Ohio Medical Marijuana Dispensary Application CANNAVATIONS OH, LLC Application ID 834
Demographic Information(Business Contact)
A-1.1 Business Name, as it appears on the Applicant’s certificate of incorporation, charter, bylaws, partnership agreement or other legal business formation documents
Cannavations OH, LLC
A-1.2 Other trade names and DBA (doing business as) names
Cannavations
A-1.3 Business Street Address
950 Francis Place, Suite 107
A-1.4 City
St. Louis
A-1.5 State
MO
A-1.6 Zip Code
63105
A-1.7 Phone
3148813981
A-1.8 Email [email protected] Demographic Information(Primary Contact/Registered Agent)
A-2.1 Please select: Primary Contact, or Registered Agent for this Application
PRIMARY CONTACT
A-2.2 First Name
Robert
A-2.3 Middle Name
Paul
A-2.4 Last Name
Greene
A-2.5 Street Address
950 Francis Place, Suite 107
A-2.6 City
St. Louis
A-2.7 State
MO
A-2.8 Zip Code
63105
A-2.9 Phone
3148813981
A-2.10 Email [email protected] Demographic Information(Applicant Organization and Tax Status)
A-3.1 Select One
Limited Liability Company
A-3.1A If other, explain
No response provided by applicant
A-3.2 State of Incorporation or Registration
OH
A-3.3 Date of Formation
09/28/2017
A-3.4 Business Name on Formation Documents
Cannavations OH, LLC
A-3.5 Federal Employer ID number
This response has been entirely redacted
A-3.6 Ohio Unemployment Compensation Account Number
No response provided by applicant
A-3.7 Ohio Department of Taxation Number (if Applicant is currently doing business in Ohio)
No response provided by applicant
A-3.8 Ohio Workers’ Compensation Policy Number (if Applicant is currently doing business in Ohio)
No response provided by applicant
A-3.9 The Applicant attests that workers’ compensation insurance will be obtained by the time the State of Ohio Board of Pharmacy determines the Applicant to be operational under the Act and regulations.
YES
A-3.10 Has the Applicant operated and conducted business in any jurisdiction other than Ohio in the past three years? If you select "Yes", answer question A-3.10.1 below.
NO
A-3.10.1 If "Yes" to question A-3.10, for each instance relevant to question A-3.10, provide the following: -Legal Business Name -Business Address -Federal Employee ID Number No response provided by applicant Demographic Information(Economically Disadvantaged Business)
A-4.1 The Applicant attests that at least fifty-one percent of the business, including corporate stock if a corporation, is owned by persons who belong to one or more of the groups set forth in this division, and that those owners have control over the management and day-to-day operations of the business and an interest in the capital, assets, and profits and losses of the business proportionate to their percentage of ownership. ORC 3796.10
NO Demographic Information(District Information )
A-5.1 Please select to indicate the medical marijuana dispensary Ohio district for which you are applying for a dispensary license
NORTHEAST-5
A-5.2 Please select to indicate the medical marijuana dispensary Ohio county for which you are applying for a dispensary license
Lake Demographic Information(Prospective Associated Key Employees Details)
Item 1 of 10
A-6.1 First Name
Brian
A-6.2 Middle Name
Christopher
A-6.3 Last Name
Fox
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Business Executive
A-6.6 Title in the Applicant’s business
CEO/Owner
A-6.7 Applicant's business related compensation
Equity
A-6.8 Number of shares owned
43
A-6.9 Types of shares owned
LLC Membership Interests
A-6.10 Percent interest in Applicant's business
43
A-6.11 Voting percentage
43
A-6.12 Proposed Role
OWNER
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Medical Marijuana and General Business Startup, Operations, and Management Expertise A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
11929 Clayton Road
A-6.17 City
Saint Louis
A-6.18 State
MO
A-6.19 Zip Code
63131
A-6.20 Phone
3147052982
A-6.21 Email [email protected]
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
This response has been entirely redacted Demographic Information(Prospective Associated Key Employees Details)
Item 2 of 10
A-6.1 First Name
Robert
A-6.2 Middle Name
Paul
A-6.3 Last Name
Greene
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Business Executive
A-6.6 Title in the Applicant’s business
COO/Owner
A-6.7 Applicant's business related compensation
Equity
A-6.8 Number of shares owned
43
A-6.9 Types of shares owned
LLC Membership Interests
A-6.10 Percent interest in Applicant's business
43
A-6.11 Voting percentage
43
A-6.12 Proposed Role
OWNER
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Medical Marijuana and General Business Startup, Operations, and Management Expertise A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
2180 White Lane Drive
A-6.17 City
Chesterfield
A-6.18 State
MO
A-6.19 Zip Code
63017
A-6.20 Phone
3148813991
A-6.21 Email [email protected]
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
This response has been entirely redacted Demographic Information(Prospective Associated Key Employees Details)
Item 3 of 10
A-6.1 First Name
John
A-6.2 Middle Name
Alexander
A-6.3 Last Name
Dix
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Pharmacist
A-6.6 Title in the Applicant’s business
Chief Pharmacy Officer
A-6.7 Applicant's business related compensation
$100,000 annually
A-6.8 Number of shares owned
N/A
A-6.9 Types of shares owned
N/A
A-6.10 Percent interest in Applicant's business
N/A
A-6.11 Voting percentage
N/A
A-6.12 Proposed Role
OFFICER
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Pharmacy and Medical Marijuana Programs Expertise A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
2505 E. 124 St
A-6.17 City
Cleveland
A-6.18 State
OH
A-6.19 Zip Code
44120
A-6.20 Phone
4407850640
A-6.21 Email [email protected]
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
31
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
No response provided by applicant Demographic Information(Prospective Associated Key Employees Details)
Item 4 of 10
A-6.1 First Name
Stephanie
A-6.2 Middle Name
Joy
A-6.3 Last Name
Zouglas
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Accountant
A-6.6 Title in the Applicant’s business
CFO
A-6.7 Applicant's business related compensation
0 (Applicant will be compensated from monthly SG&A expenses to parent company)
A-6.8 Number of shares owned
N/A
A-6.9 Types of shares owned
N/A
A-6.10 Percent interest in Applicant's business
N/A
A-6.11 Voting percentage
N/A
A-6.12 Proposed Role
OFFICER
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Financial Management and Accounting Expertise A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
6575 Tholozan
A-6.17 City
Saint Louis
A-6.18 State
MO
A-6.19 Zip Code
63109
A-6.20 Phone
3146014657
A-6.21 Email [email protected]
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
No response provided by applicant Demographic Information(Prospective Associated Key Employees Details)
Item 5 of 10
A-6.1 First Name
James
A-6.2 Middle Name
No response provided by applicant
A-6.3 Last Name
Manchisi
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Consultant
A-6.6 Title in the Applicant’s business
Business Advisor/Investor
A-6.7 Applicant's business related compensation
Equity
A-6.8 Number of shares owned
5
A-6.9 Types of shares owned
LLC Membership Interests
A-6.10 Percent interest in Applicant's business
5
A-6.11 Voting percentage
5
A-6.12 Proposed Role
PERSON WITH FINANCIAL INTEREST
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Money ($3.7mil) , Business Operations and Oversight Expertise A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
15 Winding Ridge Way
A-6.17 City
Danbury
A-6.18 State
CT
A-6.19 Zip Code
06810
A-6.20 Phone
7036777389
A-6.21 Email [email protected]
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
No response provided by applicant Demographic Information(Prospective Associated Key Employees Details)
Item 6 of 10
A-6.1 First Name
Dustin
A-6.2 Middle Name
Ross
A-6.3 Last Name
Sulak
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Osteopathic Physician
A-6.6 Title in the Applicant’s business
Medical Advisor
A-6.7 Applicant's business related compensation
Equity
A-6.8 Number of shares owned
3
A-6.9 Types of shares owned
LLC Membership Interests
A-6.10 Percent interest in Applicant's business
3
A-6.11 Voting percentage
3
A-6.12 Proposed Role
OTHER
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Medical Marijuana Research and Application Expertise A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
24 Beaver Woods Drive
A-6.17 City
Durham
A-6.18 State
ME
A-6.19 Zip Code
04222
A-6.20 Phone
2073133339
A-6.21 Email [email protected]
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
No response provided by applicant Demographic Information(Prospective Associated Key Employees Details)
Item 7 of 10
A-6.1 First Name
Scott
A-6.2 Middle Name
B
A-6.3 Last Name
Gleason
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Police Lieutenant (Retired)
A-6.6 Title in the Applicant’s business
Security Advisor
A-6.7 Applicant's business related compensation
Equity
A-6.8 Number of shares owned
2
A-6.9 Types of shares owned
LLC Membership Interests
A-6.10 Percent interest in Applicant's business
2
A-6.11 Voting percentage
2
A-6.12 Proposed Role
OTHER
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Expertise in Ensuring Security of Medical Marijuana and other Operations A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
PO Box 8
A-6.17 City
Fletcher
A-6.18 State
MO
A-6.19 Zip Code
63030
A-6.20 Phone
3145805626
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
No response provided by applicant Demographic Information(Prospective Associated Key Employees Details)
Item 8 of 10
A-6.1 First Name
Thomas
A-6.2 Middle Name
Winston
A-6.3 Last Name
Mundell
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Commander/Retired Miltary
A-6.6 Title in the Applicant’s business
Veteran's Initiatives Advisor
A-6.7 Applicant's business related compensation
Equity
A-6.8 Number of shares owned
1
A-6.9 Types of shares owned
LLC Membership Interests
A-6.10 Percent interest in Applicant's business
1
A-6.11 Voting percentage
1
A-6.12 Proposed Role
OTHER
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Expertise in Developing and Implementing Veteran-specific Programming in Medical Marijuana Space A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
12587 Gist Road
A-6.17 City
Bridgeton
A-6.18 State
MO
A-6.19 Zip Code
63044
A-6.20 Phone
3146161613
A-6.21 Email [email protected]
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
No response provided by applicant Demographic Information(Prospective Associated Key Employees Details)
Item 9 of 10
A-6.1 First Name
Wendy
A-6.2 Middle Name
Yanire
A-6.3 Last Name
Greene
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
No response provided by applicant
A-6.6 Title in the Applicant’s business
Owner (shared interest with Robert Greene in a marital entity)
A-6.7 Applicant's business related compensation
Equity
A-6.8 Number of shares owned
43
A-6.9 Types of shares owned
LLC Membership Interests
A-6.10 Percent interest in Applicant's business
43
A-6.11 Voting percentage
0
A-6.12 Proposed Role
OWNER
A-6.13 Please include any contributions of money, equipment, real estate and expertise
No response provided by applicant A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
2180 White Lane Drive
A-6.17 City
Chesterfield
A-6.18 State
MO
A-6.19 Zip Code
63017
A-6.20 Phone
6362202304
A-6.21 Email
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
This response has been entirely redacted Demographic Information(Prospective Associated Key Employees Details)
Item 10 of 10
A-6.1 First Name
Michael
A-6.2 Middle Name
John
A-6.3 Last Name
Duggan
A-6.4 Suffix
No response provided by applicant
A-6.5 Occupation
Retired
A-6.6 Title in the Applicant’s business
Investor
A-6.7 Applicant's business related compensation
Equity
A-6.8 Number of shares owned
3
A-6.9 Types of shares owned
LLC Membership Interests
A-6.10 Percent interest in Applicant's business
3
A-6.11 Voting percentage
3
A-6.12 Proposed Role
PERSON WITH FINANCIAL INTEREST
A-6.13 Please include any contributions of money, equipment, real estate and expertise
Money ($4.5 mil) A-6.14 Date of birth
This response has been entirely redacted
A-6.15 Social Security Number (use "N/A" if unavailable)
This response has been entirely redacted
A-6.16 Street Address
7442 Martinique Terrace
A-6.17 City
Naples
A-6.18 State
FL
A-6.19 Zip Code
34113
A-6.20 Phone
3144224341
A-6.21 Email [email protected]
A-6.22 Race/Ethnicity: (Only answer if applying as an Economically Disadvantaged Business)
No response provided by applicant
A-6.23 If the Prospective Associated Key Employee maintains an Ohio residence, please provide the length of time for which Ohio residency has been established:
N/A
A-6.24 Attach verification of identity. The following are acceptable forms of verification of identity: -Unexpired, valid state-issued driver's license. -Unexpired, valid photographic identification issued by the Ohio Bureau of Motor Vehicles or the equivalent from another state. -Unexpired, valid United States passport.
