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HomeMy WebLinkAboutZoning Compliance/Use Permit/ licquor license 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. Local ABT District Licensing Offices SECTION 1 -CHECK LICENSE CATEGORY Lice se erie�equested Type/Class Requested Do wish to purchase a Temporary License? Yes No Child License Requested Number of Child Licenses Requested ❑ Retail Alcoholic Beverages ❑ Alcoholic Beverage Manufacturer n--Beer/Wine/Liquor Wholesaler ❑ Passenger Waiting Lounge ❑ Retail Tobacco Products Dealer Permit(must check one or more of the below) ❑ Pipes ❑ Over the Counter ❑Vending Machine SECTION--2 LICENSE`INFORMAT(ON = 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. F IN Number Business Telhe hone N m er E-Mail Address Optional) s 3l o3 ,� C&-�44 . F Name of A : This is the name the license will be issued in) Department of Stat pplicant s ( e Document# ( Busines Name(D/B/A) i�lbt -a-Are Location Add ess(Stree Number) F) City County State Zip Code ro-�I ' � � .Y FL Mailing Address(Street or P.O. Box) City, St to Zip Cod aerce L 0c - Contact Person-This section is o tional,see a l!cat�on instructions for details Co Telephone Number act Person � p a ext. E- ail Address(Option I t17tllitl ng ress(Stree or P. U Clty Stage I Zip Code ABT District Office Received Date Stamp I - ` k =` SECTION 3 PRELATED PARTY PERS01ALINFORpIIAT,LON yTh�s sect�Qn°mustibe��ompleted=foc�each person d�rec�ly cohnect�clwith`the�lsuslne�s,'unless they. 'w i 3a�P.,��.,u�,�r,1`t,[��`.e,n.S,4e r' ': o ra,.a'+e,'BLS a.:A> ✓},:.:, � r,. . n�s__1..7.F,i ed.�.•n.a7. t.. P?bty� 4.., .9, jti-a.3'•s,%;,. 1. iness ame(D/B/A) - - • I` a 2. I Name of Indivi ual &b-1Ce ocial Security Number Home Tele one Number Date of Birth -73M9 �d R e Sex Height Weight Ey�Color- Hair C lor C� 3. Are youa U.S. citizen? l?'Yes ❑ No If no, immigration card number or passport number: 4. Home Address(Street and Number) City State ZipY-9'9q ode E` vLe 5. Do you currentl wn or have an interest in any business selling alcoholic beverages, wholesale cigarette r t cco 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�eFvoy type of alcoholic beverade, or bottle club license, or cigarette, or tobacco permit refused, ror suspended anywhere in the past 15 years? ❑ Yes 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? ❑Yes If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Applicaation Re uirements checklist: ' - Date Location Type of Offense 8. Have you been convicted of an offense in ing alcoholic beverages or tobacco-products anywhere Within the pasb6 years? ❑Yes LkNo If yes, provide-the,)information requested below'and .provide a Copy of the:Arrest Disposition, as -re uested in the A p`lication Requirements checklist. Date V. Location Type of Offense ; i L 1 `SECTICyI�aS APPLICA'�ION APRROUALS�, r 8 k _ r r �'�. v 13�.�Lr r ,F..E tq v� tip. ((';9: x {,W..-' 3kfi.Y�`saa'��.n,,77�,@�...a r ,.r.5'f `^ ,�`iT..�,+, r,- �.ul C g r"r.. .�.�:,. �"fa¢k"�d�'g,�.E�L��� •s�-�.•``..::- p'�wtbk�} S.F �0x(�����. �hr ..�>'�Sr,,:�fi�r?�4�.stc-A..-'rx.J`5i ��.�4���>v�4��.,FS7�1��`�t�<�<is3�;��:�.fi�"v!'E`��..kar�insA�4c�+."h`s'.•,r �a �f3i...�.' ki•'��,�:+.43a.'.v2��'-,:�..xx .x^�..:-nt,:-: Fu Nime of Applican This i then me the license will be issued in) B si ess Name(D/B/ IAZAY-e co Street Add reqsc�, Count State ZipCode City ?,ems C FL i'" t n4 y.x <e �'r,'7ar �xy y!►�,` x � ��` r✓�' III t"s� 'Yr� ".e .5.r St .x4I y' �' at sYi mt, ssZ Y3 , K*t. k.-as'4 n ,i' 't BEn,. PLi�If 8�fTHm>r? 4ilhlt �THITY G(V!IItO lEISINES``rC. 'TIaN _ A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series: Cl I , Type,, `0? 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 i ortant for license.fee sharing ❑ Location is within the city limits or Location is in the unincorporated county Signed \kj bVWR Date l c Title, AAa 6NX This approval`is valid for days. CaMpLETEI}BY, 'HE DEPARTMEN'1'OF.REVENU� _ y � r 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-EALTH�tW Al;e'"i�},��'' _'x,. ,?F,thy " a1, -na n TO BE COMPLETED B1�THE DIUIION�O,F HOT LS AND RESTAURANTS � � � � � O CQUNTY HEALTH AUTHORITY �'°` PART1111ENTrOFIGiIIICL€FIRE&CO�i9t7MERE�IUGE The above establishment complies with the requirements of the Florida Sanitary Code. Signed Date Title Agency This approval is valid for days. NC`_ NT,i'iCll!i10+s�NY�CCI1VVIt�t�©�1., 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 15 yea ?' i ❑-Yes [ low 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) - "as����. Otte;L.� ^sr.7.' -• �a,. , z.-x^a ra _ v. .24h ��,.�. Y+,t'r `s�. �,N � x�,� •a•-.�,�;M; 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 P 3j � Y hr SRt I t f.v' fi- S 3 a r err N} t ax 3� 'SI*C oN -O�CIrJgoE T LICI:NSEe,.Cl90�'T' qtr 4#" L � a�f $ ^la.; � �y '� " s. �'�tJ. �\;,;i.4. -.a.'4:"s�} v-ou,]{3.J 1 •Y--.,.y t .r t .:+-k D`#""y�n-t`'`41't.