HomeMy WebLinkAboutLiquor 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 AST-6001
Revised 0812013
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
SSE TCGN¢ CHECICENSE C4TGOR1f. h
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License Series Requested Type/Class Requested Do you wish to purchase a Temporary License?
117rYes-,MNo
Child License Requested Number of Child Licenses Requested
Retail Alcoholic-Beverages ❑ Alcoholic-Beverage Manufacturer
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
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112
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.
FEIN Number Business Telephone"Number E-Mail Address-(Optional)
Full Name of Applicant s): (This is these name the license will be issued in) Department of State Document
Business Name (D B/A)
1s1--
Location Address(Street and Number)
kD CC, A �—
city 1 County State Zip Code
(�S �Cnl�lt L�CI�'- V LL`G1e FL Lj Ci5 OL
Mailing Address (Street or P.O. Box)
City State Zip.Code
s �ontct P0_�rsaOf.�This=sect1o�is`o tional,:seexa'"" licat%ri}inst����lons for detai(�� ;_
Contact Person Telephone Number
VjQ!E�LA M-( i G 43(,,,G_K 6 Lk-33�4t ext.
E-Mail Address (Optional) Ke-'rCaA'-1c0
Mailing Address(Street or P.O. Box)
City State jZip Code
ABT District Office Received Date Stamp
Auth.61A-6.010A 61A-6.066,FAC
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1. Business Name (D/B/A)
2. Full Name of Individual
vn_c'�5aA
Social Security Number* Flome Telephone Number Date of Bi h
3 Lt- qko - o�° ®s-Lk(A- 3 aLk 2-1 Z(4pl 6
Race Sex Height Weight Eye Color Hair Color
3. Are you a U. citizen?
❑ Yes 1ZNo QSLeS
If no, immigration card number or passport number:
t4 - 3ako - ct1�
4. Home Address (Street and Num er
2
City State Zip C�odde��
CL%,A- � Ct� 3
5. Do you c rrently own or have an interest in any business selling alcoholic beverages, wholesale.
cigarette or bacco products, or a bottle club?
ElYes otl No
If yes, lirovide 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 had-any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit
refused, rev ed or suspended anywhere in the past 15 years?
❑ Yes 4 No
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 No
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 involving alcoholic beverages or tobacco products anywhere
within the past 5 years? [:]Yes No
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-6.010&61A-6.066,FAC 2
9. Have you been arrested or issued a no ee to appear in�any state of the United States or its territories
within the past 15 years? E Yes-, o
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. DCVvou 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, county, or municipal officer, including.reserve or auxiliary officers,,certified by the.state as
such;with25 rest powers,whose certification-is'current and active?
[]Yes No
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"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)(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.
Auth.61A-6.010&61A-6.066,FAC 3
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Business Name.(D/B/A)
1. Yes ❑ Nola***' 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?
Is the business located within_ a Specialty Center? If yes, check the applicable statute:
3. Yes ❑-- Noz 561.20 2 b 1
4. Yes ❑ Nc Are there any mobile vehicles used to sell or serve alcoholic beverages?
5. Yes p . Nox Are there more than Z 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-6.010 s 61A-6.066,FAC 4
Full Name of Applicant: (This is the name the license will be issued in)
Business Name (D/B/A)
Gl l s%CGSr1p
.Street Address
City County State Zip Code
as ���, 13ci� FL �cic15 `9-
A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale
tobacco products pursuant to this application for a Series: Type: ! '!" v license.
B. This approval includes outside areas which are contiguous to the premises which are to be part ofthe
premises sought to be licensed and are identified on the sketch?" ❑ Yes No
Check either: Please do not skip,this is important for license fee sharing
❑ Location is within the city limits or ocation is in the unincorporated county
Signed Date
Title e 1� iTc- i L terns This approval is valid for days.
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OB
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,
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.
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1 x 1 6 �:; C. .. �"fk""'t:
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The above establishment complies with the requirements of the Florida Sanitary Code.
Signed Date
Title Agency
This approval is valid for days.
Auth.61A-6.010&61A-6.066,FAC 5
_ 6= RCO �� O .
Business_Name(D/B/A)
l'C 6ac.p o
Has the applicant entity been convicted of a felony in this state, any other state, or by the United States'in
the last 15 ye ?
❑Yes Vo
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)
=SECTIOlr7? SPECIAC.Lt�CENSE REQUIREIrtIIEt�TS F
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:
PleasLand Appli Date
Auth.61A-6.010&61A-6.066,FAC 6
,.
Note: Failure to disclose an interest, direct or indirect,'couWresult in denia{, suspension and/or revocation of your license.
You MUST list all persons and entities,in.the entireowrtership.structure. To determine which of those persons
must submit fingerprints and a Related Party Personal Information,sheet,see the fingerprint•sectidn in the
application instructions.
Business Name(D/B/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 mana ers member&non-member),directors, officers, and members
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 .0'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 ,�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 "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 o
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 Z"'No
7. Is there a management contract, franchise agreement, or concession agreement in connection ❑ Yeslo
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 ,�lo
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 paq personal information sheet.
Auth.61A-6.010&61A-6.066,FAC 7
rT� t9kAF1DA1/IOfiA:PPaLCANT€ `
� ������x.. �°��- �'�'�'����. '"` �OTAti1Z�►�7`��N.�REQ�IIRED�' ;���;,��,,�� �r:�F.��"... r�,'�� � �� e.
Business Name,(D/B/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.61 A-6.010&61 A-6.066,FAC 8
p fi SECTIC N 10 +� RR6N 1»IC�E EE UR0 VD,>?L HE 7
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This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the
application to ensure the most up to date information is captured.
Business Name (D/B/A)
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.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.I.
Current Alcohol Beverage and/or Tobacco License Permit/Number(s)
Date of Birth Social Security Number*
Street Address
City State Zip Code
Auth.61A-6.010&61A-6.066,FAC 9
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