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HomeMy WebLinkAboutLiquor License ,��-` � ,- �- $FCTION 3 APP.L[C�l'CiON�►PRROVAL-3,� - -� h '��� � � �-�
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Full Name of Applicant: (This is the name the license will be issued in) :-k� V,- oL .
Business Name(D/B/A) ` 16-N
L(yl._j�L
Street Address
City County State Zip Code
-V FL
1-0W
w,TaBOMPI.ET Ei3BYTHE�ZQWN .AUTHRpYG01/EtNi�Z1G YOUR BIJSiI_9SS14K3
A. The location complies with zoning requirements for the sale of alcoholic beverages pursuant to this
application for a Series: Type:
B. license.
C. This approval includes outside areas which are contiguous to the premises which are a part of the
premises sought to be licensed and are identified on the sketch?" El Yes No
ol
Check either: Please do not skip,this is i rtant for license fee sharing
❑ Location is within the ci limits orLocation is in the unincorporated county
Signed Date —Z
Title +Y�- �n� ZtSYLc n �+/LSo<— This approval is valid for days.
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 213.758.10 (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.
,OMPLETED BY THE QIVISiON OF HOTELS ANDtRESTAURANTS , A ` ;
� r � '•` "� � ORfCOUNTYHEALTH.�AUTHORtt'Y f= ,- � '^� , y
. OR DEPARTMENT QF AGRICULTURE CNSUNIER SER1tICES, .. .. _H_ _ :'v '
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 6
x "Ok �� r� SECTION,t , APP_LIGA[ ;ENTI7Y EE�CII�Y ClJNVIGT�C>lN .�, ,a 7States
Business Name(DB/A)Has the applicant entity been convicted of a felony in this state, any other state, or by the Unit
the last 15 ye
❑Yes o
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)
r g"gRt SECTION 7 SPECIAL LICENSE REQUIREMENTS x�
BEER AND,;1lIIINE LICENSES ,,
Business Name(DB/A)
G� \ �.I/�-�� i�w.;•.mac (n.�c
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 initial and date:
Applicant's Initials Date
Auth.61A-5.010&61A-&056,FAC 7
._t .ri ,.,r...SEG7ION 8;,�O
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(DB/A)
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
LIMITED LIABILITY COMPANY—List all m nagers member&non-member),directors,officers,and members
Cj
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 s 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 13'-'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 [3--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 [DNo
7. Is there a management contract,franchise agreement, or concession agreement in connection ❑ Yes 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, ❑ Yes 0--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.61 A-5.010&61 A-5.056,FAC 8
AFFIDAVIT-0 APPLIQAW
Business Name(DB/A)
"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
APPLICANT/AUTHORIZED REPRESENTATIVE NAME
APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE
'The foregoing was( )Sworn to and Subscribed OR( )Acknowledged Before me this Day
Of ,20 , By who is( )personally
(print name(s)of person(s)making statement)
known to me OR( )who produced as identification.
Commission Expires:
Notary Public
Auth.61A5.010&61A-6.056,FAC 9
,MNF SECTION 90 AFFlDAYIT�OF TRANfSFER�Rz f
ft. fi �s� ,w `` x t i
-
Business Name(DB/A)
I,the undersigned, hereby swear or affirm that I am duly authorized to make this affidavit and do hereby
consent, on my behalf or on behalf of the transferor,to the above transfer, and represent to the Division of
Alcoholic Beverages and Tobacco that the license which is being transferred is as shown in the application
and that a bona fide sale in good faith has been made to the within applicant of the business for which the
foregoing transfer of license is sought.
STATE OF
COUNTY OF
TRANSFEROR OR AUTHORIZED SIGNATURE
TRANSFEROR OR AUTHORIZED SIGNATURE
The foregoing was( )Sworn to and Subscribed OR( )Acknowledged Before me this Day
Of ,20 , By who is( )personally
(print name(s)of person(s)making statement)
known to me OR( )who produced as identification.
Commission Expires:
Notary Public
Auth.61A-5.010&61A-5.056,FAC 10
1. Business Name(D/B/A)
2. Full Name of Individual
Social Security Number" Home Telephone Number Date of Birth
® �(fl S So i 2`3 C-/o-7 �-,L e o or Z z. /,o z k, -7
Race Sex Height Weight Eye Color Hair Color
3. Are u a U.S, citizen?
es ❑ No
If no, immigration card number or passport number:
4. Home Address(Street and Number)
�� �w.�✓Ze�t� �c�r+es 7s2 - 3Q
City State Zip Code
73 `3 �-t 1 1
5. 'Do you currently own or have an interest in any business selling alcoholic beverages, wholesale
cigWette 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(DB/A) License Number
If 1 VVI A T A v-v-v,^G t-t a z s 'i-' V i, v t 1 ca'3 0`Z C et
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 [YNo
If yes, provide the information requested below. The location address should include the city and state.
Business Name(DB/A) Date
Location Address
7. Have you been convicted of a felony within the past 15 years? ❑Yes ENo
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,�i °Iving alcoholic beverages or tobacco products anywhere
within the past 5 years? El Yes Ld"lqo
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-5.010$61A-5.056,FAC 3
9. Have you been arrested or issued a nofice to appear in any state of the United States or its territories
within the past 15 years? ❑Yes 0 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. Do u meet the standards of the moral character rule?
[�Yeses ❑ No
11. Are you an officer or employee of the Division of Alcoholic Beverages and Tobacco; are you a sheriff or
other state,county,or municipal officer, including reserve or auxiliary officers,certified by the state as
such,with arrest powers,whose certification is current and active?
❑Yes LSNo
INEZ—
H{illt � �
"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 1 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. This information is used to identify licensees for tax administration purposes,
and the division will redact the information from any public records request.
Auth.61 A-5.010&61 A-5.066,FAC 4
SECTt©NtESCR� t7©N PREMISE ' B>s 1�[�ENSEDi
'�
Business Name(D/B/A)
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 you do not have
dominion 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 Are there any mobile vehicles used to sell or serve alcoholic beverages?
5. Yes ❑ No er- 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.
Auth.61A-5.010&61A-5.056,FAC 5