This response has been entirely redacted
A-6.25 Tax Authorization: Each Prospective Associated Key Employee with an aggregate ownership interest of ten percent or more in the Applicant, must print, manually sign and attach a copy of the Tax Authorization Form. The State Board of Pharmacy may, in its discretion, require an owner or person who exercises substantial control over a proposed dispensary, but who has less than a ten percent ownership interest, to comply with statutory and regulatory ownership requirements. ORC 3796.10, OAC 3796:6-2-02
No response provided by applicant Compliance(Compliance with Applicable Laws and Regulations)
B-1.1 By selecting “Yes”, the Applicant, as well as all individually identified Prospective Associated Key Employees listed in this provisional license application, agree to comply with all applicable Ohio laws and regulations relating to the operation of a medical marijuana dispensary.
YES
B-1.2 By selecting “Yes”, the Applicant understands and attests that it must establish and maintain an escrow account or surety bond in the amount of $50,000 as a condition precedent to receiving a medical marijuana certificate of operation. OAC 3796:6-2-11
YES Compliance(Civil and Administrative Action)
B-2.1 Has the Applicant been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties or fines being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-2.2 Has the Applicant been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-2.3 Has criminal, civil, or administrative action been taken against the Applicant for obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-2.4 Has criminal, civil or administrative action been taken against the Applicant under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to any of the Applicant's Prospective Associated Key Employees' profession or occupation?
NO
B-2.4.1 If "Yes" to any question in B-2, provide the following: Respondent / Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and the Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant Compliance(Prospective Associated Key Employee Compliance)
Item 1 of 10
B-3.1 First Name
Brian
B-3.2 Middle Name
Christopher
B-3.3 Last Name
Fox
B-3.4 Proposed Role
OWNER
B-3.5 Position/Title
CEO/Owner
B-3.6 Brief description of role
Oversight of Cannavations OH Operations, Site Control, Management, Dispensary Buildout
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
YES
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
FGM Processing, LLC, 4781 Crain Hwy, Suite B, White Plains, MD 20695; Cannavations MD, LLC, 9 Cranbrook Road, Cockeysville, MD 21030; Mayfield Holdings, LLC, 608 Death Valley Jct., Death Valley, CA 92328; Terra Herbal Health, LLC, 8195 Express Dr., Marion, IL 62959
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
YES
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
FGM Processing, LLC, 4781 Crain Hwy, Suite B, White Plains, MD 20695; Cannavations MD, LLC, 9 Cranbrook Road, Cockeysville, MD 21030; Mayfield Holdings, LLC, 608 Death Valley Jct., Death Valley, CA 92328; Terra Herbal Health, LLC, 8195 Express Dr., Marion, IL 62959
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation?
NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 2 of 10
B-3.1 First Name
Robert
B-3.2 Middle Name
Paul
B-3.3 Last Name
Greene
B-3.4 Proposed Role
OWNER
B-3.5 Position/Title
COO/Owner
B-3.6 Brief description of role
Will oversee operations of Cannavations OH
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
YES
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
FGM Processing, LLC 4781 Crain Hwy, Suite B, White Plains, MD 20695; Cannavations MD, LLC, 9 Cranbrook Road, Cockeysville, MD 21030; Mayfield Holdings, LLC., 608 Death Valley Jct., Death Valley, CA 92328; Terra Herbal Health, LLC., 8195 Express Dr., Marion, IL. 62959
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
YES
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
FGM Processing, LLC 4781 Crain Hwy, Suite B, White Plains, MD 20695; Cannavations MD, LLC, 9 Cranbrook Road, Cockeysville, MD 21030; Mayfield Holdings, LLC., 608 Death Valley Jct., Death Valley, CA 92328; Terra Herbal Health, LLC., 8195 Express Dr., Marion, IL. 62959
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation?
NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 3 of 10
B-3.1 First Name
John
B-3.2 Middle Name
Alexander
B-3.3 Last Name
Dix
B-3.4 Proposed Role
OFFICER
B-3.5 Position/Title
Chief Pharmacy Officer
B-3.6 Brief description of role
Develop and implement patient care trainings at Cannavations' Ohio-based dispensaries
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
NO
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
No response provided by applicant
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
NO
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
No response provided by applicant
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation? NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 4 of 10
B-3.1 First Name
Stephanie
B-3.2 Middle Name
Joy
B-3.3 Last Name
Zouglas
B-3.4 Proposed Role
OFFICER
B-3.5 Position/Title
CFO
B-3.6 Brief description of role
Oversee financial management and record keeping
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
NO
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
No response provided by applicant
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
NO
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
No response provided by applicant
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation? NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 5 of 10
B-3.1 First Name
Dustin
B-3.2 Middle Name
Ross
B-3.3 Last Name
Sulak
B-3.4 Proposed Role
OTHER
B-3.5 Position/Title
Medical Advisor
B-3.6 Brief description of role
Provide Cannavations OH with years of Medical Cannabis expertise. Educate medical providers and patients on its clinical use, and work closely with Cannavations OH Pharmacist to ensure high quality care to patients.
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
NO
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
No response provided by applicant
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
YES
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
Healer, LLC 170 US Route 1, Suite ‘A’ 200, Falmouth, ME 04105
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction. NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation?
NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 6 of 10
B-3.1 First Name
Scott
B-3.2 Middle Name
B
B-3.3 Last Name
Gleason
B-3.4 Proposed Role
OTHER
B-3.5 Position/Title
Security Advisor
B-3.6 Brief description of role
Consult and advise on all matters related to security/diversion and serve as liaison between contracted local security companies and local law enforcement.
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
NO
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
No response provided by applicant
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
NO
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
No response provided by applicant
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation? NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 7 of 10
B-3.1 First Name
Thomas
B-3.2 Middle Name
Winston
B-3.3 Last Name
Mundell
B-3.4 Proposed Role
OTHER
B-3.5 Position/Title
Veterans' Initiatives Advisor
B-3.6 Brief description of role
To provide Cannavations OH with community outreach for the Veteran Community, leveraging past experience working with leaders across the country.
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
NO
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
No response provided by applicant
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
NO
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
No response provided by applicant
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation? NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 8 of 10
B-3.1 First Name
Wendy
B-3.2 Middle Name
Yanire
B-3.3 Last Name
Greene
B-3.4 Proposed Role
OWNER
B-3.5 Position/Title
Owner
B-3.6 Brief description of role
Shared interest with Robert Greene in a marital entity
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
YES
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
FGM Processing, LLC., 950 Francis Place, Clayton, MO 63105. Cannavations MD, LLC., 950 Francis Place, Clayton, MO 63105
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
YES
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
FGM Processing, LLC., 950 Francis Place, Clayton, MO 63105. Cannavations MD, LLC., 950 Francis Place, Clayton, MO 63105
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation?
NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 9 of 10
B-3.1 First Name
Michael
B-3.2 Middle Name
John
B-3.3 Last Name
Duggan
B-3.4 Proposed Role
PERSON WITH FINANCIAL INTEREST
B-3.5 Position/Title
Investor
B-3.6 Brief description of role
Financially support Cannavations OH
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
NO
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
No response provided by applicant
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
NO
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
No response provided by applicant
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant
B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation? NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Compliance(Prospective Associated Key Employee Compliance)
Item 10 of 10
B-3.1 First Name
James
B-3.2 Middle Name
No response provided by applicant
B-3.3 Last Name
Manchisi
B-3.4 Proposed Role
PERSON WITH FINANCIAL INTEREST
B-3.5 Position/Title
Business Advisor/Investor
B-3.6 Brief description of role
Review business and make recommendations for improvement
B-3.7 Has this individual served, or are they currently serving as an owner, officer, or board member of another medical marijuana entity in Ohio or the United States?
YES
B-3.7.1 If "Yes" to B-3.7, please provide the entity Name and Address.
FGM Processing, LLC 4781 Crain Hwy, Suite B, White Plains, MD 20695
Cannavations MD, LLC, 9 Cranbrook Road, Cockeysville, MD 21030
B-3.8 Has this individual had ownership or financial interest, or do they currently have ownership or financial interest of another medical marijuana entity in Ohio or the United States?
YES
B-3.8.1 If "Yes" to B-3.8, please provide the entity Name and Address.
FGM Processing, LLC 4781 Crain Hwy, Suite B, White Plains, MD 20695
Cannavations MD, LLC, 9 Cranbrook Road, Cockeysville, MD 21030
B-3.9 Has this individual ever been convicted of, or are charges pending for, a disqualifying offense? Include instances in which a court granted intervention in lieu of treatment (also known as treatment in lieu of conviction, ILC, or TLC), or other diversion programs. Offenses must be reported regardless of whether the case has been sealed, as described in section 2953.32 of the Revised Code, or the equivalent thereof in another jurisdiction.
NO
B-3.9.1 If "Yes" to B-3.9, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.10 Has the individual ever been convicted of, or are charges pending for, any other felony offense under state or federal law?
NO
B-3.10.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.11 Has the individual ever been convicted of, or are charges pending for, a crime (felony or misdemeanor) involving an act of moral turpitude?
NO
B-3.11.1 If "Yes", please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.12 Has this individual ever been disciplined by the State of Ohio Board of Pharmacy or any other licensing body.
NO
B-3.12.1 If "Yes", please provide the following: Name, Name and Address of Licensing Board, License Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved
No response provided by applicant
B-3.13 Has the individual ever been denied a license by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction, or is such action pending?
NO
B-3.13.1 If "Yes" to B-3.13, the reason for doing so must be provided below.
No response provided by applicant
B-3.14 Has the individual ever been the subject of an investigation or disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state or jurisdiction that resulted in the surrender, suspension, revocation, or probation of the individual's license or registration?
NO
B-3.14.1 If "Yes" to B-3.14, the reason for doing so must be provided below.
No response provided by applicant
B-3.15 Has the individual ever been the subject of a disciplinary action by the Drug Enforcement Administration or appropriate issuing body of any state jurisdiction that was based in whole or in part, on the Applicant's prescribing, dispensing, diverting, administering, storing, personally furnishing, compounding, supplying, or selling a controlled substance or other dangerous drug (i.e. prescription drug), or is any such action pending?
