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Zoning Compliance/Use Permit
PLANNING AND DEVELOPMENT SERVICES ks. Lucilu- 2300 Virginia Ave !COUNTY f , 0 R I D A Fort Pierce,FL 34982 Phone: 772-462-2822-Fax: 772-462-1581 APPLICATION FOR ZONING COMPLIANCE (Not Home Office Use) Permit#: � .16 i - (1\ \'Z-t Date of Application: Name of Business: MLV, FOOL"..., CORIACR, (,.LC.. Nameof Shopping Center, if applicable: Address of Business: '�31CA " ,ARr-CT TQ-9T RC State: L Zip: 3143+ Property Tax ID #for Business Location: -aL-1 1-1 &1 - Description of Business: CpV Are you relocating your business? tAn Number of Employees: Number of Parking Spaces: I Name�Type of Previous Business at this Location: Name of Applicant: Tiopms Address: )Nf _5TFkeLD c\igCLe \)Egp BEACVJ State: L Zip: S21(06 �W Phone Number: :44A (61,k(e 215 Email Address: 955CYPjL0H0TMjL-.Cg)ftl If beer,wine or alcohol is being served at this location a copy of your liquor license issued by the Division of Alcoholic Beverages and Tobacco will be required prior to approving this zoning compliance. I understand it is my responsibility to contact the Fire Department prior to the issuance of the Zoning Compliance.I further understand that a site inspection may be required to ensure compliance with applicable land development, building safety,and property maintenance regulations. Signature: Date: 7 POD Initials Required Yes, No Comme i Zoning Co Parking Land Use C()M Landscaping 1; SIC Code for Change of Occupancy Targeted Industry Conditional Use Permit LAe -Adult Care Services Provided(Home) TT'F Pr IN-I F New Business 0 Expanding Business 0 - Please Check One �w New Building 0 or Improvements to an Existing Building 0 - Please Check One Revised:5/11/201611:59:24 AMcww4t�u S-6x- at)W-gL Property wird http://www.paslc.org/RECard/#/propCard/26444 Michelle Franklin, CFA-- Saint Lucie County Property Appraiser -- All rights reserved. Property Identification Site Address: 1107 S 33rd ST Parcel ID:2417-214-0007-000-2 Sec/Town/Range: 17/35S/40E Account#:26444 Map ID:24/17N Use Type:1100 Zoning:CG Jurisdiction:Saint Lucie County Ownership I Cyril Thomas Bindu Cyril 9360101stAVE p Vero Beach,FL 32967 Legal Description 17 35 40 E 200 FT OF S 1/2 OF S 1/2 OF SE 1/4 OF NE 1/4 OF NW 1/4-LESS S 70 FT AND LESS ST-(31)(0.37 AC)(OR 3710-1745) Current Values Just/Market Value: $151,900 Assessed Value: $151,900 Exemptions: $0 Taxable Value: $151,900 Total Areas Taxes for this parcel: SLC Tax Collector's Office© Finished/Under Air(SF): 3,435 Download TRIM for this parcel:Download PDF© Gross Area(SF): 4,003 Land Size(acres): 0.37 Land Size(SF): 16,117.2 Sale History Date Book/Page Sale Deed Grantor Price Code Dec 31,2014 3710/1745 0001 WD Barrera Jennifer $170,000 Dec 31,2014 3710/1744 0111 QC Barrera Jennifer $0 May 23,2013 3521/1013 0111 QC Barrera,Jennifer $100 Nov 21,2011 3341/1216 0111 TD Musleh,Yosef A $23,000 Sep 27,2007 2885/2135 XX01 QC Ragubeer,Gaitri $210,000 Apr 23,2007 2804/1178 XX01 QC Fleming,Handy $100 Dec 20,2000 1350/2379 XX00 WD Difrancesco,Joseph $100,000 Sep 21,1995 0977/2467 XX01 CT 33RD STREET DISCOUNT $100 BEVERAGE Aug 1,1988 0601/0279 XX00 CV $126,400 Aug 1,1988 0601/0279 XX00 CV $126,400 Jan 1,1981 0346/1269 XX00 CV $167,000 Building Information (T of 2) e rea:2,475 SF Gross Total Area:2,745 SF Exterior Data View: Roof Cover:Asph Shingle Roof Structure:Gable Building Type:STRL Year Built: 1975 Frame: Grade:Y C Effective Year: 1975 Primary Wall:CB Stucco Story Height:I Story No.Units: 1 Secondary Wall: Interior Data Pr2peWard http://www.paslc.org/RECard/#/propCard/26444 Pedroor,$:0 Electric:MAXIMUM Primary Int Wall: Full Baths: 1 Heat Type:FrcdHotAir Avg Hgt/Floor:0 Half Baths:1 Heat Fuel:ELEC Primary Floors:CONC GRD A/C%:100% Heated%: 100% Sprinkled%:0% I r Sketch Area Legend Sub Area Description Area Fin.Area Perimeter BAS BASE AREA 2475 2475 206 OPAA Open Porch Attached Average 270 0 102 Building Information (2 of 2) Finished Area:1,25:SF Gross T l AreaF Exterior Data View: Roof Cover:Asph Shingle Roof Structure:Gable Building Type:STRL Year Built: 1975 Frame: Grade:Y C Effective Year: 1975 Primary Wall:CB Stucco Story Height:I Story No.Units: 1 Secondary Wall: Interior Data Bedrooms:0 Electric:MAXIMUM Primary Int Wall: Full Baths: 1 Heat Type:FrcdHotAir Avg Hg/Floor:0 Half Baths:0 Heat Fuel:ELEC Primary Floors:Carpet A/C%: l00% Heated%: 100% Sprinkled%:0% I ... Sketch Area Legend Propert7and http://www.paslc.org/RECard/4/propCard/26444 b Special Features and Yard Items Type Qty Units Year Blt CONCRETE LOW 1 1000 1977 Current Year Values Current Values Breakdown Current Year Exemption Value Breakdown Tax Grant Code Description Amount Building: $95,500 Year Year Land: $56,400 Just/Market: $151,900 Ag Credit: $0 Save Our Homes or $0 10%Cap: Assessed: $151,900 Exemption(s): $0 Taxable: $151,900 Current Year Special Assessment Breakdown Start Year AssessCode Units Description