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Home My WebLink AboutZoning Compliance/Use Permit (2) DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE 1101MIN"am TemporaryPermit ❑ Special Sales License Full Name of Applicant(s) The permit will be issued in the name of the applicant as provided on the application. N 2.ale, �sl en's C��b Applicant Mailing Address city County State- Zip Code FL Applicant Telephone Number Applicant E-mail Address 6 CAI �- Corporation or Other Legal Entity If the applicant is a corporation or other legal entity,enter the name and the document number related to a legal entity as registered with the Florida Department of State Division of tions. FEIN Number Florida Department of State Document Number A contact person must be designated below If the applicant prefers to designate a person other than the applicant to receive and reply to Division communications regarding this application. The designated contact person will be permitted to make changes to the application paperwork on behalf of the applicant,and the Division will communicate directly with the contact person regarding the application. The applicant will not be copied on communications from the Division to the designated contact. It is the responsibility of the applicant to inform the Division If there is a change of designated contact and/or to the contact information of the desl4nated contact Full Name of Designated Contact Designated.Contact Mailing Address l 1 City County State Zip Code SCAL FL -4-g S;2 Designated Contact E-mail Address Designated Contact Telephone Number Ext: RECEIVED ()Fly JAN 2 3 2020 132231 U:� C ST. Lucie County., Permitting INCORPORATED BY REFERENCE:61A-5.0013,F.A.C. EFFECTIVE 912019 DBPR ABT—6003 , APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE Dates of Active Use for Temporary Permit or Special Sales License Provide the dates.of the event or safe when the pennit or license will be effective. The dates provided may not exceed three da Day 1 Day 2 Day 3 'Mcwov) X)A)T�� , macc�) Addr6ss for Physical ocation of Temporary Event or/Special Sales Event CX �P, City County State Zip Code v WCd FL Is the event location currently licensed for sales of alcoholic beverages under a perma ent license issued q the Division? Yes No®if yes,obtain attestation of permanent license holder In Section S. oil Full Name of Applicant(s) Qub Florida Department of Revenue Verification of Registration The named applicant(s)fora temporary permit or special sales licen08 has complied with Florida . Statutes concerning registration for Sales and Use Tax and has paid?ry ed to pay any applicable takes due. Authorized Agency Signature fa Printed Name Title -�G x i c' + S RECEIVED FLORIDA DEPT OF REVENUE_ Date 163 FnPT F INCORPORATED BY REFERENCE:61A-5.0013,F.A.C. EFFECTIVE 912019 DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE Location of Temporary Event Street Address City 1� County State Zip Code C FL Local Zoning Approval The location of the temporary event complies with local ordinances for the temporary sale of alcoholic beverages based on the information supplied by the applicant in this application. Authorized Agency Signature "- Printed Name Title -r Laninq Date t �'" 2,0 INCORPORATED BY REFERENCE:61A-5.0013,F.A.C. EFFECTIVE 912019 DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL.SALES LICENSE Full Name of Applicant(s) Name or Title of Temporary Event Neatly draw a floor plan of the premises in ink,Including:sidewalks and other outs. as which are contiguous to the premises, walls;doors,counters,points of sale of alcoholic beverages,storage areas,restrooms bar locations,and any other specific areas which are part of the premises where the event will be held. A multi-story building where the entire building is to be licensed must show the details of each floor. Goya C 74 INCORPORATED BY REFERENCE:61A-5.0013,F.A.C. EFFECTIVE 912019 DBPR ABT-6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE Full Name of Applicant(s) 'The applicant requesting the permit in the above and foregoing application is a nonprofit civic organization,charitable organization, municipality or county,and the permit,if used,will be used only by the applicant organization on the date(s)requested and at the location stated.By acceptance of this permit,the applicant agrees that,as a nonprofit or civic organization,all net profits from sales of alcoholic beverages during the permitted period will be retained by it,or,as a municipality or county,all net profits from sales of alcoholic beverages during the permit period will be donated to A nonprofit civic or charitable organization within 90 days after the permitted event. As a municipality or county,the applicant attempted to solicit a qualified nonprofit civic or charitable organization to conduct such sales for the permitted event but has been unable to find such a