NO
B-3.15.1 If "Yes" to B-3.15, the reason for doing so must be provided below.
No response provided by applicant
B-3.16 By selecting "Yes", this individual agrees to be enrolled in the Retained Applicant Fingerprint Database (Rapback) should the Applicant be awarded a provisional license.
YES
B-3.17 Has the individual been the subject of an action resulting in sanctions, disciplinary actions or civil monetary penalties being imposed relating to a registration, license, provisional license or any other authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.17.1 If "Yes" to B-3.17, the reason for doing so must be provided below.
No response provided by applicant
B-3.18 Has the individual been the subject of a civil or administrative action relating to a registration, license, provisional license or authorization to cultivate, process, or dispense medical marijuana in any state?
NO
B-3.18.1 If "Yes" to B-3.18, the reason for doing so must be provided below.
No response provided by applicant
B-3.19 Has the individual been accused of obtaining a registration, license, provisional license or other authorization to operate as a cultivator, processor, or dispensary of medical marijuana in any jurisdiction by fraud, misrepresentation, or the submission of false information?
NO
B-3.19.1 If "Yes" to B-3.19, the reason for doing so must be provided below.
No response provided by applicant B-3.20 Has civil or administrative action been taken against the individual under the laws of Ohio or any other state, the United States or a military, territorial or tribal authority, relating to the individual's profession or occupation?
NO
B-3.20.1 If "Yes" to B-3.20, please provide the following: Defendant, Name of Case and Docket Number, Nature of Charge or Complaint, Date of Charge or Complaint, Disposition, Name and Address of the Administrative Agency Involved, and Jurisdictional Court (Specify Federal, State and/or Local Jurisdictions)
No response provided by applicant
B-3.21 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees are a physician who has a certificate to recommend medical marijuana or who has applied for a certificate to recommend medical marijuana under section 4731.30 of the Revised Code.
YES
B-3.22 By selecting “Yes”, you attest to the following statement: None of the Applicant's Prospective Associated Key Employees have ownership, investment interest, or a compensation arrangement with a laboratory licensed under Chapter 3796 of the Revised Code or an Applicant for a license to conduct laboratory testing.
YES Business Plan(Property Title, Lease, or Option to Acquire Property Location)
C-1.1 Attach one of the following: -Evidence of the Applicant’s clear legal title to or option to purchase the proposed site and facility. -A fully-executed copy of the Applicant’s unexpired lease for the proposed site and facility and a written statement from the property owner that the Applicant may operate a medical marijuana organization on the proposed site for, at a minimum, the term of the initial provisional license. -Other evidence that shows that the Applicant has a location to operate its medical marijuana organization.
Uploaded Document Name: C-1.1_Wickliffe Purchase Agreement.pdf NOTE: This applicant uploaded document is the next 9 page(s) of this document.
C-1.2 Business Name, as it appears on the Applicant’s certificate of incorporation, charter, bylaws, partnership agreement or other official documents.
Cannavations OH, LLC
C-1.3 Trade names and DBA (doing business as) names
Cannavations
C-1.4 Business Address
29017 Euclid Ave
C-1.5 City
Wickliffe
C-1.6 State
OH
C-1.7 Zip Code
44092
C-1.8 Phone
3148813981
C-1.9 Email [email protected] Business Plan(Site and Facility Plan)
C-2.1 Applicants must show that they can expeditiously use a site and facility to meet the activities described in the provisional license by attaching one of the following: -If the facility is in existence at the time that the provisional license application is submitted, submit plans and specifications drawn to scale for the interior of the facility. -If the facility is in existence at the time that the provisional license application is submitted, and the Applicant plans to make alterations to the facility, submit renovation plans and specifications for the interior and exterior of the facility. -If the facility does not exist at the time that the provisional license application is submitted, submit a plot plan that shows the proposed location of the facility and an architectural drawing of the facility, including a detailed drawing, to scale, of the interior of the facility.
Uploaded Document Name: C-2.1_Wickliffe Renovation Plans and Specifications.pdf NOTE: This applicant uploaded document is the next 2 page(s) of this document.
C-2.2 The Applicant also must submit evidence that it is in compliance with any local ordinances, rules, or regulations adopted by the locality in which the Applicant's property is located, which are in effect at the time of the application. Include copies of any required local registration, license or permit. If no relevant zoning restrictions have been enacted, provide a professionally prepared survey which demonstrates that the Applicant is not in violation of restrictions pertaining to prohibited facilities and is not located within 500 feet of a community addiction services provider as defined under section 5119.01 of the Revised Code. OAC 3796:5-5-01
Uploaded Document Name: C-2.2_Wickliffe Zoning Form.pdf NOTE: This applicant uploaded document is the next 2 page(s) of this document.
C-2.3 Provide a location map of the area surrounding the proposed facility that establishes the facility is at least 500 feet from a prohibited facility or a community addiction services provider as defined under section 5119.01 of the Revised Code. In establishing the distance between a proposed dispensary and such a facility, the distance shall be measured linearly and shall be the shortest distance between the closest point of the property lines of the proposed dispensary and the prohibited facility or community addiction services provider. The map must be clearly legible and labeled and may be divided into 8.5*11 inch sections. OAC 3796:5-5-01
Uploaded Document Name: C-2.3_Wickliffe Local Area Map.pdf NOTE: This applicant uploaded document is the next 2 page(s) of this document.
Business Plan(Business Startup Plan)
C-3.1 A business startup plan is required for all dispensary provisional license applications. The business startup plan must provide a comprehensive set of activities necessary for the startup of the facility within six months of receiving a provisional license. Provide a timeline describing the process, methods, or steps used to execute a compliant business startup plan that includes, at a minimum: 1. Security and surveillance 2. Employee qualifications and training 3. Storage of medical marijuana products 4. Inventory management 5. Record-keeping
C-3.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in C-3.1. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
Uploaded Document Name: C-3.1.1_Pro Forma.pdf NOTE: This applicant uploaded document is the next 5 page(s) of this document.
Projected Income Statement Q1 Q2 Q3 Q4 Five year sales projections Assuming No Revenue Y1
Revenue from Assumptions Tab Y1 TOTALS Total Sales $ - $ - $ - $ - $ - Cost of Goods Sold cost per lb. $ 1,800 Dry Flower $ - $ - $ - $ - $ - Manufactured Cannabis Products $ - $ - $ - $ - $ - 3% Card Processing Fees $ - $ - $ - $ - $ - Total Cost of Goods Sold $ - $ - $ - $ - $ -
Total Gross Margin $ - $ - $ - $ - $ - profit margin ratio
State and Local Sales Tax (9.75%) $ - $ - $ - $ - $ - Total Net Revenues $ - $ - $ - $ - $ -
Overhead Expenses
Rent/Mortgage $ - $ - $ - $ - $ - Building purchased outright SG&A $ 8,000 $ 8,000 $ 8, 000 $ 8,000 $ 32,000 Includes parent co CFO and backoffice fees and in-house legal Manager and Staff Payroll $ 30,000 $ 30,000 $ 30,000 $ 30, 000 $ 120,000 Reduced staffing if no revenue Benefits, payroll processing & tax $ 10,500 $ 10,500 $ 10,500 $ 10, 500 $ 42,000 35.0% of payroll (scales with payroll) Staff and Advisor Travel $ 5,000 $ 5,000 $ 5, 000 $ 5,000 $ 20,000 Security guard (2) $ 8,000 $ 8,000 $ 8, 000 $ 8,000 $ 32,000 Contracted third-party security guard Security monitoring & maintenance $ 3,000 $ 3,000 $ 3, 000 $ 3,000 $ 12,000 $1,000/mo Inventory control software $ 3,000 $ 3,000 $ 3, 000 $ 3,000 $ 12,000 $1000/mo, increasing 5% per year Marketing & Advertising $ - $ - $ - $ - $ - 2.0% Gross sales Office expenses $ 1,500 $ 1,500 $ 1, 500 $ 1,500 $ 6, 000 Equipment $ 1,500 $ 1,500 $ 1, 500 $ 1,500 $ 6, 000 Estimates for display changes/cases/etc. Repairs and maintenance $ 1,000 $ 1,000 $ 1, 000 $ 1,000 $ 12,000 Janitorial $ 2,000 $ 2,000 $ 2, 000 $ 2,000 $ 8, 000 Evening Janitorial Utilities & phone $ 900 $ 900 $ 900 $ 900 $ 3, 600 Business insurance (2% gross sales) $ - $ - $ - $ - $ - 2.0% Gross sales Industry memberships $ 1,500 $ 1,500 $ 1, 500 $ 1,500 $ 6, 000 Cannabis, veterans, wellness associations Professional services $ 2,000 $ 2,000 $ 2, 000 $ 2,000 $ 8, 000 Total Overhead Expenses $ 77,900 $ 77,900 $ 77,900 $ 77, 900 $319,600
Operating Income (EBITDA) $ (77,900) $ (77,900) $ ( 77,900) $ (77,900) $319,600 30% Provision for Federal Taxes $ - Net Profit $ (77,900) $ (77,900) $ ( 77,900) $ (77,900) $319,600
Total Startup Expenses $ 1,235,000.00 Total Y1 Expenses (no revenue) $319,600 TOTAL STARTUP & Y1 EXPENSES $ 1,554,600 Projected Income Statement: Q1 Q2 Q3 Q4
Revenue from Assumptions Tab Y1 TOTALS Notes and Total Sales $ 1,047,600 $ 1,396,800 $ 2,095,200 $ 2,444,400 $ 6,984,000 Cost of Goods Sold cost per lb. $ 6,306 $ 1,800 Dry Flower $ 449,130 $ 598,840 $ 898,259 $ 1,047,969 $ 2,994,198 71% Manufactured Cannabis Products $ 209,520 $ 279,360 $ 419,040 $ 488,880 $ 1,396,800 50% 3% Card Processing Fees $ 25,059 $ 33,411 $ 50,117 $ 58,470 $ 167,057.28 80% Total Cost of Goods Sold $ 683,708 $ 911,611 $ 1,367,416 $ 1,595,319 $ 4,558,055
Total Gross Margin $ 363,892 $ 485,189 $ 727,784 $ 849,081 $ 2,425,945 profit margin ratio 35% 35% 35% 35% 35%
State and Local Sales Tax (9.75%) $ (35,479) $ (47,306) $ (70,959) $ (82,785) $ (236,530) 9.75% Total Net Revenues $ 328,412 $ 437,883 $ 656,825 $ 766,295 $ 2,189,415
Overhead Expenses
Rent/Mortgage $ - $ - $ - $ - $ - SG&A $ 12,000 $ 12,000 $ 12,000 $ 12, 000 $ 36,000 Manager and Staff Payroll $ 111,250 $ 111,250 $ 111,250 $ 111,250 $ 445,000 Benefits, payroll processing & tax $ 38,938 $ 38,938 $ 38,938 $ 38, 938 $ 155,750 35.0% Staff and Advisor Travel $ 5,000 $ 5,000 $ 5, 000 $ 5,000 $ 20,000 Security guard (2) $ 20,000 $ 20,000 $ 20,000 $ 20, 000 $ 80,000 Security monitoring & maintenance $ 3,000 $ 3,000 $ 3, 000 $ 3,000 $ 12,000 Inventory control software $ 3,000 $ 3,000 $ 3, 000 $ 3,000 $ 12,000 Marketing & Advertising $ 20,952 $ 27,936 $ 41,904 $ 48, 888 $ 139,680 2.0% Office expenses $ 1,500 $ 1,500 $ 1, 500 $ 1,500 $ 6, 000 Equipment $ 1,500 $ 1,500 $ 1, 500 $ 1,500 $ 6, 000 Repairs and maintenance $ 3,000 $ 3,000 $ 3, 000 $ 3,000 $ 12,000 Janitorial $ 5,000 $ 5,000 $ 5, 000 $ 5,000 $ 20,000 Utilities & phone $ 900 $ 900 $ 900 $ 900 $ 3, 600 Business insurance (2% gross sales) $ 20,952 $ 27,936 $ 41,904 $ 48, 888 $ 48,519 2.0% Industry memberships $ 1,500 $ 1,500 $ 1, 500 $ 1,500 $ 6, 000 Professional services $ 5,000 $ 5,000 $ 5, 000 $ 5,000 $ 20,000 Total Overhead Expenses $ 253,492 $ 267,460 $ 295,396 $ 309,364 $1,022,549
Operating Income (EBITDA) $ 74,921 $ 170,424 $ 361,429 $ 456,932 $1,403,396 30% Provision for Federal Taxes $ (22,476) $ (51,127) $ (108,429) $ (137,080) -$ 727,784 Net Profit $ 52,445 $ 119,297 $ 253,000 $ 319,852 $675,613
Headcount & Salaries Start Beg. Sal. Beg. Sal. Year Headcount Levels, summary Month Annual Monthly 1 Chief Pharmacy Officer (.20 FTE - split w/ up to 4 other locations) Year 1 Month 1 $20,000 $ 1,667 20,000
General Manager Year 1 Month 1 $70,000 $ 5,833 70,000
Assistant General Manager Year 1 Month 1 $60,000 $ 5,000 60,000
Director of Security Year 1 Month 1 $60,000 $ 5,000 60,000 Total Management Salary ($000) 210,000
Receptionist Year 1 Month 1 $35,000 $2,917 35,000 Receptionist Year 1 Month 1 $35,000 $2,917 35,000 Patient Care Technician Year 1 Month 1 $40,000 $3,333 40,000 Patient Care Technician Year 1 Month 1 $40,000 $3,333 40,000 Patient Care Technician Year 1 Month 1 $40,000 $3,333 40,000 Patient Care Technician Year 1 Month 1 $40,000 $3,333 40,000 Product Receipt Tech Year 1 Month 1 $40,000 $3,333 40,000 Total Staff Salary 235,000
Total Headcount Total Salaries 445,000 C-3.2 The Business Startup Plan also must describe how the Applicant’s proposed business operations will comply with statutory and regulatory requirements (as described in Chapter 3796 of the Revised Code and division 3796:6 of the Administrative Code) necessary for the startup and continued operation of the facility including, but not limited to: 1. Security and surveillance 2. Employee qualifications and training 3. Storage of medical marijuana products 4. Inventory management 5. Record-keeping 6 Prevention of medical marijuana diversion
Business Plan(Description of Employee Duties and Roles)
C-4.1 Please provide a description of the duties, responsibilities, and roles of each Prospective Associated Key Employee. Please attach a Table of Organization and Control for the business. Include all individuals listed in question A-6.
