the commonwealth of massachusettsoperate a registered marijuana dispensary this opplicotion fonn is...

Cardiac Arrhythmia Syndromes Foundation (CAS Foundation) Application # 2 or 3

INSTRUCTIONS

The Commonwealth of Massachusetts

Executive Office of Health and Human Services Department of Public Health

Bureau of Health Care Safety and Quality Medical Use of Marijuana Program

99 Chauncy Street, 11th Floor, Boston, MA 02111

SITING PROFILE: Request of for a Certificate of Registration to Operate a Registered Marijuana Dispensary

This opplicotion fonn is to be completed by a non-profit corporation that wishes to apply for a Certificate of Registration to operate o Registered Marijuana Dispensary ("RMD") in Massachusetts, and hos been invited by the Department of Public Health (the "Department") to submit a Siting Profile.

If invited by the Department to submit more than one Siting Profile, you must submit a separate Siting Profile and attachments for coch proposed RMD. Please identify each application of multiple applications by designating it as Application I, 2 or 3 in the heoder of coch 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.

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

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

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

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Cardiac Arrtlythmla Syndromes Foundation (CAS Foundation)

Mail or hand-deliver the Siting Profile, with all required attachments, to:

REVIEW

Department of Public Health Medical Use of Marijuana Program

RMD Applications 99 Chauncy Street. I I 1h Floor

Boston, MA 02111

Application # 2 of 3

Applications are reviewed in the order they nre received. Aller a completed application packet is received by the Department. the Department will review the information and will contact the applicant if clarifications/updates to the submitted application materials are needed. The Department will notify the applicant whether they have met the standards necessary to receive a Provisional Certi ficnte of Registration.

PROVISIONAL CERTIFICATE OF REGISTRATION

Applicants have one year from the date of the submission ofthe Management and Operations Profile to receive a Provisional Certificate of Registration. lfan applicant does not receive a Provisional of Certificate of Registration after one year, the applicant must submit a new Application of Intent and fee.

REGULATIONS

For complete infonnation regarding registration of an RMD, please refer to I 05 CMR 725.100.

It is the applicant's responsibility to ensure that all responses arc 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 nil 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).

tnfonnatlon on this page has been reviewed by the applicant, and where provided b llcant, Is accurate and complete, as Indicated by the lnlllals of the authorized slgnatcrv her

Siling Profile - Puge :?

Cardiac Annythmia Syndromes Foundallon (CAS Foundation) Application # 2 of 3

QUESTIONS

If additional infonnntion is needed regarding the RMD application process, please contact the Medical Use of Marijuana Program at 617-660-5370 or RMDaoplicationn ~late.ma.us.

CHECKLIST

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

I!! A fully and properly completed Siting Profile, signed by an authorized signatory of the applicant non-profit corporation (the "Corporation")

t!f Evidence ofinterest in property, by location (as outlined in Section B)

l!'.I Letter(s) of local support or non-opposition (as outlined in Section C)

Information on this page has been reviewed by the applicant, and when! provided by. cant, Is accurate and complete, as Indicated by the Initials of the authorized slsnatorv here

Siling Profile - J>oge 3

Cardiac Arrhythmia Syndromes Foundation (CAS Foundallon)

SECTION A: APPLICANT INFORMATION

I. Cardiac Arrhythmia Syndromes Found4tion, Inc. aka - CAS Foundation

Legal name of Corporalion 2.-Name of Corporation's Chief Executive Officer

9 Banlct Stm:t. Unit # 335 3. Andover, MA 01810

Address of Corporation (Street, Cityffown, Zip Code)

4.

Appllcallon # 2 or 3

Applicant point of contact (mune of person Department of Public Health should contact regarding this application)

Applicant point of contact's c·mail address

7. Number of applications: How many Siting Profiles do you intend to submit? _J __ _

lnfonnatlon on this page has been revlewed by the appllcilnt, ;md where provided by w pplleant, ls accurate and complete, as Indicated by the lnltlals of the authorized signatory here:

Siting Profile -

Cardiac Anhythmla Syndromes Foundallon (CAS Foundallon) Application # 2 of 3

SECTION B: PROPOSED LOCATION(S)

Provide the physical address of the proposed dispensary site and the physical address of the addilonal location, if any, where marijuana/or medical use will be cultivated or processed.

