HomeMy WebLinkAboutMisc Letters DBPR ABT-6014—Division of Alcoholic Beverages and Tobacco Change of Location/Change
in Series or Type Application
STATE OF FLORIDA DBPR Form
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6014
Revised 07/30/2012
NOTE—This form must be submitted as part of an application packet
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation or your local district office. Please submit your
completed application 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 page of the DBPR web site at the link provided below.
http://www.mvfloridalicense.com/dbpr/abt/district offices/licensin4 html
SECTION 1 -CHECK TRANSACTION REQUESTED
Transaction Type:
❑ Change of Location ® Increase in Series
❑ Change in Series I ❑ Decrease in Series
Also include:
❑ Change of Business Name ❑ Retail Tobacco Products (must check one or more)
❑ Change of Officer/Stockholder/Amended
Corporate Name ❑ Pipes ❑ Over the Counter ❑Vending Machine
Do you wish to purchase a Temporary License? ❑ Yes ❑ No
Series Requested 11C Type/Class Requested
SECTION 2 - LICENSE INFORMATION
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.
Full Name of Licensee: (This is the name the license is issued in) Department of State Document #
NETTLES ISLAND MEN'S C1.1 JB, INC.
FEIN Number* Business Telephone Number
46-5737 "6.2, 772 2331577 ext
Current Business Name (D/B/A) Current License# I Series Type/Class
NETTLES ISLAND MEN'S CLUB INC. BEV5302588 2COP
New Business Name (D/B/A), if applicable
Location Address (Street and Number)
9801 S OCEAN BLVD
City County State Zip Code
NSEN BEACH ST. LUCIE FL 34957
Check either:
❑ Location is within the city limits or Z Location is in the unincorporated count
Contact Person (Optional) Telephone Number
ext
E-Mail Address (Optional)
Mailing Address(Street or P.O. Box)
60 NETTLES BLVD
City State Zip Code
NSEN BEACH FL 34957
ABT District Office Received/Date Stamp
Auth.61A3.020&61A-5.0017,FAC 1 Eff. 7/30/12
SECTION 3— DESCRIPTION OF PREMISES TO BE LICENSED
Business Name (D/B/A)
Street Address
City County State Zip Code
JENSEN EACH ST. LUCIE FL 34957
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
ou do not have dominion and control?
3. 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 each floor plan.
Auth.61A3.020&61A-5.0017,FAC 2 Eff. 7/30/12
SECTION 4—APPLICATION APPROVALS
Full Name of Licensee
NETTLES ISLAND MEN'S CLUB, INC.
Business Name (D/B/A)
Street Address
9801 S OCEAN BLVD
City County State Zip Code
JENSEN BEACH ST. LUCIE FL 34957
ZONING
TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION
A. The location complies with zoning requirements for the sale of a coholic beverages or wholesale
tobacco products pursuant to this application for a Series license.
B. This ap Val includes outside areas which are contiguous to the premises which are to be part of the
pre i es ou t e licensed and are identified on the sketch?' [r Yes ❑ No
Signed 9 Date
TitleZO.-71112
SALES TAX
TO BE COMPLETED BY THE DEPARTMENT OF REVENUE
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 212.10(1), 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--.--- _ V'NI IF Department of Revenue Stamp
FLORIDA DEPAP.TMENTOr REVENUF:
JAN 05 2018 GT'A -COW-PLIANCE ENFO cui*Xcj, T
337 idQIRTH U.S. HiGl-IWAY OSE, SUITE
I'iE2CI',
FORT PIERCE SERVICE CENTER FIXO RIBA 34955-4206
HEALTH
TO BE COMPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS
OR COUNTY HEALTH AUTHORITY
OR DEPARTMENT OF HEALTH
OR DEPARTMENT OF AGRICULTURE &CONSUMER SERVICES
The above establishment complies with the requirements of the Florida Sanitary Code.