1. Brian Fox (Chief Executive Officer/Owner): As the Applicant’s CEO, Mr. Fox will supervise and control all strategic and business aspects of the facility and will leverage his experience opening and overseeing medical cannabis facilities in three other states. 2. Robert Greene (Chief Operating Officer/Owner): As the Applicant’s COO, Mr. Greene will oversee all ongoing operations and procedures. Mr. Green will oversee the facility buildout as well as conduct hiring and initial training of the General Manager and Assistant General Manager. Mr. Greene will leverage his experience opening and overseeing medical cannabis facilities in three other states. 3. J. Alexander Dix, PharmD (Chief Pharmacy Officer): As the CPO, Dr. Dix will oversee all aspects of employee training and policy development as they pertain to patient care. With input from the Medical Advisor and other highly skilled experts, Dr. Dix will have final oversight on trainings and policies to ensure all dispensary employees are equipped to provide the highest level of service to patients, that trainings reflect the latest advancements in medical marijuana research, and that the Applicant’s inventory selection is appropriate to serve the needs of local patient populations. 4. Stephanie Zouglas (Chief Financial Officer): Ms. Zouglas, a Certified Public Accountant, will oversee all ongoing operations and procedures and provide internal controls and financial management. 5. James Manchisi (Business Advisor/Investor): Mr. Manchisi will advise on various strategic and operational business decisions. As an advisor, Mr. Manchisi will not be directly involved in the Applicant’s day-to-day operations, but will utilize his decades-long experience overseeing successful large-scale teams and operations to provide input and guidance as the Applicant seeks to position itself as a top-quality, patient-focused dispensary facility. 6. Dustin Sulak, D.O. (Medical Advisor): Dr. Sulak oversees integrative medical clinics in Maine and Massachusetts and is nationally renowned for his research on the endocannabinoid system and successful treatment of over 20,000 patients at his clinics. In partnership with the Chief Pharmacy Officer, Dr. Sulak will utilize his expertise to advise and guide the development of all patient care policies and procedures. Dr. Sulak will also deliver periodic training to dispensary employees to ensure all employees are highly knowledgeable in the latest research and best practice in medical marijuana developments. 7. Scott Gleason (Security Advisor): Mr. Gleason will advise on all aspects of security-related facility protocols. Mr. Gleason’s professional experience includes extensive law enforcement experience, spanning more than 30 years, including work as a federally deputized Task Force Officer at the local Drug Enforcement Administration. Mr. Gleason is an FBI National Academy graduate and graduate of the DEA Drug Unit Commander’s Academy. Mr. Gleason also advised successful medical cannabis facility applications and openings in Maryland. 8. Thomas Mundell (Veterans’ Initiatives Advisor): As the Applicant’s VIA, Mr. Mundell, a decorated war veteran and medical marijuana advocate, will develop and oversee programs and employee training on all areas and topics related to veteran populations. Specifically, Mr. Mundell will oversee Veterans’ Initiatives Programs, which will ensure Lead Patient Care Technicians are qualified and equipped to provide consultations to veteran populations that are tailored to their specific concerns and needs. 9. Wendy Greene (Owner/Tenancy by the entirety with Robert Greene): Mrs. Greene is a co-owner of the Applicant with Robert Greene. In general, Mrs. Greene will not be involved in daily facility operations. 10. Michael Duggan (Owner/Investor): Mr. Duggan is a minority owner and investor in the Applicant. Mr. Duggan will not have direct involvement in daily facility operations. Please see C-4.2_Table of Organization and Control.pdf
C-4.2 Please attach a Table of Organization and Control for the business. Include all individuals listed in question A-6.
Uploaded Document Name: C-4.2_Table of Organization and Control.pdf NOTE: This applicant uploaded document is the next 2 page(s) of this document.
Name Ownership Title Role Description Interest Brian Fox 43% Owner/Chief Supervise and control all strategic and business Executive aspects Officer Robert 43% Owner/Chief Oversees all ongoing operations and procedures Greene Operating Officer J. Chief Pharmacy Oversees standardization of clinical pathways and Alexander Officer ensures the dispensary offers the best, most effective, Dix, and cost-efficient care possible Pharm. D Stephanie Chief Financial Oversees financial well-being of the dispensary by Zouglas Officer providing financial projections and accounting services James 5% Advisor/Investor Advise on business strategy, operations, and Manchisi management Dustin 3% Advisor/Medical Advise on patient care policies; develop materials and Sulak, Care literature for patients and dispensary staff through D.O. "Healer" organization Scott 2% Advisor/Security Advise on security policies and procedures Gleason Tom 1% Advisor/Veteran Advise and lead Veteran Programs Mundell Initiatives Wendy Owner Tenancy by the entirety with Robert Greene Greene Mike 3% Investor Investor Duggan
Business Plan(Capital Requirements)
Item 1 of 5
C-5.1 Type of Capital
Equity
C-5.2 Source of Capital
Personal Savings
C-5.3 Name and Address of financial institution
This response has been entirely redacted
C-5.4 Account Number
This response has been entirely redacted
C-5.5 Illustrate that the Applicant has adequate liquid assets to cover all expenses and costs for the first year of operation as indicated in the dispensary's proposed Business Startup Plan (Question C-3). The total amount of liquid assets must be no less than $250,000. Provide unredacted documentation from the Applicant's financial institution to support these capital requirements. (ORC 3796:6-2-02)
This response has been entirely redacted
C-5.5.1 Please attach a redacted copy of documentation from the Applicant's financial institution to support the capital requirements. (ORC 3796:6-2-02)
Uploaded Document Name: C-5.5.1_Capital Commitment Evidence_Redacted.pdf NOTE: This applicant uploaded document is the next 15 page(s) of this document.
Business Plan(Capital Requirements)
Item 2 of 5
C-5.1 Type of Capital
Equity
C-5.2 Source of Capital
Personal Savings
C-5.3 Name and Address of financial institution
This response has been entirely redacted
C-5.4 Account Number
This response has been entirely redacted
C-5.5 Illustrate that the Applicant has adequate liquid assets to cover all expenses and costs for the first year of operation as indicated in the dispensary's proposed Business Startup Plan (Question C-3). The total amount of liquid assets must be no less than $250,000. Provide unredacted documentation from the Applicant's financial institution to support these capital requirements. (ORC 3796:6-2-02)
This response has been entirely redacted
C-5.5.1 Please attach a redacted copy of documentation from the Applicant's financial institution to support the capital requirements. (ORC 3796:6-2-02)
Uploaded Document Name: C-5.5.1_Redacted Capital Commitment Evidence_1.pdf NOTE: This applicant uploaded document is the next 15 page(s) of this document.
Business Plan(Capital Requirements)
Item 3 of 5
C-5.1 Type of Capital
Equity
C-5.2 Source of Capital
Living Trust
C-5.3 Name and Address of financial institution
This response has been entirely redacted
C-5.4 Account Number
This response has been entirely redacted
C-5.5 Illustrate that the Applicant has adequate liquid assets to cover all expenses and costs for the first year of operation as indicated in the dispensary's proposed Business Startup Plan (Question C-3). The total amount of liquid assets must be no less than $250,000. Provide unredacted documentation from the Applicant's financial institution to support these capital requirements. (ORC 3796:6-2-02)
This response has been entirely redacted
C-5.5.1 Please attach a redacted copy of documentation from the Applicant's financial institution to support the capital requirements. (ORC 3796:6-2-02)
Uploaded Document Name: C-5.5.1_Redacted Capital Commitment Evidence 2.pdf NOTE: This applicant uploaded document is the next 5 page(s) of this document.
Business Plan(Capital Requirements)
Item 4 of 5
C-5.1 Type of Capital
Equity
C-5.2 Source of Capital
Personal Savings
C-5.3 Name and Address of financial institution
This response has been entirely redacted
C-5.4 Account Number
This response has been entirely redacted
C-5.5 Illustrate that the Applicant has adequate liquid assets to cover all expenses and costs for the first year of operation as indicated in the dispensary's proposed Business Startup Plan (Question C-3). The total amount of liquid assets must be no less than $250,000. Provide unredacted documentation from the Applicant's financial institution to support these capital requirements. (ORC 3796:6-2-02)
This response has been entirely redacted
C-5.5.1 Please attach a redacted copy of documentation from the Applicant's financial institution to support the capital requirements. (ORC 3796:6-2-02)
Uploaded Document Name: C-5.5.1_Redacted Capital Commitment Evidence 2.pdf NOTE: This applicant uploaded document is the next 5 page(s) of this document.
