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HomeMy WebLinkAboutApplication for Zoning Compliance - Use Permit _ PLANNING AND DEVELOPMENT SERVICES 1,e1,1Vine w;,= 2300 Virginia Ave • Fort Pierce,FL 34982 Phone: 772-462-2822—Fax: 772-462-1581 APPLICATION FOR A BUS/NESS NAME OR OWNERSHIP CHANGE Oft Y q (Not Home Office Use) Permit Number: `fir°' 3 Date of Application:6 )� ._ BUSINESS INFORMATION' Name of Business: ARM 6119A0 ' ob New Business Name(if changing): ABIR a2L!�an�n Fmcbvvi� Name of Current Business Owner: , Name of New Business Owner Address of Business: Bte: Zip: Name of Shopping Center, if applicable: Property Tax ID #for Business Location: Description of Business: (include a detailed description) Name &Type of Previous Business at this Location: Attach a copy of the current,active copy of the Business Tax Receipt for the business/property. APPLI ANT MAILING ADDRESS=. Name of Applicant: --c' e— Address: State: Zip: Phone Number: I Email Addre s: v This application is only to update an owner name or business name. To qualify for this application,there must be an active business tax receipt for the business/property;no change of use(change or modification of the character,type or intensity of an existing use or the inclusion of additional uses) may be proposed; and no erection, alteration, construction, reconstruction or any type of development involving a building, structure, paved parking area, driveway connection, or impact upon a protected natural habitat. I further understand that a site inspection may be required to ensure compliance with applicable land development,building safety,and property maintenance regulations. ' s Applicant's Signature: Date: a I OFFICE USE ONLY Required Yes No Comments POD Initials Business Tax Receipt Revised: March 2019 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 fee(s)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. hfp://www.myflorida.com/dbpr/abt/distridt offices/licensing.html € r�: a ,...�rz:. h v - R- _..,. .r.,,. 5 "ft011CtIECst L1GEhISE d�1iEGORIC..._ a , . ._.. , . License Series Requested Type%Class Requested Do you wish to purchase a Temporary License? ZAPS El Yes ❑ No Child License Requested Number of Child Licenses Requested 0 Retail Alcoholic Beverages ❑ Alcoholic Beverage Manufacturer ❑ Beer/Wine/Liquor Wholesaler ❑ Passenger Waiting Lounge 0 Retail Tobacco Products Dealer Permit(must check one or more of the below) ❑ Pipes ❑■ Over the Counter ❑Vending.Machine VAR 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 NumberBusiness Telephone Number E-M it Addre s( tional) z� 841882624 772-801-5196 (� j Full Name ofApplicant(s): (This is the name the license will be issued in) Department of State Document# ABIR&SAMI FOOD MART INC P19000042934 Business Name(DB//j) ABIR&SAMI FOOD MART Location Address(Street and Number) 2243 N 25TH ST City County State Zip Code FORT PIERCE ST LUCIE FL 34946 Mailing Address(Street or P.O. Box) SAME AS ABOVE City State Zip Code ����- �, ,Contacf�1?ersonx-;7h�s sectionYis,o tiona[,�s.,ee�a , icatronnstructlo,Qs�for�detals���,.� �� Contact Person Telephone Number ext. E-Mail Address(Optional) Mailing Address(Street or P.O. Box) City State Zip Code ABT District Office Received Date Stamp Auth.61A-5.010&61A-5.056,FAC 1 TQE CQMPL'ETE©BYTHE,ATPLlCANTxF4' Business Name(D/B/A) ABIR&SAMI FOOD MART INC 1. Yes ❑ No 9 Is the proposed premises movable or able to be moved? 2. Yes ❑ Nop Is there any access through the premises to any area over which you do not have dominion and control? 3. Yes ❑ No❑p 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 ❑ 1 No 9 Are there any mobile vehicles used to sell or serve alcoholic beverages? 5. . Y�[:] Nop 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. J f AZ) I u I I, LL.. Auth.61A-5.010&61A-5.056,FAC 4 � ; ' ` SECION�S 'APOS/ALS }F " Eh>: Full Name of Applicant: (This is the name the license will be issued in) ABIR&SAMI FOOD MART INC Business Name(D/B/A) ABIR&SAMI FOOD MART Street Address 2243 N 25TH ST City County State Zip Code FORT PIERCE ST LUCIE FL 134946 L 3+.ca, -to.Y-,^3.�'+"i"�i�vNING`E"�-'a;,, t+v .,,''; ,.a,e, ,s•, ry e u.� 'r`, �" _. EN _. . TC SHE�t?Mt L ECI,Bl�Tk ZONI IGEAl1"f Hog 1Nu�SS A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series: o�A�S Type: license. B. This approval includes outside areas which are contiguous to the premises which are to be part of the premises sought to be licensed and are identified on the sketch?" ❑ Yes ❑ No Check either: Please do not skip,this is important for license fee sharing ❑E Location is within the city limits or❑ Location is in the unincorporated county Signed i ►�Y W � 'LWT 6-A— Date (,I/P / Title Zen LAThis approval is valid for days. ti SALES TAX 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. .