Amount 2013 0054 0.37 North St.Lucie Water Management $25.00 District This does not necessarily represent the total Special Assessements that could be charged against this property.The total amount charged for special assessments is reflected on the most current tax statement and information is available with the SLC Tax Collector's Office©. Historical Values Year Just/Market Assessed Exemptions Taxable 2016 $151,900 $151,900 $0 $151,900 2015 $146,100 $146,100 $0 $146,100 2014 $145,900 $145,900 $0 $145,900 Permits Number Issue Date Description Amount Fee C1504-0212 Apr 10,2015 Electric $0 $0 C1604-0383 May 24,2016 Air Conditioning $0 $0 Only Notice:This does not necessarily represent all the permits for this property. Click the following link to check for additional permit data in Saint Lucie County This information is believed to be correct at this time but it is subject to change and is not warranted. ©Copyright 2017 Saint Lucie County Property Appraiser.All rights reserved. PLANNING AND DEVELOPMENT SERVICES 2300 Virginia Ave COUNTY Fort Pierce,FL 34982 Phone: 772-462-2822-Fax: 772-462-1581 APPLICATION FOR ZONING COMPLIANCE (Not Home Office Use) Permit 6 ' _ �-&C7 Date of Application: r , Name of Business: MLV, FQOL" CoRhCR LLC-. Name of Shopping Center, if applicably Address of Business: 3'rTr Fpja N RCc State: I, Zip: M4 Property Tax ID # for Business Location: Sy _ W - Nn CM Description of Business: Cph9aCeme p Are you relocating your business? Number of Employees: 2 Number f Parking Spaces: Name&Type of Previous Business at this Location: Name of Applicant: CY RIL TwmAs Address: $ LD C, C CH State: -L Zip: S2166 Phone Number: tk(o a 5 E ail Address: 5 L a He->Tmll�- If beer,wine or alcohol is being served at is location a copy of your liquor license issued by the Division of Alcoholic Beverages and Tobacco will b quired prior to approving this zoning compliance. I understand it is my responsibil' to contact the Fre Department prior to the issuance of the Zoning Compliance.I further understand ata site inspection maybe required to ensure compliance with applicable land development, building saf ,and property maintenance regulations. Signature: Date: POD Initials Required Y No Comments Zoning Parking +— Land Up6 COM Landscaping ' SIC a Building Permit for Change of Occupancy Ta eted Industry Conditional Use Permit Lai �-�►-� Adult Care Services Provided (Home) ! New Business ❑ Expanding Business ❑ - Please Check One New Building❑ or Improvements to an Existing Building❑ - Please Check One Revised:5/11/201611:59:24 AM �r�V�p61S ep1��1Rn� SAUc L -lv 2� cc9 Prp ett)--•ud http://www.pasle.org/RECard/#/propCard/2644, Michelle Franklin, CFA -- Saint Lucie County Property Appraiser--All rights reserved. Property Identification Site Address: 1107 S 33rd ST Parcel ID:2417-214-0007-000-2 Sec/Town/Range:17/35S/40E Account#:26444 Map ID:24/17N Use Type:1100 Zoning:CG Jurisdiction:Saint Lucie County Ownership Cyril Thomas Bindu Cyril 9360 101 st AVE Vero Beach,FL 32967 Legal Description 17 35 40 E 200 FT OF S 1/2 OF S 1/2 OF SE 1/4 OF NE 1/4 OF NW 1/4-LESS S 70 FT AND LESS ST-(31)(0.37 AC)(OR 3710-1745) Current Values Just/Market Value: $151,900 Assessed Value: $151,900 Exemptions: $0 Taxable Value: $151,900 Total Areas Taxes for this parcel: SLC Tax Collector's Office© Finished/Under Air(SF): 3,435 Download TRIM for this parcel:Download PDF© Gross Area(SF): 4,003 Land Size(acres): 0.37 Land Size(SF): 16,117.2 Sale History Date Book/Page Sale Deed Grantor Price Code Dec 31,2014 3710/1745 0001 WD Barrera Jennifer $170,000 Dec 31,2014 3710/1744 0111 QC Barrera Jennifer $0 May 23,2013 3521/1013 0111 QC Barrera,Jennifer $100 Nov 21,2011 3341/1216 0111 TD Musleh,Yosef A $23,000 Sep 27,2007 2885/2135 XX01 QC Ragubeer,Gaitri $210,000 Apr 23,2007 2804/1178 XX01 QC Fleming,Handy $100 Dec 20,2000 1350/2379 XX00 WD Difrancesco,Joseph $100,000 Sep 21,1995 0977/2467 XX01 CT 33RD STREET DISCOUNT $100 BEVERAGE Aug 1,1988 0601/0279 XX00 CV $126,400 Aug 1,1988 0601/0279 XX00 CV $126,400 Jan 1,1981 0346/1269 XX00 CV $167,000 Building Information (T of 2) rea:2,475 SF Gross Total Area:2,745 SF Exterior Data View: Roof Cover:Asph Shingle Roof Structure:Gable Building Type:STRL Year Built:1975 Frame: Grade:Y C Effective Year:1975 Primary Wall:CB Stucco Story Height:1 Story No.Units:1 Secondary Wall: Interior Data Propert}-�7ard http://www.paslc.org/RECard/#/propCard/2644, Pedrooms:0 Electric:MAXIMUM Primary Int Wall: Full Baths:1 Heat Type:FrcdHotAir Avg Hgt/Floor:0 Half Baths:1 Heat Fuel:ELEC Primary Floors:CONC GRD A/C%:100% Heated%: 100% Sprinkled%:0% Sketch Area Legend Sub Area Description Area Fin.Area Perimeter BAS BASE AREA 2475 2475 206 OPAA Open Porch Attached Average 270 0 102 Building Information (2 of 2) Finished Are F Gross T Area: 1 258 SF Exterior Da View: Roof Cover:Asph Shingle Roof Structure:Gable Building Type:STRL Year Built: 1975 Frame: Grade:Y C