Business Plan(Capital Requirements)
Item 5 of 5
C-5.1 Type of Capital
Equity
C-5.2 Source of Capital
Individual Retirement Account
C-5.3 Name and Address of financial institution
This response has been entirely redacted
C-5.4 Account Number
This response has been entirely redacted
C-5.5 Illustrate that the Applicant has adequate liquid assets to cover all expenses and costs for the first year of operation as indicated in the dispensary's proposed Business Startup Plan (Question C-3). The total amount of liquid assets must be no less than $250,000. Provide unredacted documentation from the Applicant's financial institution to support these capital requirements. (ORC 3796:6-2-02)
This response has been entirely redacted
C-5.5.1 Please attach a redacted copy of documentation from the Applicant's financial institution to support the capital requirements. (ORC 3796:6-2-02)
Uploaded Document Name: C-5.5.1_Redacted Capital Commitment Evidence 2.pdf NOTE: This applicant uploaded document is the next 5 page(s) of this document.
Business Plan(Business History and Experience)
Item 1 of 14
C-6.1 First Name
Brian
C-6.2 Middle Name
Christopher
C-6.3 Last Name
Fox
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
Greene Fox Enterprises
C-6.6 Business Address
950 Francis Place Ste 107, Clayton, MO. 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
9/2016-present Business Plan(Business History and Experience)
Item 2 of 14
C-6.1 First Name
Brian
C-6.2 Middle Name
Christopher
C-6.3 Last Name
Fox
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
Jade Harvest LLC
C-6.6 Business Address
950 Francis Place Ste 107, Clayton, MO. 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
June 2016-present Business Plan(Business History and Experience)
Item 3 of 14
C-6.1 First Name
Brian
C-6.2 Middle Name
Christopher
C-6.3 Last Name
Fox
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
FGM Processing, LLC.
C-6.6 Business Address
950 Francis Place Ste 107, Clayton, MO. 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
10/2015-present Business Plan(Business History and Experience)
Item 4 of 14
C-6.1 First Name
Brian
C-6.2 Middle Name
Christopher
C-6.3 Last Name
Fox
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
Cannvations MD, LLC
C-6.6 Business Address
950 Francis Place Ste 107, Clayton, MO 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
9/2015-present Business Plan(Business History and Experience)
Item 5 of 14
C-6.1 First Name
Brian
C-6.2 Middle Name
Christopher
C-6.3 Last Name
Fox
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
Harbory Dispensary
C-6.6 Business Address
8195 Express Dr, Marion, IL 62959
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
6/2014-12/2016 Business Plan(Business History and Experience)
Item 6 of 14
C-6.1 First Name
Brian
C-6.2 Middle Name
Christopher
C-6.3 Last Name
Fox
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Medical Device Sales Representative
C-6.5 Business Name
Stryker Endoscopy
C-6.6 Business Address
5900 Optical Ct, San Jose, CA 95138
C-6.7 Position of management or ownership of a controlling interest
NO
C-6.8 Dates
11/2009-5/2014 Business Plan(Business History and Experience)
Item 7 of 14
C-6.1 First Name
Robert
C-6.2 Middle Name
Paul
C-6.3 Last Name
Greene
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
Greene Fox Enterprises
C-6.6 Business Address
950 Francis Place Ste 107, Clayton, MO, 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
9/2016-present Business Plan(Business History and Experience)
Item 8 of 14
C-6.1 First Name
Robert
C-6.2 Middle Name
Paul
C-6.3 Last Name
Greene
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
Jade Harvest, LLC
C-6.6 Business Address
950 Francis Place Ste 107, Clayton, MO. 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
6/2016-present Business Plan(Business History and Experience)
Item 9 of 14
C-6.1 First Name
Robert
C-6.2 Middle Name
Paul
C-6.3 Last Name
Greene
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
FGM Processing, LLC
C-6.6 Business Address
950 Francis Place Ste 107, Clayton, MO 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
10/2015-present Business Plan(Business History and Experience)
Item 10 of 14
C-6.1 First Name
Robert
C-6.2 Middle Name
Paul
C-6.3 Last Name
Greene
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
Cannavations MD, LLC
C-6.6 Business Address
950 Francis Place Ste 107, Clayton, MO 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
9/2015-present Business Plan(Business History and Experience)
Item 11 of 14
C-6.1 First Name
Robert
C-6.2 Middle Name
Paul
C-6.3 Last Name
Greene
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner
C-6.5 Business Name
Harbory Dispensary
C-6.6 Business Address
8195 Express Dr, Marion, IL 62959
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
6/2014-12/2016 Business Plan(Business History and Experience)
Item 12 of 14
C-6.1 First Name
Robert
C-6.2 Middle Name
Paul
C-6.3 Last Name
Greene
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Managing Member
C-6.5 Business Name
Dardenne Creek Partners, LLC
C-6.6 Business Address
777 Winghaven Blvd, O'Fallon, MO 63368
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
2013-2016 Business Plan(Business History and Experience)
Item 13 of 14
C-6.1 First Name
Robert
C-6.2 Middle Name
Paul
C-6.3 Last Name
Greene
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner/CFO
C-6.5 Business Name
Sciometrics LLC
C-6.6 Business Address
14150 Parkeast Circle, Ste 140, Chantilly, VA 20151
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
2012-present Business Plan(Business History and Experience)
Item 14 of 14
C-6.1 First Name
Robert
C-6.2 Middle Name
Paul
C-6.3 Last Name
Greene
C-6.4 Previous Role (e.g. Owner, Officer, Board Member, Person with Financial Interest, Person Exercising Substantial Control, Support Employee)
Owner/President
C-6.5 Business Name
Cypress Management Group, LLC
C-6.6 Business Address
950 Francis Place, Ste 107, Clayton, MO 63105
C-6.7 Position of management or ownership of a controlling interest
YES
C-6.8 Dates
2010-present Business Plan(Business History and Experience Narrative)
C-6.9 Provide a narrative description not to exceed 1500 words demonstrating any previous experience at operating other businesses or non-profit organizations and any demonstrated knowledge or expertise with regard to the medical use of marijuana to treat qualifying conditions (for all Prospective Associated Key Employees with an ownership interest of ten percent or more in the prospective dispensary). Include the number of years of experience, the type of business, and any administrative discipline history associated with each business.
The Applicant is comprised of a leadership team that has extensive experience in building and leading successful teams in a variety of business endeavors and medical marijuana enterprises.
Brian Fox is knowledgeable in the establishment of successful medical cannabis dispensaries, having won the first such license in the state of Illinois. He also understands the complexities of operating a business that serves patients in a personalized and compassionate fashion. Mr. Fox is involved with Show Me Cannabis in Missouri and is helping to advocate for cannabis reform across the state. He has testified as an expert witness on proposed medical cannabis legislation, and has met with several House and Senate members to discuss medical cannabis. He is providing his expertise and input on medical cannabis legislation currently being drafted, which is expected to be introduced in the 2016 legislative session. Fox spearheaded the application in winning the first Illinois dispensary. He also is Owner/Operator of FGM Processing in Charles County Maryland, and Cannavations MD in Cockeysville, MD. Brian is also on the operating board for a large-scale cultivation facility (45,000 SF) in Death Valley, CA. Brian co-founded Greene Fox enterprises, which has successfully raised $6.3M dollars for three businesses they currently own/operate in the Cannabis industry.
Robert Greene is also a founding member of the first licensed dispensary in the state of Illinois. He also is Owner/Operator of FGM Processing in Charles County Maryland, and Cannavations MD in Cockeysville, MD. Robert is also on the Board of Directors for a large-scale cultivation facility (45,000 SF) in Death Valley, CA. Robert co-founded Greene Fox enterprises, which has successfully raised $6.3M dollars for three businesses they currently own/operate in the Cannabis industry In 2010, Mr. Greene founded Cypress Management Group, LLC and currently serves as the President and Managing Member. He oversees the management of multi-family properties, numerous scattered site properties, and commercial spaces. Mr. Greene is responsible for raising capital, daily cash management, accounting, financial reporting duties, and oversight of all operations at the executive level, including all acquisition and disposition activities for all properties. Mr. Greene also has over 30 years of in-depth experience in the real estate industry. In 1984, Mr. joined Gannon Management Company of Florida, where he soon became President and was responsible for hiring and supervising staff to support field operations for the management of 10,250 units in Miami and Ft. Lauderdale. He was also responsible for occupancy, budgeting, and reporting requirements and oversaw a staff of approximately 200 employees. Mr. Greene was promoted to Executive Vice President of Gannon International, Ltd. in 1996, where, in addition to his real estate responsibilities, he undertook the supervision of the technology company located in Herndon, Virginia and a collection of businesses operating within the country of Vietnam. Mr. Greene holds a Bachelor of Arts degree in Accountancy from the University of Missouri, Columbia. Operations Plan(Dispensary Oversight)
D-1.1 By selecting "Yes", the Applicant attests that it will appoint a designated representative responsible for the oversight, supervision and control of operations of the medical marijuana dispensary. When there is a change in the appointed designated representative, the Applicant will notify the State Board of Pharmacy within 10 business days of appointment. OAC 3796:6-3-05
YES Operations Plan(Security and Surveillance )
D-2.1 By checking “Yes,” the Applicant attests that it is able to continuously maintain effective security, surveillance and accounting control measures to prevent diversion, abuse and other illegal conduct regarding medical marijuana and medical marijuana products.
YES
D-2.2 Please provide a summary of the Applicant's proposed security and surveillance equipment and measures that will be in place at the proposed facility and site. These measures should cover, but are not limited to, the following: 1. General overview of the equipment, measures and procedures to be used 2. Alarm systems 3. Surveillance system 4. Surveillance storage 5. Recording capability 6. Records retention 7. Premises accessibility 8. Inspection/servicing/alteration protocols Please reference OAC 3796:6-3-16 for more information.
This response has been entirely redacted
D-2.2.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in D-2.2. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
Uploaded Document Name: D-2.2.1_Security Overlays and Datasheets.pdf NOTE: This applicant uploaded document is the next 31 page(s) of this document.
D-2.3 By selecting “Yes”, the Applicant attests that the answer provided in response to Question D-2.2 is voluntarily submitted to the State Board of Pharmacy in expectation of protection from disclosure as provided by section 149.433 of the Revised Code.
YES Operations Plan(Receiving of Product)
D-3.1 By selecting "Yes", the Applicant attests that it is able to safely and securely receive medical marijuana and medical marijuana products.
YES
D-3.2 By selecting "Yes", the Applicant attests that it will implement standard operating procedures to inspect, prior to accepting any medical marijuana. Defective products must be rejected. Defective products include, but are not limited to the following: expired, damaged, deteriorated, misbranded or adulterated medical marijuana. OAC 3796:6-3-06; OAC 3796:8
YES
D-3.3 Please describe the Applicant's processes, procedures, and controls regarding the inspection of medical marijuana from cultivators and processors prior to accepting any delivery at the proposed dispensary. Include a description of the proposed space for delivery and inspection. OAC 3796:6-3-06 D-3.3.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in D-3.3. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant Operations Plan(Storage of Product)
D-4.1 There will be separate, locked, limited access areas for the storage of medical marijuana that is expired, damaged, deteriorated, mislabeled, contaminated, recalled, or whose containers or packaging have been opened or breached, until the medical marijuana is returned to a cultivator, or processor, destroyed or otherwise disposed.