Attach supporting documl!nts as evidence of interest in t/11! property, by location. Interest may be demonstrated by (a) a clear legal title lo the proposed site; {b) an option to purchase the proposed site; (c) a lease; (d) a legally enforceable agreement lo give such title under (a) or (b), or such lease under (c), in the event that Department determines that the applicant qualifies for registration as a RMD; or (e) evidence of binding permission to use the premises.

Location Full Address County

Somerville, 67 Broadway Middlc:sc:1t 1 Dispensing

Fitchburg, One (I) Oak Hill Road Worccstc:r 2 Cultivation

Fitchburg. One (I) Oak Hill Rood Worc:cstc:r 3 Processing

D Check here if the applicant would consider a location other than the county or physical address provided within this application.

Information on this page has been reviewed by the appllcant, and where provided . pllcant, ls accurate and complete, as Indicated by the Initials of the authorized signatory her _

Siting Profile - l'llgc 5

Cardiac Arrhythmia Syndromes Foundation (CAS Foundation) Application 2 of 3

SECTION C: LEITER OF SUPPORT OR NON-OPPOSITION

Anach a letter of support or non-opposition, using one of the templates below (Option A or 8), signed by the local municipality in which the applicant intends to locate a dispensary. The applicant may choose to use either template, in consultation with the host community. If the applicant is proposing a dispensary location and a separate cultivation/processing location, the applicant must submit a letter of support or non-opposition from both municipalities. This letter may be signed by (a) the Chief Executive Officer/Chief Administrative Officer, as appropriate.for the desired m1111icipality: or (b) the City Council, Board of Alderman, or Board of Selectmen for the desired municipality. The Idler of support or nan-opposition must contain the Ian page as pnn/dd below. The Idler must be printed on the municipality's offldal later/read.

Template Option A: Use this language ifsignatory is a Chief Executive Officer/Chief Administrative Officer /, (Name of penon), do hereby provide (:rupportlnon-oppo:ritlon) to (name of non-profit argani::ation) IO operate o Registered ManJl.llllUl Dispensnry ("RMO") in (name of city or town) I ha1."e verified with the appropriate local afficiall that the propo1ed RMD facility i:r located in a :aning district that allows such use by right or punllillll ta /or:al permi11ing.

Name and Title oflndividuol

Signature

Date

Template Option B: Use this language if signatory is acting on behalf of a City Council, Board of Alderman. or Board of Selectman The (name of counr:i/lboard], docs hereby provide (s11pportlnon-oppositio11) lo [name of non-profit organi:atlan) to operate a Registered Marijuonn Dispensnry in (name of city or town]. I hnve been outhorilCd lo provide lhis lcller on behalf of the (name of councillboarclj by a vote IDken 11t 11 duly noticed meeting held on [dnte).

The (namt of council/board] has verified with the appropriate local officials that the propo1td RMD facility is located in a :oning district that allow3 s11eh use by righJ or pursuant to local ptrmitling.

Name and Title of lndividuol (or person outhorilCd to net on behalf of council or board) (add more line:r for names if needed)

Si8llllture (add more Ii Ms for signatures if needed)

Dace

Information on this page has been reviewed by the applicant, and where provided by the applicant, Is accurate and complete, as Indicated by the Initials of the authorized signatory here:~

Siting Profile -

STEPHEN L. DINATALE MAYOR

166 BOULDER DRIVE

FITCHBURG, MA 01420

TEL. (978) 829·1801

May 9, 2016

The CAS Foundation Attn: Jayne Vining 9 Bartlet Street #335 Andover,MA 01810

OFFICE OF THE MAYOR

CAS Foundation. Application # 2 of 3

AARON TOURIGNY CHIEF OF STAFF

[email protected]

JOAN DAVID

ADMINISTRATIVE AIDE

[email protected]

I, Stephen L. DiNatale, Mayor of the City of Fitchburg, do hereby provide this letter of non-opposition to the CAS Foundation, Inc. to operate a Registered Marijuana Dispensary (RMD) facility in the City of Fitchburg, MA.

