HomeMy WebLinkAboutZoning Compliance/Use Permit (3) DBPR ABT-6029—Division of Alcoholic Beverages and Tobacco
Application for Extension or Amended Sketch of Licensed Premises
STATE OF FLORIDA DBPR Form
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6029
Revised 0212013
ff 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 AS&T's web site at the link provided below:
hgp://www.mvflorida.com/dbi)r/abtidistrict offlces/licensina.htmi
=nsactUlon nsion ❑ Amended Sketch
nsion
Licens (as li Vd on alWh lic bev ge ' nsPAe
Busine Name(D/B/A) UwA q' -fwNro �6�yya�
Location Address(Street)
Cly CTFL to [Zi Cod
Alcoholic Eleveraae License Nu Series Type/Class
Business Tel h Nu ber ail d ( ti i
ext.
FOR TEMPORARY EXT NSIONS ONLY.•
Date(s)of Extension:
REC7Permitting
JAN
ST. Lucie Co
ABT District Office Received/Date Stamp
FILr. %aopy
Auth.61A-5.0017 1
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Location Street •. -
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0 there outside contiguous t• the premises which are to •- art of the premises soughtj
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to belicensed?" _ No
The PERMANENT extension of the licensed premises as shown in the sketch complies with zoning i;
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requirements for the sale of alcoholic beverages pursuant to this application.
The TEMPORARY exte
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I sion of the licensed premises as shown in the sketch complies with zoningrequirements for the sale of alcoholic beverages pursuant to this application. I
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Signed: Title 4bna1Zvn1nA Date: —0.3
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iThis approval Is valid unfilma" , s
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The above establishment complies with the requirements of the Florida Sanitary Code.,
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Agency,
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This approval Is valid until
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it
Business Name(D/B/A) i
"I,the undersigned individually,or if a registered legal entity 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 hereby swear
or affirm that the attached sketch is a true and correct representation of the extended licensed premises and
agree that the place of business 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 cigarette 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 correct."
If Oplying for a temporary extension,check the box to confirm the following statement:
ha "I understand that the premises must be restored to its original form at the conclusion of the
authorized temporary event."
STATE OF
COUNTY OF
APPLICANT SIGNATURE
APPLICANT SIGNATURE
The foregoing was( )Sworn to and Subscribed OR( )Acknowledged Before me this Day
of Sl 00-N 20 , By Q who is(personally
(print names of person(s)making statement)
known to me OR( )who produced �- �- as identification.
0-a"ko- Commission Expires: �a g
Notary Public
s�v Pie%, CARLA NELSON
z r e -
° Commission #FF 965535
P.
%;�o�i�o`o;` My Comm.Expires Feb 28,2020 _
Auth.61A-50017 3
Business Name(D/B/A)
�QAcnA
MeD'
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1. Yes ❑ No❑ Is the proposed premises movable or able to be moved?
2. Yes ❑ No o Is there any access through the premises to any area over which you do not
have dominion and control?
3. Yes ❑ No( Are there more than 3 separate rooms or enclosures with permanent bars or
counters?
4. Yes E3 No Is the business located within a Specialty Center? If yes,check the applicable statute:
❑ 561.20(2xb)1,F.S.or❑ 561.20(2)(b)2,F.S.
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 multistory building where the entire building is to be licensed must show
the details of each floor.
CUD
Auth.e1A-5.0017 4