qualifying nonprofit civic or charitable organization in a reasonable and practicable manner and timeframe.The applicant organization has not received more than twelve(12)permits within the calendar year,unless otherwise authorized by law,and the applicant agrees that the location may be inspected and searched during the time that the permit Is issued and business is being conducted without a search warrant by authorized agents or employees of the Division of Alcoholic Beverages and Tobacco,the Sheriff,Deputies,and Police Officers for purposes of determining compliance with the Florida Beverage Law. I,the undersigned individual,or if a corporation,for itself,its officers and directors,hereby swear or affirm that I am duly authorized to make the above and foregoing application and,as such,l swear under oath or affirmation under penalty of perjury as provided for in sections 559.791,56245,and 837.06,Florida Statutes,that the foregoing information is true and correct" aa 9) 1rture of Applicant/Affiant STATE OF COUNTY OF Sworn to(or affirmed)and subscribed before.me this a day of CL(-H 20 , by (print affiant name). LZPersonally Known (_)Produced Identification Type of Identification Produced CL KI Q- izc�� Signature of Notary Public-State of Florida CARLA NELSON Notary Public-State ofFlorida .Commission#FF 965535 o fig,. IV9y Comm.Expires Feb 28,2020 Name of Notary Public-Typed, Printed,or Stamped (NOTARY SEAL) Commission Expires: ��'�1* R,' � ?'F,Y� �'C r�.4�� ...ii`. :!• '`+3ifA,t`�3 4 '�"��++r_�}�y� �; .t`di��d . DATE ACCEPTED BY DISTRICT OFFICE: INCORPORATED BY REFERENCE:61A-5.0013,F.A.C. EFFECTIVE 912019 DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE , x ",=01-14MME Full Name of Applicant(s) ` "As the applicant requesting the special sales license in the above and foregoing application,I understand that this license allows package sales in sealed containers for a period of up to three days,and does not permit the sale of alcoholic beverages for consumption on the premises.I agree that the location may be inspected and searched during the hours that the special sale is being conducted without a search warrant by authorized agents or employees of the Division of Alcoholic Beverages and Tobacco, the Sheriff,Deputies,and Police Officers for purposes of determining compliance with the Florida Beverage Law. I,the undersigned individual,or if a corporation,for itself,its officers and directors,hereby swear or affirm that I am duly authorized to make the above and foregoing application and,as such,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 for oing information is true and cored.' ature of Applicant/Afriant STATE OF COUNTY OF Sworn to(or affirmed)and subscribed before me this a d day of SQLr) j )n. CW 20 by A (print affiant name). (__L)Personally Known Produced Identification Type of Identification Produced Signature of Notary Public—State of Florida o;,a�P B� CARLA NE7,s,.o.N, a��;°= Notary Public-SFlorida Commission#FF 965535 Name of Nota Public—Typed,*Punted,or Stamped '%,OFF�o�; My Comm.Expires Feb 28,2020 . Notary p (NOTARY SEAL) Commission Expires: MIN DATE ACCEPTED BY DISTRICT OFFICE: INCORPORATED BY REFERENCE:61A-5.0013,F.A.C. EFFECTIVE 912019 DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE An attestation is.to be obtained from the current,permanent alcoholic beverage license holder when the temporary event of the applicant nonprofit civic organization,charitable organization,municipality,or county is hosted at a location that is permanently licensed by the Division of Alcoholic Beverages&Tobacco for the sale of alcoholic beverages. NOTE:The attestation must have the original signature of the alcoholic beverage license holder(only persons on file with the Division may sign)and must be submitted by the nonprofit civic organization,charitable organization,municipality,or county as part of the application for the Temporary Permit Full Name of Permanent License Holder at Tem orary Event Location Business Name(D/B/A) License Number Series of Permanent License nit Series \ Type: Contact Person for Permanent License Holder Contact Person Telephone Number Contact Person E-mail Address Name of Applicant for Tempora Permit Lt:�� A. %") - ��ii Dates)of Temporary Event Day 1 Day 2 Day 3 A temporary.permit is Peing requested for an event to be h6ld on your licensed premises. During the permitted dates and times of the event, no sales or service of alcoholic beverages may be made under your permanent alcoholic beverage license in the area identified for use by the temporary permit applicant in Section 5 of this application.,Failure to comply may result in administrative charges being filed against your license. Date Signature of Permanent License Holder at Temporary Event Location Printed Name of Permanent License Holder at Temporary Event Location INCORPORATED BY REFERENCE:61A-5.0013,F.A.C. EFFECTIVE 912019