Signed ,! Date
Title Eli Vtyzin fYV:Ftc!e,l Agency OVA. CID kali 1%
Auth.61A-3.020&61A-5.0017,FAC 3 Eff. 7/30/12
SECTION 5—CONTRACTS OR AGREEMENTS
Business Name (D/B/A)
These questions must be answered about this business for every person or entity listed as the applicant and
copies of agreements must be submitted with this application. If the management, service, or other contractual
agreement gives a person or entity control of the licensed premises or the sale of alcoholic beverages,
disclosure of those persons must be made in the section labeled "DIRECT INTEREST" in the DISCLOSURE OF
INTERESTED PARTIES section. They must also submit fingerprints and a related party personal information
sheet.
1. Yes ❑ No ® Is there a management contract, franchise agreement, or service agreement in
connection with this business?
2. Yes ❑ No ® Are there any agreements which require a payment of a percentage of gross or net
receipts from the business operation?
3. Yes ❑ No ® Have you or anyone listed on this application, accepted money, equipment or
anything of value in connection with this business from a manufacturer or
wholesaler of alcoholic beverages?
j SECTION 6—SPECIAL LICENSE REQUIREMENTS
(DOES NOT APPLY TO BEER AND WINE LICENSES)
Please check the appropriate"Special Alcoholic Beverage License" box of the license for which you are
applying. Fill in the corresponding requirements for each Special License type.
❑ Quota Alcoholic Beverage License ❑ Special Alcoholic Beverage License
® 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 sign and date:
Applicant's Signature: Date:
Auth.61A3.020&61A-5.0017,FAC 4 Eff. 7/30/12
SECTION 7—DISCLOSURE OF INTERESTED PARTIES
Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of
our license.
Business Name (D/B/A)
1. When applicable, please complete the appropriate section below. Attach extra sheets if necessary.
Title/Position Name Stock%
CORPORATION (CORP/INC)
President RICHARD BELLAVANCE
Vice President DAVID LLOYD
Secretary KENNETH ERICKSON
Treasurer JAMES PETERSON
Director(s)
Stockholder(s)
LIMITED LIABILITY COMPANY LLC/LC
Managing Members)
and/or Managers
Members
(must be printed if
there are no
managing members
or managers)
LIMITED PARTNERSHIP (LTD/LP/LTDLLP)
General Partner(s)
Limited Partner(s)
Bar Manager(Fraternal Organizations of National Scope only):
DIRECT INTEREST
Name of Individual or Entity (If a legal entity, list name under which the entity does business and its principles)
Title/Position Name Stock%VP WALTER JONES
VP JAMES VITALE
2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan, or any person
or entity who has loaned money to the business that is not a traditional lending institution?
❑ Yes ® No
If yes, and the terms create a direct interest in the business, you must list the person(s)or entity and
indicate which of the below applies. Each directly interested person must submit fingerprints and a related
party personal information sheet. Copies of a reements must be submitted with this application.
Name Guarantor Co-signer Lender Interest Rate
Ej List
Auth.61A-3.020&61A-5.0017,FAC 5 Eff. 7/30/12
SECTION 8 -AFFIDAVIT OF APPLICANT
NOTARIZATION REQUIRED
Business Name (D/B/A)
"I, the undersigned individually, or if a registered legal entity for itself and its related parties, 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 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."
"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 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
COUNTY OF-
APPLICANY 8IGNATURE
APPLICANT SIGNATURE /
The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ��I {1 Day
of '(1l�CLC'u 20 I By Keo C)e--h Er10 �-son - QO-MpS who Is personally
(print name(s) of person(s) making statement)
known to me OR ( ) who produced as identification.
nnr
Commission Expires:
Notary Public
`?o%a "�e�c; CARLA NELSON
Notary Public -State of Florida
Commission N FF 965535
""OFFS My Comm.Expires Feb 28,2020
Auth,61A-3.020 8 61A-5.0017, FAC 6 Eff. 7/30/12
SECTION 7--DISCLOSURE OF INTERESTE6 PARTIES
Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of
our license.
