeled accurately with the section number of the application to which it corresponds.

Blind Grading

With the exception of Sections 11, 14 and 15, Part II of the application will be evaluated using a blind grading method and must be de-identified. Each application will be assigned a random application number. Part II will be separated from Parts I and III and will be distributed to the evaluators electronically, identified only by the random application number.

It is important that Part II, Sections 1-10, 12-13, and 16 are prepared without reference to proper nouns or other identifying information for individuals and business entities.

The only sections that should include identifying information are Section 11 ? Personnel: Medical Director, Section 14 ? Financials: Certified Financial Documents and Section 15 ? Financials: Business Structure.

An application that includes information that identifies the organization, consultants, entities, or people in Sections 1-10, 12-13 and 16 will be redacted prior to forwarding to the evaluators for grading.

Each section must be saved as a separate file on the USB flash drive. Files must be named using the following format: Section Number ? Section Title

Examples:

Section 1 ? Technical Ability Cultivation Knowledge and Experience Section 2 ? Technical Ability Medical Marijuana Cultivation

Applications not submitted on USB flash drives or in the required format will be denied.

2. Page Limit: Narrative responses must be double-spaced and written in Times New Roman, 12 point font with 1-inch margins. Applicants are required to abide by the page limits for each section. Pages in excess of the page limit will be removed from the application prior to evaluation.

3. Addendums: Sections 8, 9, 15 and 16 allow for the submission of specific documentation such as leases or property sketches, or other information that would be difficult to express in a narrative response, such as photographs, maps, diagrams, or blueprints. Such documents may be submitted as addendums, as indicated in those sections. Addendums must be included with the section that they support and do not count against that section's page limit.

Addendums are not an opportunity for applicants to provide additional narrative responses in excess of a section's page limit. Additional narrative responses provided in addendums will be removed prior to evaluation and will not be considered.

Rule 64-4.002, F.A.C. Effective: 04/2018 Form DH8013-OMMU-04/2018

Page 2 of 14

4. Redactions and Public Records Law: Applications are public records. Any exemptions to public records laws must be identified at the time the application is submitted. In order to claim a public records exemption, the applicant must provide a redacted copy of the application with the statutory basis for each exemption clearly identified.

UNLESS INFORMATION FALLS UNDER ANOTHER PUBLIC RECORDS EXEMPTION, FAILURE TO SPECIFICALLY AND CLEARLY IDENTIFY INFORMATION CLAIMED AS EXEMPT AS A TRADE SECRET OR FAILURE TO PROVIDE A REDACTED COPY OF THE APPLICATION AT THE TIME OF SUBMISSION WILL RESULT IN THE RELEASE OF THE FULL APPLICATION IN RESPONSE TO PUBLIC RECORDS REQUESTS.

Rule 64-4.002, F.A.C. Effective: 04/2018 Form DH8013-OMMU-04/2018

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Part I

Applicant:

Name: ________________________________________________________________________________________ (Name must be the same as the name registered with the state)

Florida Department of Agriculture Certificate of Registration Address:

Street Address

City

Mailing Address (if different):

ZIP Code

Street Address

City

ZIP Code

Contact Name: ________________________________________________

Phone Number: _____________________________ Email Address: _____________________________________

Medical Director:

Name of Medical Director Employed by the MMTC:_____________________________________________________

Mailing Address: ________________________________________________________________________________

Street Address

City

ZIP Code

Phone Number: _____________________________ Email Address: _____________________________________

Florida MD or DO License Number: ____________________________________________

Rule 64-4.002, F.A.C. Effective: 04/2018 Form DH8013-OMMU-04/2018

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A. Provide certified documentation from the Florida Department of State or Florida Department of Revenue, as applicable under Florida law, demonstrating that the applicant has been registered to do business in the state of Florida for the previous five (5) consecutive years.

B. Provide a certified copy of a valid certificate of registration used by the Department of Agriculture and Consumer Services pursuant to section 581.131, Florida Statutes.

C. Provide a list of all owners, managers, officers, and board members indicating the date of each individual's most recent level-2 background screening. With each name, include their position or proposed position in the proposed MMTC.

D. Is the applicant applying as a recognized class member of Pigford v. Glickman, 185 F.R.D. 82 (D.D.C. 1999) ("Pigford") or In Re Black Farmers Discrimination Litig., 856 F. Supp. 2d 1 (D.D.C. 2011) ("BFDL") (Pigford Class Applicant)?

Yes

No

If yes has been selected, provide documentation evidencing qualification as a class member in Pigford or BFDL. If the applicant is only applying for licensure as a Pigford Class Applicant, the Applicant does not need to provide the documents set forth in item B above.

* Note that if the applicant wishes to be considered as both a Pigford Class Applicant and a general applicant, the applicant must submit the documentation set forth in items A through D above.

E. Does the applicant own one or more facilities that are, or were, used for the canning, concentrating, or otherwise processing of citrus fruit or citrus molasses and will use or convert the facility or facilities for the processing of medical marijuana?

Yes

No

If yes has been selected, provide ownership documentation, certification from the Florida Department of Citrus and a description of how the property will be used.

Rule 64-4.002, F.A.C. Effective: 04/2018 Form DH8013-OMMU-04/2018

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