Effective Year:1975 Primary Wall:CB Stucco Story Height:1 Story No.Units:1 Secondary Wall: Interior Data Bedrooms:0 Electric:MAXIMUM Primary Int Wall: Full Baths: 1 Heat Type:FredHotAir Avg Hgt/Floor:0 Half Baths:0 Heat Fuel:ELEC Primary Floors:Carpet A/C%: 100% Heated%:100% Sprinkled%:0% f x z= 3 u Sketch Area Legend Properh_Card http://www.paslc.org/RECard/#/propCard/2644-� Special Features and Yard Items Type Qty Units Year Blt r CONCRETE LOW 1 1000 1977 t Current Year Values Current Values Breakdown Current Year Exemption Value Breakdown Tax Grant Code Description Amount Building: $95,500 Year Year Land: $56,400 Just/Market: $151,900 Ag Credit: $0 Save Our Homes or $0 10%Cap: Assessed: $151,900 Exemption(s): $0 Taxable: $151,900 Current Year Special Assessment Breakdown Start Year AssessCode - Units Description Amount 2013 0054 0.37 North St.Lucie Water Management $25.00 District This does not necessarily represent the total Special Assessements that could be charged against this property.The total amount charged for special assessments is reflected on the most current tax statement and information is available with the SLC Tax Collector's Office G. € Historical Values Year Just/Market Assessed Exemptions Taxable 2016 $151,900 $151,900 $0 $151,900 2015 $146,100 $146,100 $0 $146,100 2014 $145,900 $145,900 $0 $145,900 Permits Number Issue Date Description Amount Fee C1504-0212 Apr 10,2015 Electric $0 $0 C1604-0383 May 24,2016 Air Conditioning $0 $0 Only Notice:This does not necessarily represent all the permits for this property. Click the following link to-check for additional-permit data in Saint_Lucie_County .__,- This information is believed to be correct at this time but it is subject to change and is not warranted. ©Copyright 2017 Saint Lucie County Property Appraiser.All rights reserved. INSTRUCTIONS FOR COMPLETING DBPR ABT—6001 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR NEW ALCOHOLIC BEVERAGE LICENSE If you have any questions or need assistance in completing this application,please contact the Division of Alcoholic Beverages& Tobacco's(AB&T) local district office. Please submit your completed application and required feels)to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T's web site at the link provided below: hftp://www.myfloridalicense.com/dbpr/abt/district offices/licensing.html GENERAL INSTRUCTIONS Submitting Your Application Applications for new alcoholic beverage licenses are filed with the Division of Alcoholic Beverages and Tobacco. Please complete all information. All questions must be answered fully and truthfully. You must provide an original application with original signatures. If you are required to submit any supporting documentation,such as the items listed below, a copy of the document is acceptable. Once submitted, your application cannot be returned to you. We will notify you in writing if your application has any errors or omissions and you will be given the opportunity to submit the corrected or required document. Note:When applicable, you must submit a legible and executed copy of the following: Right of Occupancy, lease, or deed (must be in the name of the entity applying for the license), Franchise Agreement, Management Contract, Concession Agreement,and any agreement which requires a percentage payment from the business operation,Certified Copy of Death Certificate, Letters of Administration, Certificate of Title, Certified Copy of all Court Orders pertaining to the alcoholic beverage license. If eligible, a temporary license may be purchased. Permanent and temporary license fees may found at http://www myfloridalicense com/dbpr/abt/forms/documents/abtdistrictofficelist.pdf. Contact Person All communications regarding your application and invoices for payments of initial and renewal fees will be sent to the applicant/licensee at the mailing or email address provided. However, if you would like for us to communicate with someone other than the applicant regarding your application, please provide the name and contact information for that person in the"License Information"section. Your named contact person will be permitted to make changes to the application paperwork on your behalf(except Related Party Personal Information Sheet)and we will communicate directly with them regarding any application issues or deficiencies, and you will not be copied by the division with the correspondence. Once the application is approved,all invoices and any subsequent communications will be sent to the mailing address of the licensee. APPLICATION REQUIREMENTS AND INSTRUCTIONS FOR COMPLETING THIS APPLICATION License Types Refer to the"Alcoholic Beverages and Tobacco" page on the Department of Business and Professional Regulation's Internet site for the License Type data chart. This is provided to guide applicants in knowing how each license type is defined in order to clarify which license type suits their