�' 9�3 v;�1 �c'=` _ This section is to be completed for all current alcoholic beverage and/or tobacco license holders.listed xon the application to ensure the most up to date information is captured. ` Business Name(D/B/A) Last Name First M.0 Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth 7Social 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 Cbde 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.F. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth. Social Security Number* Street Address City State Zip Code 9. Have you been arrested'or issued a noti to appear in any state of the United States or its territories within the past 15 years? ❑Yes o If yes, provide the information requested below and a Copy of the Arrest Disposition. Attach additional sheet if necessary. Date Location [Typeof Offense 10. Do you meet the standards of the moral character rule? ❑Yes ❑ No 11. Are you.an officer or employee of the Division of Alcoholic Beverages and Tobacco; are you a sheriff or other state, count , or municipal officer, including reserve or auxiliary officers, certified by the state as such,with acre powers, whose certification is current and active? ElYes o � '.I x}� , � ,_ , F !NOTARIZATION ST TEIfAENT a r s � + r,fr N. ty«xC- # .hs < -.r fix .e.-5 r,�23. .»v£ uY31.k.n'wS n .F Q.r�M. .5. •!3. - -+3Ca k,.it-vJ _; ih .ark. _«lhi4'+fa 5' r _ �..lK l./)at n.d4 c' '4 -.. "- "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 /In a4l, �� 1 wu e_ _ APPLICANT SIGNATURE The foregoing was( )Sworn to and Subscribed OR( )Acknowledged Before me this Day of , 20 0t j , By 074rjer)e 90WP1H_re4yhois-( ) personally (print name of person making statement) kriovrn to me OR )-who produced a' -, s identification. Commission Expires: 'd5 Notary Public - - - 3 G ATTACH ADDITIONAL COPIES AS NECESSARY) ; o<PYP" AuoREY B.HUMPG 300 ( '?' *_ EY MY COMMISSION#GG 300817 *: p ' EXPIRES:March 6,207 *Social Security Number Fv O'� Bonded ThmNotaryP1trir,Underwriters Under the,Federal Privacy Act,disclosure of Social Security nur> ire ess a fie eral 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 allowLP`l efficient screening of applicants and licensees by a Title IV-D child support agency#o assu� compliance with child support obligations. Social Security numbers must•also tie I"recorded on ail 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 Stated 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. SECTION 4. vDESCRIPTION;OF P„„REMISES TO,BE LICENSED f � hx rA , >;s TO,BE COINPLET�p C E i�PLICANT, Business Name(D/B/A) 1. Yes ❑ No I e 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 inion and control? 3. Yes ❑ No 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 Ar there any mobile vehicles used to sell or serve alcoholic beverages? 5. Yes ❑ No 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. SECTION 9.=AFFID`AUIT OF APPLICANT 5� � �? 4+iSy`4�Lisri.�,'+` i�,l k`...�'.E `.ry.1RS Sk 4-: .. . . Y... Liiy:•1e4� diw'�.."nsr ��1� rt a ' si' .Y .�a`L � B i ess 16,e(D/B/A)IW u Q id 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." STATE OF COUNTY OF APP I A T/AUTHORIZED REPRESENTATIVE NAME AP LICANT%AUTHORIZED REPRESENTATIVE SIGNATURE The foregoing was( ) Sworn to and Subscribed OR(✓*Acknowledged Before me this Day of , 20 P 1 ' By Chit Nen e APWOW)r&N who is( ) personally (print name(s)of persons) making statement) JJ known to me OR( )who produced • !�� C� as identification. Commission Expires: tary Public ' ton ,•krnyp '' AUDREY B.HUMPHREY MY COMMISSION#GG 300817 EXPIRES:March 6,2023 'rFOF;F°o Bonded Thru Notary Public Underwriters 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) l` '4 fl 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 . L LIMITED LIABILITY COMPANY—List all managers(member&non-member),directors, officers, and members v -e_ LIMITED PARTNERSHIP—List all general and limited partners. LIMITED LIABILITY PARTNERSHIP—List all partners Bar Manager(Fraternal Organizations of National Scope only): OTHER INTERESTS 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 o 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 Leo 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 o 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 ❑ Yes1940 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 1940 6. Are there any persons or entities not disclosed who have co-signed the lease or loan? ❑ Yes DVNo., 7. Is there a management contract, franchise agreement, or concession agreement in connection ❑ Yes o 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 o LFIorida Administrative Code? ou answered yes to any of the above questions,a copy of the agreement must be submitted with this plication. The terms of the agreement may require the Interested persons or parties related to an entity to bmit fingerprints and a related party personal Information sheet.