I have verified with the appropriate local officials that the proposed RMD facility is located in a zoning district that allows such use by right or pursuant to local permitting.

Respectfully yours,

March 2, 2016

CAS Foundation, Application # 2 of 3

ONE OAK HILL, LLC 1 Oak Hill Road

Fitchburg, Massachusetts 01421

RE: Cardiac Arrhythmia Syndromes Foundation, Inc. ("CAS"). Letter of Intent to Lease; 1 Oak Hill Road, Fitchburg, MA

On behalf of ONE OAK HILL, LLC, owner of 1 Oak Hill Road, Fitchburg, Massachusetts, we are pleased to present the following binding Letter of Intent to Lease to CAS. If these terms are acceptable, please have the appropriate authority indicate so by signing below and returning a copy of this letter to me. I would then forward a lease draft for your review.

LEASE PROPOSAL

Property:

Building Size:

Landlord:

Tenant:

Use(s):

Premises:

Term:

Option to Renew:

1 Oak Hill Road, Fitchburg, Massachusetts

244,120 RSF

ONE OAK HILL, LLC

CAS

Business and professional offices as well as laboratory, research and manUfacturing facilities and other uses legally permitted under the laws of the Commonwealth of Massachusetts, including the operation of a Medical Marijuana Cultivation Facility pursuant to Chapter 369 of the Acts of 2012, An Act for the Humanitarian Medical Use of Marijuana, and 105 CMR 725.100 et seq.

Approximately 70,000 rentable square feet located on the first and second floor of Building Four. The Premises shall be measured according to SOMA standards by Landlord's architect.

Ten (10) years.

CAS shall have the option to renew the term of the Lease for one (1) five (5) year period at Fair Market Value, but not less than previous year's rent and shall increase $0.50 per square foot per year. The

Pagel of4

Lease/Rent Commencement:

ABSOLUTE NNN Rent:

Type of Lease:

Tenant Utilities:

Right to Audit:

Tenant Improvements:


renewal option shall be exercised no later than nine (9) months prior to the expiration of the then Lease Term.

On July 1, 2016 CAS will commence paying its pro-rata share of all operating expenses, insurance and taxes, as well for its utilities, cleaning and trash removal for the Premises.

Year 1: Year2: Year3: Year4: Year 5: Year6: Year7: Years: Year9: Year 10:

$8.00 $8.50 $9.00 $9.50 $10.00 $10.50 $11.00 $11.50 $12.00 $12.50

ABSOLUTE NNN ABSOLUTE NNN ABSOLUTE NNN ABSOLUTE NNN ABSOLUTE NNN ABSOLUTE NNN ABSOLUTE NNN ABSOLUTE NNN ABSOLUTE NNN ABSOLUTE NNN

This would be a ABSOLUTE triple net lease whereby CAS pays for its Premises expenses and for its pro-rata share of common area operating expenses, Premises real estate taxes, insurance and building maintenance including parking lot, roof and structure.

Any costs associated with increased security shall be a CASI tenant specific expense.

The Premises shall be separately metered or sub-metered and billed accordingly. CAS shall be responsible for its utility costs (including, but not limited to electricity, water and gas), which shall be based on CAS's consumption.

CAS shall have the annual right to audit Operating Expenses and Real Estate Taxes by a nationally recognized accounting firm, which shall not be on a contingent fee basis.

CAS would take the space "As Is." Any additional amounts required for tenant improvements will be provided by CAS.

Pagel of4


CAS shall also be responsible for its own telephone and data requirements and costs associated therewith.

Also, at CAS's request, Landlord would oversee CAS's improvements, including design, engineering, permitting and construction, for a 3% construction management fee.

Building Systems: Landlord will be responsible for delivering at Lease Commencement all base building common systems in good working order.

ADA: Landlord shall be responsible to keep the common areas of the Premises in compliance with the Americans with Disabilities Act C-ADA"). CAS shall be responsible for ADA compliance associated with its design, construction and use of the Premises.

Sublease & Assignment: CAS shall have the right to assign the entire lease, and to sublease all or part of the Premises, with Landlord's consent, which consent shall not to be unreasonably withheld.