needs. http://www myfloHdalicense com/dbpr/abVdocuments/LicenseSeriesTypesABT2004 table.pdf Zoning Approval Zoning approval is executed by the city or county zoning authority in which the business to be licensed is located. Zoning approval is required on all new and change of location applications unless the applicant is a state college or university located on State owned property. Zoning approval may also be required for certain change or increase in series applications. Zoning approval is not required on new applications for 1APS licenses unless required pursuant to a Special Act for the county in which you are applying. This information can be found at http://www myfloridalicense com/dbpr/abt/forms/documents/abtdistrictofficelist.pdf. 'd-?-1 a3g a,a-3a Auth.61A-5.010&61A-5.056,FAC 1 Department of Revenue Clearance Department of Revenue clearance is required on applications for all new, transfer,change of location,and applications which change the licensee's name.T he address for the office serving your area of interest can be found at hfp://www mvfloridalicense com/dbpr/abt/forms/documents/abtdistrictofficelist.pdf. Health Approval Health approval is required on all applications for consumption on the premises. Businesses that serve food or are located on premises licensed by the Division of Hotels and Restaurants, must obtain approval from that division. Businesses that do not serve food must contact the County Health Authority or the Department of Health. Food service establishments located in grocery and convenience stores, bakeries or delicatessens must contact the Department of Agriculture and Consumer Services. The address for the office serving your area of interest can be found at hfp://www mvfloridalicense com/dbpr/abVforms/documents/abtdistrictofficelist.r)df. Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant,each partner of a general partnership, a general partner of a general partnership of a limited partnership, a managing member,manager,or officer of a limited liability company,each partner of a limited liability partnership, or one of the officers of a corporate applicant. Fingerprints Note: If you are a current licensee with the Florida Division of Alcoholic Beverages&Tobacco you are not required to submit a new set of fingerprints with your application unless you have been arrested since your prior submission of fingerprints to the division. If you are not a current licensee but have been fingerprinted for this division in the past three(3) years,and you have not been arrested since that time, you are not required to submit new fingerprints unless the prior application was withdrawn or non-consummated. Applicants whose fingerprints are returned to the division as illegible will be required to submit a second set of fingerprints. Fingerprints must be submitted by each sole proprietor, officers,directors, individual share holders owning more than%of 1 percent of stock in non-public corporations; general partners of general partnerships; general partners of a limited partnership; officers,managing members or managers of a limited liability company; partners of a.limited liability partnership,and persons directly interested and receiving financial proceeds from the business. Applicants must use a Livescan vendor that has been approved by the Florida Department of Law Enforcement to submit their fingerprints to the department. Costs associated with the fingerprint process will be collected by the vendor. Vendor options and contact information can be viewed at Livescan Device Vendors List(Livescan Device Vendors List). Please ensure that the Originating Agency Identification (ORI) number for the Division of Alcoholic Beverages and Tobacco is provided to the vendor when you submit your fingerprints. The ORI number is FL920150Z. If you do not provide the ORI number,or if you provide an incorrect ORI number to the vendor,the Department of Business and Professional Regulation will not receive your fingerprint results. Out of State Alcoholic Beverage and Tobacco Applicants only: Your fingerprint card can be obtained from the Department of Business and Professional Regulation by contacting the Division of Alcoholic Beverages and Tobacco at 850.488.8284, or one of the division's district offices.A listing of the district offices on the web can be found at hftp://www.mvfloridalicense,com/dbpr/abt/district offices/licensing.html Out of state applicants must be fingerprinted by a law enforcement agency on cards provided by the division (note: law enforcement agencies may charge for this service). The Division of Alcoholic Beverages and Tobacco has a unique ORI number that is required for processing the fingerprints back to the division,therefore, you must contact one of our offices to make a request for a card to be mailed to you. Once your fingerprint card is received, you may then go to a local law enforcement office in your area to