YES
D-4.2 All storage areas will be maintained in a clean and orderly condition and free from infestation by insects, rodents, birds, and pests.
YES
D-4.3 A separate and secure area for temporary storage of medical marijuana that is awaiting disposal will be established.
YES
D-4.4 Please describe the Applicant's plans regarding the storage of medical marijuana within the proposed dispensary. The plan should include, but is not limited to, descriptions of the following: 1. Oversight of medical marijuana storage 2. Physical security measures 3. Record maintenance 4. Persons who will have access to medical marijuana 5. Climate control and lighting maintenance, including any necessary equipment 6. Sanitation of storage areas Please reference OAC 3796:6-3-07 for more information. D-4.4.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in D-4.4. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant Operations Plan(Dispensing of Product)
D-5.1 By selecting "Yes", the Applicant attests that it is prepared and willing to join the American Society for Automation in Pharmacy (ASAP) annually in order to facilitate near-real-time reporting to the Ohio Automated Rx Reporting System (OARRS). American Society for Automation in Pharmacy; OAC 3796:6-3-08; OAC 3796:6-3-10
YES
D-5.2 By selecting "Yes", the Applicant attests that it will use the patient registry to verify the registration of a patient or caregiver. OAC 3796:6-3-08
YES
D-5.3 Please indicate the expected number of Patient Registry scanners needed for the Applicant's facility (Information Only).
7
D-5.4 By selecting "Yes", the Applicant attests that it will have at least two employees physically present at the dispensary location, one of whom is a dispensary key employee, when the dispensary is open for the sale of medical marijuana. OAC 3796:6-3-03
YES
D-5.5 Please describe the Applicant's processes, procedures, and controls regarding the dispensing of medical marijuana, updating the patient record, and product labeling. Describe how these will be supported by the Applicant's internal inventory system including integration with the state inventory tracking system and for reporting to OARRS using the current ASAP format. Please attach a sample product label, with any identifiable information redacted or anonymized. OAC 3796:6-3-08; OAC 3796:6-3-09; OAC 3796:6-3-10
D-5.5.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in D-5.5. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
Uploaded Document Name: D-5.5.1_Sample Product Labels.pdf NOTE: This applicant uploaded document is the next 5 page(s) of this document.
Operations Plan(Inventory Management of Product)
D-6.1 By selecting "Yes" the Applicant attests that it will establish inventory controls and procedures for the conducting of weekly inventory reviews and annual comprehensive inventories of medical marijuana at the facility. OAC 3796:6-3-20
YES
D-6.2 By selecting "Yes" the Applicant attests that its written or electronic weekly and annual inventory records described in D-6.1 will include: 1. The date of the inventory 2. A summary of the inventory findings 3. The employee identification numbers, and titles or positions, of the individuals who conducted the inventory Please reference OAC 3796:6-3-20 for more information.
YES
D-6.3 By selecting "Yes", the Applicant attests that it will use the state inventory tracking system. ORC 3796.07; OAC 3796:1-1-01; OAC 3796:6-3-06
YES
D-6.4 By selecting "Yes" the Applicant attests that it will maintain records of medical marijuana received from a cultivator or processor in its internal inventory control system. OAC 3796:6-3-20
YES
D-6.5 By selecting "Yes" the Applicant attests that it will maintain records of medical marijuana dispensed to a patient or a caregiver in its internal inventory control system. OAC 3796:6-3-08
YES
D-6.6 By selecting "Yes" the Applicant attests that it will maintain records of expired, damaged, deteriorated, misbranded, or adulterated medical marijuana awaiting return to a cultivator / processor or awaiting disposal, in its internal inventory control system. OAC 3796:6-3-20
YES
D-6.7 Please provide an explanation for selecting "No" in response to questions D-6.1 through D-6.6
No response provided by applicant
D-6.8 Please describe the Applicant's approach regarding the implementation of an inventory management process. This approach must also include a process that provides for the recall of medical marijuana and the management of medical marijuana product returns from the proposed dispensary to the originating cultivator and/or processor. OAC 3796:6-3-20
D-6.8.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in D-6.8. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant
D-6.9 Please describe the Applicant's processes, procedures and controls regarding a patient or caregiver’s ability to return unused medical marijuana for the purpose of dispossession and destroying. Include, at a minimum, a description of 1. How patients and caregivers will be charged for such returns 2. How returns will be tracked 3. How any returned medical marijuana will be secured at the facility D-6.9.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in D-6.9. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant Operations Plan(Diversion Prevention of Product)
D-7.1 Please provide a summary of the procedures and controls that the Applicant will implement at the dispensary for the prevention of the unlawful diversion of medical marijuana, along with the process that will be followed when evidence of theft/diversion is identified. OAC 3796:6-3-01; OAC 3796:6-3-05; OAC 3796:6-3-16
Operations Plan(Sanitation and Safety)
D-8.1 Please provide a summary of the intended sanitation and safety measures to be implemented at the dispensary. These measures should include, but are not limited to, plans, procedures, and controls to address the following: 1. Processes for contamination prevention 2. Pest protection procedures 3. Instruction to dispensary employees regarding the handling of medical marijuana 4. Hand-washing facilities Please reference OAC 3796:6-3-02 for more information.
Operations Plan(Record-Keeping)
D-9.1 By selecting “Yes,” the Applicant attests that it will notify State Board of Pharmacy at least 7 days prior to rendering medical marijuana unusable. All waste and unusable product will be weighed, recorded and entered into both its internal inventory system and in the state inventory tracking system. The destruction of medical marijuana will be witnessed by a key employee and conducted in a designated area with fully functioning video surveillance. OAC 3796:6-3-14
YES
D-9.2 Please provide a summary of the Applicant’s record-keeping plan at the dispensary. This plan should cover, but is not limited to, a description for how the following records will be maintained: 1. Employee records, including a background check conducted by the proposed dispensary and training provided by the proposed dispensary 2. Operating procedures and controls 3. Audit records 4. Staffing plans; Business records 5. Surveillance records 6. Attendance logs 7. Quality assurance review logs Please reference OAC 3796:6-3-17 for more information.
Operations Plan(Other )
D-10.1 Please provide a summary of any other services or products to be offered by the Applicant at the dispensary. OAC 3796:6-2-02
In addition to a demonstrated commitment to providing high-quality medical marijuana at a range of price points, the Applicant is also committed to providing supplemental services that will enhance the health and wellness of the local population. To this end, the Applicant has several advisory board and staff members who will develop and oversee supplemental programs. The Applicant will offer onsite Holistic Patient Wellness workshops and classes. Holistic Patient Wellness events will focus on supplemental activities patients can explore that might compliment their treatment. Offerings will include activities such as yoga, meditation, reiki, and massage therapy and will be led by highly qualified instructors, each of who retains certification, as appropriate. The Applicant will also offer Medicinal Cooking workshops. During these workshops, patients will learn tools and techniques to create foods and edibles using medical marijuana. The workshops will focus on simple techniques and include information about basic food preparation, product selection, and dosing. These workshops will be informative only and no medical marijuana shall be prepared or consumed onsite. Additionally, the Applicant will host regular workshops and discussions on a variety of topics deemed important by the local patient populations. Such additional topics might include opioid dependency reduction strategies, pain management strategies, microdosing, and others. In addition to providing the above opportunities for supplemental patient wellness practices, the Applicant shall also take every opportunity to ensure that patient comfort and privacy is a top priority among all staff. In addition to thorough, private, in-person consultations with the Chief Pharmacy Officer or Lead Patient Care Technician, patients will also have the opportunity to schedule phone call consultations, at their convenience and in the privacy of their home, with the Chief Pharmacy Officer. Following such consultations, pending recommendation and ID verification, the patient will then have the option to request to have their medical marijuana order on hold at the facility. When the patient arrives at the facility, pending verification, they will receive expedited service with a shorter wait time to complete their transaction.
D-10.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in D-10.1. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant
D-10.2 Please provide a summary of intended services for veterans and/or the indigent. OAC 3796:6- 2-02; OAC 3796:6-3-22
The Applicant is highly committed to supporting local veteran and indigent communities through its policies and supplemental programs. Medical marijuana is recommended by many medical experts as a highly effective treatment for PTSD and one of the few treatment options that has relatively few side effects or complications. In particular, there have been recent studies linking the prevalence of medical marijuana to reduced opioid dependency. According to recent data, an estimated 20% of all US veterans suffer from post-traumatic stress disorder (PTSD). And, according to www.va.gov, in the Applicant's proposed Ohio medical marijuana district, there are an estimated 32,000 veteran residents, indicating approximately 6,000 veteran residents who could potentially benefit from the use of medical marijuana to treat PTSD symptoms. In addition to a historical lack of access to medical marijuana, several longstanding social taboos often prevent veteran support groups from recommending medical marijuana as a viable treatment option for PTSD sufferers. One of the Applicant’s goals is to bridge the gap to inform and serve these individuals as a State-licensed, fully compliant, legal medical marijuana dispensary in the state of Ohio. To this end, the Applicant has recruited a seasoned Veterans’ Initiatives Advisor (VIA) to its Advisory Board. The VIA is a decorated war veteran who has been a medical marijuana advocate on the national level and has several years’ experience in working with local veterans’ groups, holding conversations with leaders, delivering lectures and workshops, and serving as a general resource for veterans who are seeking information about using medical marijuana as part of a treatment program. The VIA will oversee the development and implementation of programming for local veteran populations. The Veterans’ Initiatives Program (VIP) will have two initial goals: VIP 1) to educate veterans who are medical marijuana patients about strains, treatment options, and supplemental treatments that have been proven to treat the effects of PTSD and other issues recurring in veteran populations; and VIP 2) to work with local veterans’ groups and leaders to provide education to veteran populations who are not patients about medical marijuana as a treatment option through the use of meetings, presentations, and literature. The VIP 1 program will target local veterans who are currently medical marijuana patients or interested in becoming one. Under VIP 1, the VIA will develop a series of materials and literature and will collaborate with the GM to provide training to dispensary employees to enhance their knowledge about needs specific to the veteran community. With oversight from the Chief Pharmacy Officer, Lead Patient Care Technicians will undergo specific training in addition to broader veterans’ topics that will allow them to provide in-depth consultative services to incoming and returning veteran patients. The VIA will stay abreast of emergent strains and dosing options that are relevant to veterans and will conduct period training sessions to ensure dispensary staff knowledge remains current. The VIA will also work with the GM and AGM to advise on strains, products, and supplemental programming to ensure the dispensary has appropriate medicine and programs tailored specifically to veteran populations. Under VIP 2, the VIA will conduct quarterly visits to various areas throughout the proposed district during which he will meet with local veterans’ group leaders and participants, with the overarching goal being to educate veteran groups, encourage dialogue, and reduce social stigma around utilizing medical marijuana in veteran populations. To demonstrate the Applicant’s dedication to supporting local veterans receiving access to medical marijuana and to stimulate trial, the Applicant will develop a series of discount coupons for both first- time and returning veteran patients. Similarly, the Applicant is committed to supporting the health and well-being of the entire population of the proposed district, including indigent residents. In order to support local indigent populations, the Applicant will form partnerships with local government and nonprofit service providers. The Applicant is currently exploring partnering with local shelters as well as food pantries to supply donated in-kind items as well as cash from a matched “keep the change” donation program in which patients would have the option to donate their change at the point of purchase and the Applicant would match the donation, thereby doubling it. Additionally, all dispensary employees will receive training on topics common to indigent populations, including stigma, mental health, and homelessness issues. Employees will be trained to provide effective, compassionate care to all patients and Lead Patient Care Technicians will receive specific training on providing in-depth consulting services to indigent populations. Finally, in an effort to offset the costs of access to quality medical marijuana, the Applicant will develop a series of discount coupons to be disseminated to indigent populations onsite and at local service providers.