� * TO BE COMPLETED BYTH Di1/ISION OFAHOTELS AND RESTAURANTS 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 Business Name(D/B/A) ABIR&SAMI FOOD MART Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15 years? ❑ Yes ❑■ No 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) V ��fiy SECTION? ' SPECtAIf IiCENSE RE 11[REMENTS � s a , .,, w � ,(DQES NfJT APRLYTQ SEER AND,WIIE.LICENS §.W, 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: N/A Please initial and date: Applicant's Initials Date Auth.61A-5.010&61A-5.056,FAC 6 SECTIONf8,N.pISCLOSURE OFJNTERESTE,D PARTIES 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) ABIR&SAMI FOOD MART INC 1. When applicable, complete the appropriate section below. Attach extra sheets if necessary. Title/Position Name Stock% CORPORATION—List all officers,directors, and stockholders PRESIDENT MD AL AMIN HOWLADER 100 GENERAL PARTNERSHIP—List all general partners LIMITED LIABILITY COMPANY—List all managers(member&non-member), directors, officers, and members 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 W 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 ❑ Yes W 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 X 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 W No 7. Is there a management contract,franchise agreement, or concession agreement in connection ❑ Yes W 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, ElYes Q 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. Auth.61A-5.010&61A-5.056,FAC 7 SECTION 9 AFFIDAVIT OFrAPRL[CANT s° b x , > :., N"}TARIZATI_tN RE4UIRED „ � , Business Name(D/B/A) ABIR&SAMI FOOD MART "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." "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." r STATE OF COUNTY OF L-A4 f^i� APPLICANT/AUTHORIZE ESENTATIVE NAME APPLICANT/AUTHORIZE EP ESENTATIVE SIG 4AJTURE The foregoing was( ) Sworn to and Subscribed OR,('( )Acknowledged before me this 17 Day of J U `f'L 20a, ByMX, who is( ) personally (print name(s) of person(s) making statement) known to me OR�l who produced aaa= Otj'✓'e J5 as identification. Commission Expires: Notary Public �ot';:::�P�•� ASIAM M.HUSSAIN * * MY COMMISSION#FF 942303 EXPIRES:April 9,2020 N,9TFOF FLOP\o' Bonded Thry Budget Notary Services Auth.61A-5.010&61A-5.056,FAC 8 P _ n ;;ACTION 1!} CUR2ENTi.ICENSE UiSbATE t7ATA SHEET �i a ,d`.a,":§ P ���� r a._ 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) ABIR.&SAMI FOOD MART INC Last Name First M.I. HOWLADER MD AL AMIN Current Alcohol Beverage and/or Tobacco License Permit/Number(s) 6603169 Date of Birth Social Security Number` 10/13/89 1714-22-4626 Street Address 2822 A STONEWAY LANE City State Zip Code FORT PIERCE I FL 134982 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 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 06/12/19 DR-11 WrAf Certificate of Registration R. 10/18 Issued Pursuant to Chapter 212, Florida Statutes 0 FLORIDA 66-8017824649-3 06/12/19 Certificate Number Registration Effective Date This certifies that ABIR AND SAM] FOOD MART INC 2243 N 25TH ST FORT PIERCE FL 34946-1201 has met the sales and use tax registration requirements for the business location stated above and is authorized to collect and remit tax as required by Florida law.This certificate is non-transferable. This is your Sales & Use Tax Certificate of Registration. Detach and Post in a Conspicuous Place. Notify the Department immediately if you change Submit a new registration (online or paper) your: when you: • business name; • move your business location from one Florida • mailing address; county to another; • location address within the same county; or • add another location; • close or sell your business. • purchase or acquire an existing business; or You can also notify the Department when you • change the form of ownership of your business. temporarily suspend or resume your business operations. The quickest way to notify the Department is by visiting floridarevenue.com/taxes/updateaccount. Below is your Florida Annual Resale Certificate for Sales Tax. New dealers who register after mid-October are issued annual resale certificates that expire on December 31 of the following year. These certificates are valid immediately. DR-11R,R.10118 ETA DR 2019 Florida Annual Resale Certificate for Sales Tax R. 10 _ This Certificate Expires on December 31, 2019 O FLORIDA Business Name and Location Address Certificate Number ABIR AND SAMI FOOD MART INC 66-8017824649-3 2243 N 25TH ST FORT PIERCE FL 34946-1201 By extending this certificate or the certificate number to a selling dealer to make eligible purchases of taxable property or services exempt from sale tax and discretionary sales surtax,the person or business named above certifies that the taxable property or services purchased or rented will be resold or re-rented for one or more of the following purposes: • Resale as tangible personal property. • Re-rental as commercial real property. Incorporation as a material,ingredient,or • Re-rental as tangible personal property. • Incorporation into tangible personal property being component part of tangible personal property • Resale of services. repaired. that is being produced for sale by manufacturin< • Re-rental as transient rental property. compounding,or processing. Florida law provides for criminal and civil penalties for fraudulent use of a Florida Annual Resale Certificate. ZONING COMPLIANCE CERTIFICATE Planning&Development Services Building&Code Regulation Division 2300 Virginia Avenue Permit#: 1906-0366 Fort Pierce,FL 34982 Phone:(772)462-1553 Fax:(772)462-1578 Issue Date: This is to certify that the following discribed property is property zoned for: CONVENIENCE STORE WITH ALCOHOLIC BEVERAGE LICENSE. Type of Business: CONVENIENCE STORE WITH ALCOHOLIC BEVERAGE LICENSE. Business Name and Address: ABIR AND SAMI FOODMART, INC 2243 N 25TH ST, FORT PIERCE, FL 34946 Parcel ID No: 1432-441-0000-00015 SIC Code: COC Required? NO Signature Date