have your fingerprints rolled onto the card. Other information will be completed at the local law enforcement agency. For all programs,the completed card must be mailed to Pearson WE at: FLDBPR, Florida Fingerprinting Program, Prints Inc. 119 East Park Avenue, Tallahassee, FL 32301 where the fingerprint card will be scanned. Prior to mailing your fingerprint card, you must complete the following steps in order to make advance payment of$54.50 (do not send any money to Printslnk, please follow the procedure below): OUT OF STATE LIVESCAN FINGERPRINTING REGISTRATION DIRECTIONS with Pearson VUE and or its subcontractor Morpho Trust(formerly known as L-1) 1. Log onto the Pearson WE website at hfps://pearson.ibtfiingerprint.com/ Auth.61A-5.010&61A-5.056,FAC 2 2.Select Continue in English 3.Enter your legal first and last name. 4.Choose your agency from the drop down list 5.Select Pay For Ink Card Submission 6.Complete all ofthe required demographic information 7.Once you have entered your information select"Send"at the bottom of the page and you will be provided a verification page.You should verify that all the information you provided is correct and that you are being printed for the correct agency. B. |feverything iocorrect select^Qo~atthe top ofthe page and you have completed the entering ofthe required demographic information. 8.Choose your form pfpayment the option and then^Qe|oct".Adthis time you will baable toenter either your onadittdebitcard information,ore -check information. 10. Print the confirmation page. NOTE:you MUST include a copy of the confirmation page in the package with the fingerprint card sent to Prints Ink. Failure to provide the confirmation page may cause a delay in processing your fingerprint card. PLEASE NOTE: Failure to follow these instructions and make payment will result in your fingerprint card being returned to you and delay the processing of your fingerprints, and therefore, your application. Tocheck onthe status cfyour card, please call 1-W00'528-1358and not Phnto|nk. Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires itprallows states hmcollect the number. Inthis instance,disclosure ofsocial security numbers is mandatory pursuant to Title 42 United States Code,Sections 653 and 654;and sections 409.2577, 4U9.259W.and 550.79.Florida Statutes. Social Security numbers are used toallow efficient screening nf applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of1B98(Welfare Reform/ct). 104Pub.L1S3. Sec. 317. The State oyFlorida in authorized hncollect the social security number of licensees pursuant to the Social Security Act,42 U.S.C. 405(c)(3)(C)(1). This information is used to identify licensees for tax administration purposes, and the division will redact the information from any public records request. DirectlyfindirectlyVntermsted Person A direct interest is created by a person or entity having an interest with the applicant in the business sought to be licensed and,includes but imnot limited to: 1- an interest which is created by virtue of the interested party deriving revenue from the sale of alcoholic beverages; 2. a person or entity having the right toreceive revenue based onocontractual na/aUoneNpmdab»dbotheconbn| of the sale of alcoholic beverages,the terms of which, are contrary to 561.17, Florida Statutes,or 61A-3.017, Florida Administrative Code; 3. a person or entity who has a right to a percentage payment from the proceeds of the business pursuant to a lease; 4. aguarantor mnalease orloan, 5. aco-signer onolease orloan. An indirect interest includes, but is not limited to,any person or entity that derives revenue from the license solely through a contractual relationship with the licensee,the substance of which is not related to the control of the sale of alcoholic beverages,or is specifically exempt by statute or rule. Note: Direct and indirect interests must bedisclosed inthe~D|GCLOSUREOF INTERESTED PARTIES'section nfthe application. Registration wfLegal Entity All corporations,domestic or foreign;general partnerships;limited liability companies; limited liability partnerships; and limited partnerships are required to be registered with the Florida Department of State,Division of Corporations. Ifyou have not already registered, ypuwi||naedtouontonttheDaportmerdof8batmot(B5O) 488-9000 or www.sunbiz.org for further information. Your application will beconsidered incomplete without this active registration. umm.o1A-5.o1omo1A-5.056.FAC 3 - Related Party Personal Information This section ofthe application must becompleted byeach applicant orpanaon(s)directly connected with the business, unless they are acurrent licensee. The signature ofeach person filling out this section nfthe application must beanoriginal. This will include the sole proprietor,all partners,officers, directors, individual share holders owning more than%of I percent of stock in non-public corporations, all partners of each