D-10.3 Describe the Applicant's efforts to minimize the environmental impact of the proposed dispensary. OAC 3796:6-2-02
The Applicant is committed to upholding the highest environmental standards to ensure that the business is a responsible steward of the community. The Applicant will take steps to mitigate any possible environmental impacts that could emanate from the dispensary’s operations, including energy management, environmentally sound construction practices, recycling programs and greenhouse gas reduction. The Applicant will make efforts to make sure that the facility minimizes its ecological footprint from the design and construction phase all the way through to implementing SOPs that incorporate environmental best practices into daily operations. Green Building: In the design and construction phase, the Applicant will make necessary steps to ensure that the building itself is constructed to the highest standards. Additionally, it will take measures to secure energy efficiency. Using LEED Certification as a guideline, the Applicant will consider practices such as using recycled content and reusable materials, and using locally sourced, regional materials for the building. It will also optimize energy performance. To the extent possible, the Applicant will seek to implement energy and cost savings into the building process. Stormwater Management: The Applicant will use stormwater management practices to ensure that the area surrounding the site is properly drained, including using pervious paving materials to minimize the risk of pooling and flooding.
Energy Plan: The Applicant has developed a comprehensive energy plan that includes using energy efficient, LED bulbs in all lighting instances, optimizing HVAC system efficiency and other factors that contribute to an efficient, sustainable structure.
D-10.3.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in D-10.3. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant Operations Plan(Security & Infrastructure Records )
D-11.1 By selecting "Yes", the Applicant attests that all responses identified as containing security and infrastructure are voluntarily submitted to the State Board of Pharmacy in expectation of a protection from disclosure as provided by section 149.433 of the Revised Code.
YES Patient Care(Staff Education and Training)
E-1.1 Describe the Applicant's education and training plan and how it will meet the foundational and ongoing training required for dispensary employees to be authorized to dispense medical marijuana. Include a summary of the substantive training content, the number of hours each dispensary employee will receive for each mandatory training requirement, the number of training hours each dispensary employee will receive for any elective training, and the anticipated source of each type of training described. OAC 3796:6-3-19
All licensed medical marijuana employees shall be highly qualified to perform tasks according to their respective role. The General Manager (GM) shall be qualified to oversee and make decisions on all aspects of dispensary operations and, with support from the Assistant General Manager (AGM), ensure all employees participate in ongoing training as mandated by the training program. All dispensary employees shall receive foundational training on the drug database, inventory tracking system, responsible use, toll-free telephone line, medicine abuse or adverse events, security measures and controls, confidentiality requirements, forms, methods of administration, strains, qualifying conditions, authorized uses, regulatory inspection preparedness, and operational legal requirements as well as receive a minimum of 16 hours of continuing education on topics such as holistic wellness, the endocannabinoid system, opioid reduction strategies, microdosing, and topical applications.
Training records will be retained in a secure office for a minimum of two years and will be made available to the State Board of Pharmacy for inspection or audit immediately upon request.
Prior to the dispensing of any medical marijuana, each dispensary employee will be trained in the standard operating procedures related to the receipt, storage, dispensing, and disposal of medical marijuana. As part of their foundational training, all employees will receive approximately 40 hours of in-depth and recurring training on the following topics:
1) Drug Database: As applicable, employees will receive training on the drug database established by the State Board of Pharmacy with the purpose of monitoring the misuse and diversion of medical marijuana. This will include training on the information required to be submitted, transmitting information as specified by board rules, time limits on information transmittal, contingency solutions if the dispensary suffers a mechanical or electrical failure or is unable to meet transmittal deadline for other reasons beyond its control. Specific transmittal information will include dispensary identification, patient identification, physician recommendation date and identification, date, quantity, and number of days’ supply of dispensation, and originating source of medical marijuana. Employees will receive training on patient confidentiality within the database as well. This training will be delivered by the GM or AGM and will require approximately 2 hours initially. 2) Inventory Tracking System: Employees will be trained to correctly use the statewide inventory tracking system with the intention of monitoring medical marijuana from its seed source through its cultivation, processing, testing, and dispensing. Employees will also receive detailed training on policies and processes ensuring patient confidentiality. This training will be delivered by the GM or AGM and will require approximately 4 hours initially. 3) Responsible Use Training: Employees will be trained on utilization and advising use of the toll-free telephone line established by the State Board of Pharmacy to respond to inquiries from patients, caregivers, and health professionals regarding adverse reactions to medical marijuana and to provide information about available services and assistance and in recognizing signs of medicine abuse or adverse events. This training will be delivered by the Chief Pharmacy Officer (CPO) and will require approximately 4 hours initially. 4) Security: Measures and controls to prevent diversion, theft, and loss. This training will be delivered by the Director of Security and will require approximately 2 hours. 5) Confidentiality requirements: Policies and processes to ensure patient confidentially is secured at all times. This training will be delivered by the GM or AGM and will require approximately 2 hours initially. 6) Instruction on different forms, methods of administration, and strains of medical marijuana. This training will be delivered by the CPO and will recur on a quarterly basis. It will require approximately 8 hours. 7) Instruction on qualifying conditions for medical marijuana patients. This training will be delivered by the CPO and will recur quarterly. It will require approximately 2 hours. 8) Authorized uses of medical marijuana in the treatment of qualifying conditions. This training will be delivered by the CPO and will recur quarterly. It will require approximately 2 hours. 9) Instruction regarding regulatory inspection preparedness and law enforcement interaction. This training will be delivered by the GM or AGM and will require approximately 2 hours initially. 10) Awareness of the legal requirements for maintaining status as a licensed dispensary employee. This training will be delivered by the GM or AGM and will require approximately 2 hours. 11) Other topics as determined by the State Board of Pharmacy
Optional elective training topics, which, upon completion, will allow Patient Care Technicians (PCT) to advance to Lead Patient Care Technicians include the following:
1) Advanced Medical Marijuana: The Applicant’s Medical Advisor is regarded as one of the world’s leading practicing experts on the clinical applications of medical marijuana and is the founder of a nationally renowned training program for patients, healthcare providers, and dispensary professionals on how to best use medical marijuana to find an optimal dosage, product deliveries, and using less medical marijuana to achieve better results while controlling unwanted side effects. The Advanced Medical Marijuana training will include lectures, videos, worksheets, and observational findings. Participants will receive training on the endocannabinoid system, working with patients and communicating with medical providers, understanding the delivery system, specific dosage protocols for new patients, and cannabinoid ratios and deliveries for approved conditions. The Advanced Medical Marijuana training will require approximately 16 hours and will be offered at a minimum of twice yearly.
2) Veteran Services and Initiatives: Training about topics and treatment methods particularly applicable to veteran patients. Please refer to Application Section D-10.2 for more specific information. This training will equip PCTs to provide in-depth consultative services to incoming and returning veteran patients. It will be delivered by the Veterans’ Initiatives Advisor and will recur twice per year. Each training will require approximately 8 hours.
3) Holistic Patient Care: Training on supplemental activities and programs to enhance patient wellness and wellbeing. Topics will include nutrition, meditation practices, yoga, and acupuncture. This training will be delivered by the CPO, Medical Advisor, or other topical experts and will require approximately 8 hours.
4) Medicinal Cooking: This training will equip PCTs to deliver programming to patients on simple and safe approaches to incorporating medical marijuana into various edible consumption options. This training will be delivered by an expert in this field and will require approximately 8 hours.
E-1.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in E-1.1. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant
E-1.2 Summarize how the Applicant's training plan will identify and incorporate advancements in medical marijuana research. Include a description of the frequency with which the training plan will be updated, how new information will be incorporated into the training plan, the method for providing updated training to dispensary employees, and the frequency with which updated training will be provided to dispensary employees. OAC 3796:6-3-19
The Applicant will provide patient treatment consultations and options that consistently reflect the latest advancements in medical marijuana research. Accordingly, all dispensary employees will receive periodic, ongoing training in addition to their foundational training. The development of ongoing training in advancements medical marijuana treatment and research will be overseen by the Medical Advisor (a Doctor of Osteopathy who has several years’ experience developing medical marijuana programs in other legal states) and the Chief Pharmacy Officer (CPO, a Doctor of Pharmacy, licensed under Chapter 4729. of the Revised Code, who has completed several supplemental certification programs in medical marijuana practices). Both the Medical Advisor and the CPO will continually stay abreast of advancements in medical marijuana research and developments though their involvement in national and regional associations, attendance of topical conferences, and study of relevant academic research journals and publications. The Medical Advisor and CPO will meet on a quarterly basis to discuss medical marijuana advancements and develop training plans and materials accordingly as well as alter existing foundational training materials. The CPO will then facilitate the quarterly trainings to impart knowledge of medical marijuana advancements to all dispensary staff. The Applicant’s Medical Advisor has conducted significant research analyzing the correlation between diet, exercise and cannabis use. This research has shown a high correlation between the consumption of specific foods (including essential fatty acids), and properly dosed medical cannabis optimizing performance of the endocannabinoid system. Additionally, the Applicant’s team shall continually incorporate the most innovative cannabinoid isolation techniques targeting specific conditions set forth by the Ohio Board of Pharmacy. The Applicant’s Medical Advisor is regarded as one of the world’s leading practicing experts on the clinical applications of medical marijuana and is the founder of a nationally renowned training program for patients, healthcare providers, and dispensary professionals on how to best use medical marijuana to find an optimal dosage, product deliveries, and using less medical marijuana to achieve better results while controlling unwanted side effects. The training will include lectures, videos, worksheets, and observational findings. Participants will receive training on working with patients and communicating with medical providers, understanding the delivery system, and specific dosage protocols for new patients.
E-1.2.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in E-1.2. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant Patient Care(Patient Care and Education)
E-2.1 Describe how dispensary employees will be trained to provide patient education regarding: 1. Recognizing the signs of abuse or adverse events in the medical use of marijuana 2. Instruction on use of medical marijuana to treat a qualifying condition 3. Risks associated with medical marijuana, including possible drug interactions 4. Guidelines for support to patients related to the patient's symptoms 5. Guidelines for refusing to provide medical marijuana to an individual who appears to be impaired or abusing medical marijuana. Include the sources of the training and the sources' qualifications to provide such training. Please reference OAC 3796:6-3-19 for more information.
