Loading...
HomeMy WebLinkAboutLiquor License ,��-` � ,- �- $FCTION 3 APP.L[C�l'CiON�►PRROVAL-3,� - -� h '��� � � �-� � ] ^,., ,.z^"3"�4i ..,,Z u�: '`e a ' £ 2 Z �._ �"� S� n-_3 '-., a c^• ��,,�`-Gh ,�, . i ^v-x ,�{ .,'e ?I.,._a�.,._..kk..,a.,,=. ,s:1u.r.;La.r+ ...3.'7°� t�'rst_�.a.�,�-^ass`�?'�._,,.s'ru�n�t_:5..r,°.,_. 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