Signage: Landlord agrees to provide, if requested by CAS, directory signage in either the lobby, monument signage at either the parking entrance and CAS entry signage at its Premises. All signage will be in compliance with local

Parking:

Access:

Life Safety:

Environmental:

Security Deposit:

Contingency:

and Department of Public Health rules and regulations.

CAS will be allocated its pro rata share of parking spaces at the Premises. Landlord will provide CAS some reserved parking.

CAS shall be provided 24-hour, seven days per week, access to the building and Premises. The building is secured by a common area card access system. CAS may install Its own security system for its Premises and coordinate its system at the headend with Landlord's system to allow employees to carry one access card.

The building is fully-sprinklered.

At CAS's request, Landlord agrees to share with CAS its most current Phase I & II environmental reports for the Premises, which indicate there are no environmental conditions at the Premises.

To be determined; and subject to Landlord's satisfactory review of CAS's financial statements.

Any lease agreed to by the parties shall be contingent on the CAS obtaining approval for its proposed use from the

of4

Non-Disturbance:


Commonwealth's Department of Public Health and all local zoning approvals and permits.

If applicable, Landlord agrees to cooperate with its lender and CAS to obtain a mutually-acceptable Subordination and Non-Disturbance Agreement.

We appreciate the opportunity to present to you this Letter of Intent and look forward to finalizing this document...

The purpose of this document is to memorialize certain business points and the parties hereby agree to negotiate in good faith to execute a mutually agreeable lease based on these terms by August 1, 2016. The patties mutually acknowledge that their agreement is qualified and that they therefore contemplate the drafting and execution of a more comprehensive agreement.

Signatures

ONE OAK HILL, LLC

3/0312016

Date

AGREED AND ACCEPTED:

3/0312016

Date


CITY OF SOMERVILLE. MASSACHUSETTS

JOSEPH A. CURTATONE

MAYOR

Ms. Jayne Vining Cardiac Arrhythmia Syndromes, Inc. (aka CAS Foundation) 9 Bartlett Street, Unit 335 Andover, MA 01810

Dear

I, Joseph A. Curtatone, Mayor of the City of Somerville, do hereby provide this statement of non-opposition to the CAS Foundation to operate a Registered Marijuana Dispensary at 67 Broadway in the City of Somerville.

The City has verified with the appropriate local officials that the RMD facility at 67 Broadway is located in a zoning district that will allow such use pursuant to local permitting, in the form of a zoning Special Permit under Section 7.15 of the Somerville Zoning Ordinance.

This letter is subject to withdrawal or revocation at any time.

~d~ 1 Joseph A. Curtatone

t Mayor

Ctn' HALL• 93 HIGHLAND AVENUE• SOM[JlVllLE. MASSACHUSITTS 02143 1617> <>25-6600. EXT. 2100 •·TTY: '866> 808-~85 l • FAX: 1617, <>25·3434 • www.somervillema.gov

E-mail: mayor@somervil[emu.gov

One Cell to City Hall

[3][1][1] City of Somerville

August 31, 2016 EXTENSION of LOI Dated 2129/2016

CAS Foundation and/ or Nominee 9 Bartlett Street,# 335 Andover, MA 01810

67 BROADWAY REALTY TRUST . P.O. BOX 281

SOMERVILLE, MA 02143 TEL: (617) 625-8866

(617) 440-1100 FAX: (617) 627-9966

LETTER OF INTENT

CAS Foundation, app. # 2 of 3

67 Broadway Realty Trust is pleased to offer you a Tenancy at 67 Broadway, Somerville, Massachusetts on the following terms and conditions:

LESSOR:

LESSEE:

GUARANTOR:

LEASED PREMISES*:

LEASE TERM:

OPTION TO EXTEND LEASE TERM:

RENT:

67 Broadway Realty Trust

CAS Foundation, and/or Nominee.

T.B.D., subject to Satisfactory Financials

The entire building located at 67 Broadway, Somerville, Massachusetts consisting of approximately 6,842 sq. ft. gross area along with the unattached five garage bays and the entire parking parcel on land area consisting of approximately 12,034 sq. ft.