Business Name (D/B/A)
1. When applicable, please complete the appropriate section below. Attach extra sheets if necessary.
Title/Position Name Stock%
CORPORATION (CORP/INC)
President RICHARD BELLAVANCE
Vice President DAVID LLOYD
Secretary KENNETH ERICKSON
Treasurer JAMES PETERSON
Director(s)
Stockholder(s)
LIMITED LIABILITY COMPANY LLC/LC
Managing Members)
and/or Managers
Members
(must be printed if
there are no
managing members
or mans ers
LIMITED PARTNERSHIP (LTD/LP/LTDLLP)
General Partner(s)
Limited Partner(s)
Bar Manager(Fraternal Organizations of National Scope only):
DIRECT INTEREST
Name of Individual or Entity (If a legal entity, list name under which the entity does business and its principles)
Title/Position Name Stock%
VP WALTER JONES
VP JAMES VITALE
2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan; or any person
or entity who has loaned money to the business that is not a traditional lending institution?
❑ Yes ® No
If yes, and the terms create a direct interest in the business, you must list the person(s)or entity and
indicate which of the below applies. Each directly interested person must submit fingerprints and a related
party personal information sheet. Copies of a reements must be submitted with this application.
Name Guarantor Co-signer Lender Interest Rate
List
Auth.61A-3.020&61A-5.0017,FAC 5 Eff. 7/30/12
SECTION 9— RELATED PARTY PERSONAL INFORMATION
This section must be completed for each person directly connected with the business, unless they
area current licensee.
1. Business Name (D/B/A)
2. Full Name of Individual
Social Security Number" Home Telephone Number Date of Birth
Race Sex Height Weight Eye Color Hair Color
3 Are you a U.S. citizen?
❑ Yes ❑ No
If no, immigration card number or passport number:
4. Home Address (Street and Number)
City State Zip Code
5. Do you currently own or have an interest in any business selling alcoholic beverages, wholesale
cigarette or tobacco products, or a bottle club?
❑ Yes ❑ 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, revoked or suspended anywhere in the past 15 years?
❑ Yes ❑ 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? El Yes D No
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 anywhere within the past 5
years? ❑Yes ❑ No
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
Auth.61A-3.020&61A-5.0017,FAC 7 Eff. 7/30/12
9. Have you been arrested or issued a notice to appear in any state of the United States or its territories
within the past 15 years? ❑ Yes ❑ No
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. Are you an official with State police powers granted by the Florida Legislature?
Yes [:] No
NOTARIZATION STATEMENT
"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
COUNTY OF
APPLICANT SIGNATURE
The foregoing was ( ) Sworn to and Subscribed OR ( )Acknowledged Before me this Day
of 20 , By who is ( ) personally
(print name of person making statement)
known to me OR( )who produced as identification.
Commission Expires:
Notary Public
(ATTACH ADDITIONAL COPIES AS NECESSARY)
*Social Security Number
Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal
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)(I). This information is used to identify licensees for tax
administration purposes.
Auth.61A-3.020&61A-5.0017,FAC 8 Eff. 7/30/12
SECTION 10-CURRENT LICENSEE UPDATE DATA SHEET
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)
BEV 530 2588
Date of Birth Social Security Number*
12121942 034 30 8023
Street Address
978 NETTLESBLVD
City State Zip Code
TFNSEN BEACH FL 34957
Last Name First M.1.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
BEV 530 2588
Date of Birth Social Security Number*
41
080619
0131134
Street Address
NETTLES573
City State Zip Code
TENSEN BEACH IL 1 ,34957
Last Name First M.1.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
BEV 530 2588
Date of Birth Social Security Number*
11241929 132 20 1225
Street Address
30 NETTLES BT.VT)
City State Zip Code
TENSEN BEAM FL 34957
Last Name First M.1.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
BEV 530 2588
Date of Birth Social Security Number*
01211941 282,36 7236
Street Address
406 NETTLES BLVD
City State Zip Code
TENSEN BEACH I F 134957
Last Name First M.1.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
BEV 530 2588
Date of Birth Social Security Number*
04061938
Street Address
1201 NETTLES BLVD
City State Zip Code
JENSEN BEACH FL 7
Auth.61A-3.020 s,61A-5.0017,FAC 9 Eff. 7/30/12
SECTION 10 -CURRENT LICENSEE UPDATE DATA SHEET
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)
BEV 530 2588
Date of Birth Social Security Number*
05 061945 213 44 6317
Street Address
153 NETTLES BLVD
City State Zip Code
NSEN BEACH FL 34957
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.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
Auth.61A-5.010&61A-5.056,FAC 9