general partnership,all general partners of a limited partnership,all managing members or managers of a limited liability company, partners of a limited liability partnership,an d persons directly interested and receiving financial proceeds from the business. It is important that each individual discloses any arrests they have had within the past 16 years,even if they were charged, but not formally arrested, and regardless of the disposition. Copy of Arrest Disposition If the applicant answers"yes"to any of the criminal background questions asked in this application, provide a copy ofthe Arrest Disposition boenmunathea U tim4ua|ified. puneumnttoEuatubaandRu|e. Applicable Statutes and Rule: 561'15&561.17,Florida Statutes;and o1A4.017.Florida Administrative Code. Moral Character The applicant is required to meet the moral character standards to have an interest in an alcoholic beverage license. Any person failing tpmeet those standards shall berequired tosubmit mitigation under the moral character rule in order for the division to determine if the person is qualified. Acopy ofthe rule and requirements can befound od . Federal Employer's Identification Number(FEIN) All licensees who pay wages to one or more employees must have a Federal Employer's Identification Number. Contact the Internal Revenue Service(|RB)sd1-80O-829-3G7gand request Form#8G4. Surety Bond Surety bonds are required on all new applications for manufacturers,wholesale distributors of alcoholic wholesale distributors ofcigarettes,and other tobacco products. Asurety bond prarider hothe original bond must be submitted on any change of business name,change of location or change of ownership name application bythe aforementioned. You may wish bohave anauditor review your surety bond prior hm submitting this application. Contact the division's Auditing Office serving your area of interest for further inKmnnoUnn. Alist pfthe Auditing offices can bafound at: . Sketch of Premises Acpmp|ste sketch of the premises,drawn in ink or computer generated(letter size)which includes all permanent walls,doors,windows,counters, labeling each room and area. Include any outside areas where alcoholic beverages will besold,consumed,orserved. Due kpthe difficulty mfscanning,moblueprints are accepted. DBPR ABT-6001 —Division of Alcoholic Beverages and Tobacco Application for New Alcoholic Beverage License STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6001 Revised 08/2013 If you have any questions or need assistance in completing this application,please contact the Division of Alcoholic Beverages& Tobacco's(AB&T)local district office. Please submit your completed application and required feels)to your local district office. This application may be submitted by mail, through appointment or it can be dropped off A District Office Address and Contact Information Sheet can be found on AB&T's web site at the link provided below: hftp://www.myflorida.com/dbpr/abt/district offices/licensing.html -411101 00,110 0 ,11 License Series Requested Type/Class Requested Do you wish to purchase a Temporary License? Yes No Child License Requested Number of Child Licenses Requested Retail Alcoholic Beverages ❑ Alcoholic Beverage Manufacturer ❑ Beer/Wine/Liquor Wholesaler ❑ Passenger Waiting Lounge Retail Toba Products Dealer Permit(must check one or more of the below) ElPi es Over the Counter [:]Vending Machine If the applicant is a corporation or other legal entity,enter the name and the document number as registered with the Florida Department of State Division of Corporations on the line below. FEIN Number Business Telephone Number E-Mail Address(Optional) .2 X15' CO t . com Full Name of Applicant(s): (This is the name the license will be issued in) T�D29artment of State Document# (000 3 Business Name(D/B/A) MLK FOOL CORACR Location Address(Street and Number) S ?1 - City � T County State Zip Code L�uC�T4e FL 34-4 Mailing Address(Street or P.O. Box) 2 ST Cl2Cl.. City S at Zip Code ERo 6E CH S 324 6� 000" t-TFi .a' ect;c n±fs o~ orral see. ition str c iari8,diMM Contact Person Telephone Number GY RSL MA5 �o4�G 2215 ext. E-Mail Address(Optional) Mailing Address(Street or P.O. Box) City State I Zip Code ABT District Office Received Date Stamp Auth.61A-5.010&61A-5.056,FAC 1 11 MMW k 1. Business Name(D/B/A) MLK R>op cov'kcg 2. Full Name of Individual Social Security Number* Home Telephone Number Date of Pirth 3 q o -4;T2 .214-0 cM10 C>37/3 o I0 6 Race Sex Height Weight EYYe Color Hair Color t� 5'S«' 1 o Aot.wM LACK 3. Are you a U.S. citizen? I Yes ❑ No If no, immigration card number or passport number: 4. Home Address(Street and Number $12 E City State Zip Code PI- I 3P-11Ga 5. Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or tpbacco products, or a bottle club? [:1Yes 92r No If yes, provide the information requested below. The location address should include the city and state. Business Name(D/B/A) License Number Location Address 6. Have you had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit refused, reevgked or suspended anywhere in the past 15 years? ElYes P No If yes, provide the information requested below. The location address should include the city and state. Business Name(D/B/A) Date Location Address 7. Have you been convicted of a felony within the past 15 years? LjYes ONo If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense 8. Have you been convicted of an offense involving alcoholic beverages or tobacco products anywhere within the past 5 years? ❑ Yes 4No If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the A lication Requirements checklist. Date Location Type of Offense Auth.61A-5.010&61A-5.056,FAC 2 9. Have you been arrested or issued a n ice to appear in any state of the United States or its territories within the past 15 years? ❑ Yes WNo If yes, provide the information requested below and a Copy of the Arrest Disposition. Attach additional sheet if necessary. Date Location Type of Offense 10. Do you meet the standards of the moral character rule? VYes [INo 11. Are you an officer or employee of the Division of Alcoholic Beverages and Tobacco; are you a sheriff or other state , county , or municipal officer, including reserve or auxiliary officers, certified by the state as such,with rest powers, whose certification is current and active? El Yes MNo "I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in the Disclosure of Interested Parties of this application. I further swear or affirm that the foregoing information is true and correct." STATE OF � E -- COUNTY O1A17AV CV- 1 A PLI A T SIGNATURE The foregoing was( )Sworn to and Subscribed OR(VAcknowledged before me this _Day of 11� -T , 20j_1 , By "Y 1 1 1DV\q$ who is( ) personally (print a of person making statement) known to me OR(Vwho produced VL-- -j--)r11 trS L-1 CeAV-- as identification. ,-Y� 1 S VLJ Commission Expires:! :-J—) N to Pu is Ir (ATTACH ADDITIONAL COPIES AS NECESSARY) - MARILYN G.WRIGHT MY COMMISSION#FF194809 *Social Security Number EXPIRES May 07.2019 Under the Federal Privacy Act, disclosure of Social Securi a '' ° R4 'q 4,14 '40e719;4; al statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577,409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act,42 U.S.C.405(c)(2)(C)(1). This information is used to identify licensees for tax administration purposes. This information is used to identify licensees for tax administration purposes, and the division will redact the information from any public records request. Auth.61A-5.010&61A-5.056,FAC 3 u rStreet ame of Applicant: (This is the name the license will be issued in) L ess Name (D/B/A) D Address �t 0 3 'ST Er 3*9 fO erkgcc- County SI: UC FtLtep Conde A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series: `` S Type: license. B. This approval includes outside areas which are contiguous to the premises whichareto be part of the premises sought to be licensed a d are d tiff don the et 2 No f �° Yes Check either: Please do not skip,this is i ortant for license fee sharin ❑ L2//2717MI, ' 7ecfty limits or[Location is in the unincorporated co mySigne � Date 7 a Title /11-7 If This approval is valid for days. IEMA WN ■y� ` � n:.. ...,.•:.. .,E... M,� �'; �i .� '{���� � F .gib' 1 �",yE l: The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax. 1. This is to verify that the current owner as named in this application has filed all returns and that all outstanding billings and returns appear to have been paid through the period ending or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not constitute a certificate as contained in Section 213.758(4), F.S. (Not applicable if no transfer involved). 2. Furthermore,the named applicant for an Alcoholic Beverage License has complied with Florida Statutes concerning registration for Sales and Use Tax, and has paid any applicable taxes due. Signed Date Title Department of Revenue Stamp This approval is valid for days. a The above establishment complies with the requirements of the Florida Sanitary Code. Signed Date Title Agency This approval is valid for days. Auth.61A-5.010&61A-5.056,FAC 5 NNW ROOM Business Name(D/B/A) Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15y ars? ❑ Yes [TNo If the answer is "Yes," please list all details including the date of conviction, the crime for which the entity was convicted,and the city, county, state and court where the conviction took place. (Attach additional sheets if necessary) Mw Please check the appropriate box of the license for which you are applying. Fill in the corresponding requirements for the license type sought. ❑Quota Alcoholic Beverage License ❑ Specialty Alcoholic Beverage License(e.g. SRX, S.etc) ❑ Club Alcoholic Beverage License This license is issued pursuant to Florida Statutes or Special Act, and as such we acknowledge the following requirements must be met and maintained: Please