1/1/2017-12131 /2021

One additional five year option period for the period 1/1/2022-12131/2026

1/1/2017-12131/2017 $17,000./MO NNN Base Rent 1/1/2018-12/31 /2021 Rent increased by 5% commencing on 1/112018 and 5% additional on each annual anniversary for the term of the lease.

OPTION RENT:

OPTION TO TERMINATE LEASE:

SECURITY DEPOSIT:

USE:

BUILD-OUT:

UTILITIES:

REPAIRS& MAINTENANCE:

WATER:


1/1/2022-12/31/2026, Rent increased by 5% commencing on 1/1/2022 over 1/1/2021 Rent and 5% additional on each annual anniversary for the term of the Option Period.

9/1/2016-12/3112016 For the period of9/l/2016-12/3 l/2016, the Lessee shall be granted an Option To Terminate Lease said Lease to be executed on the terms and conditions as set forth in the within Letter of Intent. This Option To Terminate Lease may be exercised for the sole purpose of Lessee not securing any and all permits and licenses to operate a Medical Marijuana Dispensary at 67 Broadway, Somerville, Massachusetts despite the use of diligent efforts. The Option to Terminate Lease is granted by Lessor to Lessee in consideration of the payment of an Option Fee of $5,000./per month, commencing on September 1, 2016 and continuing throughout the Option to Terminate Lease Period terminating on December 31, 2016. If despite the use of diligent efforts, Lessee is unable to secure permits as needed, and chooses to terminate Lease prior to Lease commencement, Lease may be terminated upon notice to the Lessor, but only provided that notice is given to Lessor by Lessee after December 1, 20 I 6, but before December 16, 2016. Upon said notification, said Indenture of Lease shall terminate as of December 31, 2016, without recourse to either party. The money paid by Lessee to Lessor as the Option Fee shall be non-refundable to Lessee.

Two (2) months Security Deposit (to be updated); payable on Lease execution

Medical marijuana dispensary and associated uses all as lawfully permitted.

100% Lessee Lessee shall accept premises in their "as-is" condition.

100% Lessee

100% Lessee, to include parking parcel

100% Lessee

REAL ESTATE TAXES:

EXTERMINATION:

INSURANCE:

PERMITTING:

SNOW REMOVAL:

TRASH REMOVAL:

ADVANCE RENT:

LEASED PREMISES*:

Point of Information;


100% Lessee for the land and buildings at 67 Broadway, Somerville, Massachusetts, starting on Lease commencement.

As needed

$2,000,000. per person, $4,000,000. per accident, Personal Property Insurance $1,000,000., Additionally Lessee to reimburse Lessor for Property Insurance

Lessee's obligation, Lessee to use all due diligence in applying for all state and municipal permits and other permits as needed.

100% Lessee along sidewalks as well.

100% Lessee V three ~

Lessee to pay Lessor ~~ months Advance Base Rent upon Lease Commencement 3

Lessee shall have the Right to reduce the leased premises by the five (5) garage Bays and the eight (8) parking spaces presently occupied by Zipca.r in consideration of a reduction in Base Rent from $17,000. NNN to $15,000. NNN, in which case Rent commencement during the Term and Rent during the Option Period shall be adjusted accordingly. Notice of such reduction in leased premises shall be given to Lesso o less than 60 days prior to Lease commencement.

The above insurance requirements are applicable to this lease only. CAS Foundation will also provide insurances as required by 105 CMR 725.105 (Q). CAS Foundation shall at all time maintain compliance with 105 CMR 725.000.

Cardiac Arrhythmia Syndromes Foundation (CAS Foundation) Application # 2 of 3

SECTION D: LOCAL COMPLIANCE

Describe how the Corporation hos ensured. und will continue to ensure, thnt the proposed RMD is in complinnce will local codes, ordinances. und bylaws for the physical nddress(es) of the RMD.

Fitchburg (cultivation & processing facility);

rrior to entering into o LOI for I Oak Hill Rd. CAS met with The Moyor, Mayor's Chief ofSllllf, Cny Solicitor, ond Building Commissioner who oil determined tho\ this location is properly sited ond is compliant with Fitchburg codes ond byfows rcgnnling the siting of o RMD.