The Chief Pharmacy Officer will develop and oversee all training regarding patient education, with support from the Medical Advisor. All training will take place in a classroom setting and be provided through slide show presentations, printed handouts, videos, and interactive demonstrations. Employees will be educated on recognizing signs of abuse, which include patients coming at least several days early to pick up cannabis on multiple occasions, attempting to procure more than what’s been allotted for the current 90-day supply, talking openly about sharing medicine with others, talking about smoking cannabis, seeing unusually high doses or dose changes on a recommendation, and patients requesting to pick up for multiple individuals. Employees will report abuse to the State Board within 24 hours and provide all required information. Employees will also be trained on recognizing adverse events which include but are not limited to sedation, dizziness, drowsiness, facial flushing, diaphoresis, and patient reported symptoms including tachycardia, anxiety, hallucinations, confusion, palpitations, among others. A full list of known side effects will be provided to all employees and patients to allow discussion and education. Note: some signs of intoxication may be due to drug interactions with pharmaceutical or over-the-counter (OTC) products and should be considered when evaluating adverse effects. A drug interaction check will be performed and provided to patient at point-of-sale. Herbal and dietary supplements may be included in this interaction check given sufficient data. Employees will refer to company references to determine which strain is appropriate for patient’s qualifying condition. Once the strain is identified and the delivery system agreed upon by patient, the employee will educate, demonstrate, and ensure patient’s knowledge of administration by using “teach- back method”. Employees will educate on vaporization, oral, sublingual, and rectal administration, as well as transdermal application, and any new delivery systems that become available. Employees will recommend against smoking due to current law and health hazards. Employees will recommend cannabis naïve patients to “start low, and go slow”, administering up to 1 inhalation/application three times daily for several days until therapeutic window is established and the patient is able to titrate up accordingly. Patients will be instructed to use as little medicine as possible to achieve desired relief and reduce adverse effects of cannabis. An experienced medicinal marijuana patient will be encouraged to follow the same dosing schedule, and will likely find their therapeutic window much sooner. Employees will remind patients that medicine should not be administered in public locations and to avoid driving and/or operating machinery during or after medical marijuana use. Employees will discuss with patients the importance of using medical cannabis only, and that cannabis from anywhere else may contain contaminants and unknown variations of active compounds, which may exacerbate preexisting conditions. Employees will also provide a list of common adverse effects, which the patient may experience when using cannabis, and potential effects of the specific strain they’ve chosen. Employees will educate patients regarding the compounding of adverse effects when combining cannabis with other medications, and the dangers of using it concurrently with illicit substances and/or alcohol. Other risks that are associated with cannabis will be addressed with the patients as the program progresses and further data is collected. Employees will access patient records and assess contraindications and drug interactions with current medications. Identification of any contraindications or drug interactions not identified by the referring physician will be documented and communicated to the patient immediately, informing them that the use of medical marijuana is either contraindicated, or that the risk of use outweighs its benefit. In such case, the patient will be denied the cannabis until further investigation is conducted and referring physician informed. Patients will be provided printed information on the contraindication or interaction(s). Upon receipt of medical marijuana, all patients will receive pamphlet outlining the effects of cannabis and a company phone number to call to report adverse events. In all cases, if the patient is experiencing a life threatening emergency they will be directed to hang up and call 911 immediately. Employees will inform patients they cannot provide medical advice, but if any non-life threatening side effects are experienced, the patient should remain calm, stay hydrated, lie down, and have a caretaker present for observation until the effects diminish. If possible, the patient should also record as much information about the events leading up to the side effect, and share with the dispensary so that proper evaluation and education can take place. If employees identify an impaired patient or caretaker, or recognize signs of abuse or diversion, employee will inform said person that they are unable to perform the sale at this time due to signs of abuse/impairment. Persons identified as being impaired or abusing cannabis will be referred to counseling or other similar service. If there are further issues such as refusal to vacate the premises, the Security team shall be notified and manage the situation. Such cases will be documented and reported to the State Board within 24 hours by the Applicant. The Applicant will document and store this information in its database as well.
E-2.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in E-2.1. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
No response provided by applicant
E-2.2 Describe the Applicant's processes, procedures and controls addressing reports of adverse events. Include, at a minimum, a description of: 1. How reports will be documented 2. The circumstances that will require reports of adverse events will be reported to a cultivator, processor, and / or the State Board of Pharmacy 3. The time frame for which to provide such reports
The Applicant will define an adverse event as psychological or physical reactions due to a dose that is too high, a product that is not appropriate for the patient, or serious problems with the medication that were not caught by the quality control systems. The Chief Pharmacy Officer (CPO) will ensure that all dispensary employees are trained on the proper response to calls and situations regarding adverse events, determine the dispensary’s recommended, evidence-based approach to taking too high a dose, and overseeing the development of materials that document that approach. Each sale will include a pamphlet outlining the steps of reporting an adverse event to the dispensary. Patients will make reports either by telephone (to a specific adverse event reporting line), on the Applicant’s website, or in person. When a patient makes a report via phone, they will be advised to hang up and dial 911 if they’re having a life-threatening emergency. When a patient calls the adverse event phone line, the responding employee will collect the following information and enter it manually into the computer system. If no employees are available to answer, or a call is made after business hours, the information will be recorded by an interactive answering service that collects all pertinent information. The patient will be asked the following: 1) Patient first and last name; 2) Patient registry number; 3) What symptom are they experiencing (i.e. abnormal thinking, increased heart rate); 4) The characteristics, if able (i.e. tingling, squeezing, hot, cold); 5) The type of symptom, if able (i.e. metabolic, physiologic, psychological); 6) If the symptom is listed on the patient pamphlet they were given; 7) The onset of symptom(s) after using the cannabis; 8) Date and time of administration; 9) The location on/in the body; 10) Aggravating factors; 11) Remitting factors; 12) Strain/product identifier; 13) Quantity ingested/used; 14) Cultivator license number; 15) Processor license number (if applicable); 16) Lot/serial number. All recorded telephone information will be reviewed daily and entered into the patient’s medical record and a separate adverse event report list to be reviewed by a medical professional. All messages left after normal business hours will be processed the next day. If patients are experiencing adverse effects at the facility, the General Manager, Assistant General Manager, or Chief Pharmacy Officer will interview patients and complete a digital copy of adverse effect information. All adverse events will be recorded into the patient’s personal medical record that will closely model the MedWatch reporting system. All reports will be cross-examined by the Chief Pharmacy Officer or other medically trained personnel to determine etiology of adverse event, and transmission of information to appropriate parties (Board of Pharmacy, cultivators, processors) will commence within the specified time. Patients will receive a follow-up phone call from trained medical personnel within one week to counsel them on the adverse event and educate them as to why it occurred, and any potential mitigation strategies. All adverse events will be recorded in patient records and compared with common adverse effects of concurrent medications using a drug information resource such as LexiComp, Clinical Pharmacology, or Micromedex. If it is determined the patient is experiencing toxicity from elevated pharmaceutical or OTC drug levels, due to a drug interaction, a report will be made to the State Board of Pharmacy. Any adverse events not associated with a drug-drug interaction, as determined by trained medical personnel, will be reported to cultivators, processors, and the State Board of Pharmacy. Parties will receive all pertinent identifying information related to the strain and source of cannabis, as well as patient/physician information if appropriate. Documentation will also be retained by the Applicant for tracking purposes and upon receiving or completing one of these reports, the General Manager will assign each incident with a unique number, and cross-reference the reports in the inventory control system in the patient and product records. Patients will be encouraged to report adverse effects immediately upon recognizing them. Pharmacist or other trained medical personnel will review all adverse event reports daily. When the severity and etiology of the adverse event is determined, an employee will send required information to the necessary parties within the specified time periods. Cultivators and processors will be notified within one week and the State Board of Pharmacy will be notified within 24 hours of receipt of adverse event report. In the event that information does not contain all pertinent information, the Applicant will follow up with a phone call or other means of communication to learn more details. The Applicant will investigate the record and circumstances of the production of the batch and lot, in partnership with the grower/processor who created the related product, to determine if there was a deviation from the SOP in the production of the medical cannabis as detailed in the production logs by submitting parts of the retention samples of the batch and lot to an independent testing laboratory. If sample analysis of the batch or lot reveals that the batch or lot fails to meet specification, the GM will order a recall of all products derived from or included in the batch or lot, following the established recall procedures. Follow up with Patient: For serious adverse events, the CPO will follow up by phone with the patient and will explain the conditions that contributed to the situation, and explain what will be done to mitigate further harm or prevent future events, regardless of how the event was caused. Such harm reduction strategies might include dosage reminders or recommendations, different product recommendations, improved labeling, or actions related to a recall. If the event was a known risk, explain or remind the patient of the risk of complications or side effects and request the patient’s input and concerns. Patient Care(Patient Care Facilities)
E-3.1 Describe the adequacy of the size of the proposed dispensary to serve the needs of patients and caregivers, including building and construction plans with supporting details. Such plans shall illustrate, at a minimum, the size and location of the following within the prospective dispensary location: 1. The dispensary department 2. Restricted access areas 3. Waiting room 4. Patient care areas or other areas designated for patient and caregiver consultation and instruction. Include a summary of the patient flow through each area, the maximum patient and caregiver occupancy in each area at any given time, the amount of time the Applicant expects to interact with both new and returning patients, and the number of dispensary employees who will staff each area Please reference OAC 3796:6-2-02 for more information. E-3.1.1 Applicants may include images or diagrams, in PDF format, demonstrating the measures described in E-3.1. The images or diagrams may contain a brief descriptive caption. Additional language responding to the question will not be considered.
Uploaded Document Name: E-3.1.1_Floor Plan.pdf NOTE: This applicant uploaded document is the next 1 page(s) of this document.
Patient Care(Dispensary Operating Hours)
E-4.1 By selecting "Yes", the Applicant attests that it will make the dispensary available to patients and caregivers to purchase medical marijuana for a minimum of 35 hours per week, between the hours of 7 am and 9 pm, except as authorized by State Board of Pharmacy. OAC 3796:6-3-03
YES
E-4.2 Provide the proposed hours of operation during which the prospective dispensary will available to dispense medical marijuana to patients and caregivers. (Information only) OAC 3796:6-3-03
11AM-7PM Patient Care(Patient Information)
E-5.1 By selecting "Yes", the Applicant attests that it will post a sign directing patients and caregivers with medical marijuana inquiries or adverse reactions to the toll-free hotline established by the State Board of Pharmacy. OAC 3796:6-3-15
YES
E-5.2 By selecting "Yes", the Applicant attests that it will make information regarding the use and possession of medical marijuana available to patients and caregivers. The Applicant agrees to submit all such information to the State Board of Pharmacy prior to being provided to patients and caregivers. OAC 3796:6-3-15
YES Attestations and Acknowledgements(Attestations and Acknowledgements)
F-1.1 Fill out and attach the “Trade Secret Form” to Question F-1.1, specifying the question and / or attachment references of the application submission that are exempt from disclosure under Ohio public records law and articulate how the information meets the definition of “trade secret” under Ohio Revised Code section 1333.61(D). If no material is designated as trade secret information, a statement of “None” should be listed on the form.
Uploaded Document Name: F-1.1_Trade Secret Form (2).pdf NOTE: This applicant uploaded document is the next 2 page(s) of this document. Cannavations OH, LLC /0/& F-1.2 To be considered complete, each application must be submitted with an Attestation and Release Authorization. The form must be completed by a Prospective Associated Key Employee who may legally sign for the Applicant and who can verify the information provided in the application is true, correct, and complete.
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