initial and date: Applicant's Initials Date Auth.GIA-5.010&61A-5.056,FAC 6 Note: Failure to disclose an interest, direct or indirect,could result in denial, suspension and/or revocation of your license. You MUST list all persons and entities in the entire ownership structure. To determine which of those persons must submit fingerprints and a Related Party Personal Information, sheet, see the fingerprint section in the application instructions. Business Name(D/B/A) K Fbob COIRNER 1. When applicable,complete the appropriate section below. Attach extra sheets if necessary. Title/Position Name Stock% CORPORATION-List all officers,directors,and stockholders GENERAL PARTNERSHIP-List all general partners LIMITED LIABILITY COMPANY—List all managers member&non-member), directors, officers, and members 3 �V 50•. LIMITED PARTNERSHIP-List all general and limited partners. LIMITED LIABILITY PARTNERSHIP-List all partners Bar Manager(Fraternal Organizations of National Scope only): OTHERINTERESTS These questions must be answered about this business for every person or entity listed as the applicant 1. Are there any persons or entities not disclosed who have loaned money to the business? ❑ Yes No 2. Are there any persons or entities not disclosed that derive revenue from the license solely —/ through a contractual relationship with the licensee, the substance of which is not related to the ElR Yes No control of the sale of alcoholic beverages, or is exempt by statute or rule? 3. Are there any persons or entities not disclosed that have the right to receive revenue based on ❑ Yes &3/No a contractual relationship related to the control of the sale of alcoholic beverages? 4. Are there any persons or entities not disclosed who have a right to a percentage payment from ❑ Yes No the proceeds of the business pursuant to the lease? 5. Are there any persons or entities not disclosed who have guaranteed the lease or loan? ❑ Yes No 6. Are there any persons or entities not disclosed who have co-signed the lease or loan? ❑ Yes PrNo 7. Is there a management contract,franchise agreement, or concession agreement in connection ❑ Yes No with this business? 8. Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from any industry member as described in 61A-1.010, ❑ Yes Pf No Florida Administrative Code? If you answered yes to any of the above questions,a copy of the agreement must be submitted with this application. The terms of the agreement may require the interested persons or parties related to an entity to submit fingerprints and a related party personal information sheet. ALM.61A-5.010&61A-5.056,FAC 7 SEEM WI� N Business Name(D/B/A) FooD Co N R "I,the undersigned individually, or on behalf of a legal entity, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a true and correct representation of the entire area and premises to be licensed and agree that the place of business, if licensed, may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the beverage and retail tobacco laws." "1 swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes,that the foregoing information is true and that no other person or entity except as indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license and/or tobacco permit." STATE OF Fl bt►l/un E396.0'53 a➢L�'➢d G.WRIGHT '(� OMMISSION#FF194809COUNTY OF�.Ln ,� XPIRES May 07,2019 Flor,dallotayServir:e con, APPLICANT/AUTHORIZED qEPFZESENTATIVE NAME G P IL- 7bQ� APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE The foregoing was( )Sworn to and Subscribed OR(Acknowledged before me this !S� Day of , 20ij—, By CV r i 1 1%0YY IS who is( )personally (prin names)of person(s)making statement) known to me OR(%/who produced rL. Nw t_S L iCG\g- as identification. Commission Expires: Notary Fibblic Auth.61A-5.010&61A-5.056,FAC 8 WoOMYR This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date information is captured. Business Name(D/B/A) Last Name First M.1. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.1. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Auth.61A-5.010&61A-5.056,FAC 9 qg Business Name(D/B/A) LK FOOD CO'RtkG2 1. Yes ❑ No Is the proposed premises movable or able to be moved? 2. Yes ❑ No Is there any access through the premises to any area over which you do not have —/ dominion and control? 3. Yes ❑ No�7 Is the business located within a Specialty Center? If yes,check the applicable statute: ❑ 561.20 2 b 1, F.S.or❑ 561.20 2 b 2, F.S. 4. Yes ❑ No 2r Are there any mobile vehicles used to sell or serve alcoholic beverages? 5. Yes ❑ No V Are there more than 3 separate rooms or enclosures with permanent bars or counters? Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the premises,walls,doors,counters,sales areas,storage areas,restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show the details of each floor. CIO Z m X N H d CA -< r . rn rn LJ o - 0 r m X cA43H VVE n C�RI LI... Z -t Auth.61A-5.010&61A-5.056,FAC 4