Somerville, 67 Broodwoy ( dispcnsory loc:ition);

67 Broodwoy, is in the Ovcrfoy District known os MMD - Zone 2. This location mcct.~ or cJ1cecds oli or the city's requirements for the siting of on RMD. CAS is fully knowledgeable of oil opplicoble locol codes, ordinonces, ond hy·lows. CAS hos met with the Moyor. ond CAS 's lcgol rcprcscnllltion ond govcmmcntol olfairs linn hos met informally with others.

Bccousc or the seriousness of these molters, the continued compliance with nll locol codes, ordinances, and by-lows ha.~ been tasked l~CEO ond CAS's legal team.

Information on this page has been reviewed bv the applicant, and where provided b. lcant, is accvrate and complete, as indicated bv the initials of the authorized signatory her

Suing Profile - Page 7

Cardiac Armythmla Syndromes Foundation {CAS Foundation)

SECTION E: THREE· YEAR BUSINESS PLAN BUDGET PROJECTIONS

Provide the lhree~year business plan for the RMD, including revenues and e:xpenses.

Projec1ed Start Date for the First Full Fiscal Year: 01/01/2017

FIRST FULL FISCAL SECOND FULL FISCAL YEAR PROJECTIONS YEAR PROJECTIONS

20 17 20 18

Proicctcd Revenue s 3,576,960.00 $5,216,400.00

Proicctcd Exocnscs s 3,544,200.00 s 4,246,000.00

VARIANCE: s 32.000.00 s

Number of uniauc oaticnts for the vcor 1380 2070

Number of n11ticnt visits for the vcar 24840 37260

Proicctcd % of natient nrowth rate annual Iv - 50'%

Estimalcd nurch11SCd ounces ocr visit .40 .40

Estimated cost ~ ounce $360.00 SJ50.00

Total FTEs in staffinc. 26 32

Total marijuana for medical use inventory 652 980 for the year (in lbs.)

Total marijuana for medical use sold for the 621 932 year {in lbs)

Total marijuana for medical use left for roll 31 48 over (in lbs.)

Projected date the RMD plans to open: _0_112_0_12_0_17 __________ _

lnfonnatlon on this page has been reviewed by the applicant, and where provided by . cant, Is accurate and complete, as Indicated by the lnltlals of the authorized signatory here:

970,400.00

THIRD FULL FISCAL YEAR PROJECTIONS

20 19

$7.319,520.00

s s. 780,000.00

s 1,539,520 00

2990

53820

44.44%

.40

$340.00

40

1412

1345

67


Siring Profile - Page 8

Cardiac Arrhythmia Syndromes FoundaUon (CAS Foundation) Application # 2 or 3

SECTION F: CERTIFICATION OF ASSURANCE OF COMPLIANCE: ADA AND NON-DISCRIMINATION BASED ON DISABILITY

Apphconts must ccnify that they will comply with oll 5tolc and federal rcquin:mcnts n:glllding equal employmen~ opponunity. nond1scnmmot1on. and clVll nghls for persons with disobili11es. The Applicant must complete 11 Ceniftcation of Assurance of Compliance: ADA ond Non-Discrimination based on Disobility By signing. the Applicant formally noutics the Dcpanment that the Applicant is in compliance and shall moint111n compliance with all applicable n:qu1n:mcn1s.

I ccnify, 1ha1 the Applic11111 i5 in compliance and shall lllllinlain compliance with all applicable federal and Slllle law5 protecting the rights of persons with disabili11es, including bul not limited lo the Americans with Disob1h11es Acl (•ADA~). 42 U.S.C. §§ 12131· 12134, Anicle CXIV of the Mossachuscus Constllution, lllld. Chapter 93, § 103; Chapter I SIB; and Chapter 272, §§ 98 ond 98A of the Massachuselts General Laws.

I understood that federal ond state laws proh1b11 d1scnmination in publk: accommodations and employment based solely on disability I rceognii.c that to make goods, services, facil111cs. privileges, odvantoges, or accommodations readily accessible to ond usable by persons wilh disabilities, the Applicant, under the ADA, must

remove an:h11ectural and communication barriers in existing facilities, when readily achievable and, if not readily achievublc, musl use 11ltcm;i1ive methods, purchase accessible equipment or modify equipment; modify policies and practices; and furnish appropriate auxiliary aids and services when: nccCSSllry to ensure efTectsvc communication.

• I understand that reosonable accommodation is required in both program services and employment, except when: to do so would co use 1111 undue hards hi fl or burden. I also understand that lhe Massachusetts Consutution Anicle CXIV provides that no otherwise qualified individuol shall, solely by reason of d1sabili1y, be excluded from the panicipallon In, denied the benefits of, or be subject to discrimination under any program or activity within the Commonwealth.

• I agree that the Applicant shall cooperate in any compliance review ond shall provide re11SOnoblc access to the premises of all places of business and employment and to records, tiles, information, and employees therein for reviewing compliance with the ADA. the Mnssachuseus Constitution, other applicable state and federal lows, mcludmg I OS CMR 725.000, ct seq.

• I agree that any violation of the specific prov1s1ons and lcrms of this Assurance or of lhe ADA. nnd/or of any Plan of Correction shall be deemed o bn:ach ofa matcnal condition of any Ccnificote of Registration issued to the Applicant for operation of a Registen:d Marijuano Dispensary. Such a bn:ach shall be grounds for suspension or revocation. in whole or in pan, of 11 Ceniticotc of Registration issued by the Ocpanmenl

• I ogn:e that. 1f selected. I will submit a detoiled noor plan of the premises of 1he proposed dispensary in compliance with I 05 CMR 72S. I OO(m) m compllonce with the Architectural Review required pursuant to IOS CMR 72S. IOO(B)(S)(f).

Signed under the pains anil pcnalllC!S or perjury, I. the authoriud signatory ror the applicant non-profit corporation, understand the obligations or the Applicant under the Certlrscatlon or Assunince or Com lance: ADA and Non·Dbcrlmlnatlon buc:d on Dlsablllty, and •i:rcc and attC!SI lhal lhe Appllcut will comply with those

Print Nome of Authorized Signatory

CEO and President

i iiie of Auth orized Signatory

0912812016

oate S.gncT

Information on this page has been reviewed bv the applicant, and where provided bv the aDDlicant, Is accurate and complete, as Indicated bv the Initials of the authorlred signatory here:

Siting Profile - Page 9

Cardiac Antlythmla Syndromes Foundation (CAS Foundation) Application # 2 of 3

A TIESTATIONS

Signed under the pains and penalties of perjury, I, the authorized signatory for the applicant non-profit corporation, agree and attest that oil infonnation included in this application is complete and accurate and th11t I have an ongoing obligation to submit updated infonnation to the

· · · · · · as changed.

CEO and l'n:sidcnt

Title of Authorized Signatory

Print Name of Authorized Signatory

CEO and !'resident

Tille of Authorized Signatory

0912812016

Date Signed

lit corporation, hereby attest that the corporation has notified the chief administrative officer and hich the RMD would be sited, as well as the sheriff of the applicable county, of the intent to Siting Profile.

09128/2016

Date Signed

Information on this page has been re11lewed bv the applicant, and where pro11lded by.iliiliPllcant, Is accurate and complete, as Indicated by the Initials of the authorized slenatory here-

Siting Profile - Page 10

Cardiac An1lylhmia Syndromes Foundation (CAS Foundation) Application # 2 of 3

I, the authorized signatory for the applicant non-profit corporation, hereby attest that if the corporation is approved for a provisional certificate of registration, the corporation is pre ared to a a non-refundable registration fee ofS50,000, as specified in 105 CMR 725.000, after being notified

registration.

Print Name of Authorized Signatory

CEO nod President

Title of Authorized Signatory

Information on this page has been reviewed by the applicant, and where provided b Is accurate and complete, as Indicated by the Initials of the authorized signatory her

09121112016

Date Signed

Sums Profile - Pase 11

the commonwealth of massachusettsoperate a registered marijuana dispensary this opplicotion fonn is...

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