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Home My WebLink AboutLiquor License Office Use Only Permit# �� V� Date of Application 77 `�F'�,'� a�" �ice. PLANNING AND DEVELOPMENT SERVICES DEPARTMENT �� Building and Code Regulations Division ' 2300 Virginia Ave Fort Pierce,FL 34951 772-462-1553 APPLICATION FOR ZONING COMPLIANCE —USE PERMIT/ Name of Business: / Ty a and description of busine s: _� Number of Employees (/ Number of(Paajrking spaces available for business Address of Business: FL Zip,. c� Name of Shopping Center,if applicable: Name of Applicant• Mailing Address: U Business Phone: -12:1 / . Email: Property Tax ID#: (Available from the Property Appraiser's Office) Is this a conditional Use?Yes /No If yes,please attach Conditional use document with conditions of approval. I understand it is my responsibility to contact the Fire Department prior to the issuance of the Zoning Compliance. This application certifies tlthe property on which the above described business will ope ate is properly zoned fort at purpose pursuant to applicable county land development code. ,D%, , g� -�� App cant's Signature / Date Please Print Name ;OFFICE USE ONLY Zoning: C�'" L:XdUs l SIC Code: Date Verified: Landscaping ReXuse Yes No:_ Handicap Parking: Yes' No:_ Fire Dept.: Yes No: Name;&type ofs business in this location: Does the propo igger a"Change in Occupancy"? Yes No: If yes,it is r commended the applicant meet with the Building Official to determine if any modifications to the interior of the b iness are necessary per the Fla.Building Code. Planning Tech/Zoning Staff Date *A Fire Department inspection is required for all applicaAir.�EIVED SLCPDSD Revised 05/14//2014 MAY 9 2015 DBPR ABT-6.001 —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 maybe 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: hfp://www.mvflorida.com/dbprlabt/district offices/licensin4.html License Series Requested Type/Class Requested Do you wish to purchase a Temporary License? ❑ Yes ❑ No 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) El Pipes ❑Over the Counter ❑Vending Machine �- �, � �F �SECTION 2� LiCENSEIN_FORMiAT10N=, A t � x 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. FF-IN Numbpy� C. Q Business Telephone Number E-Mail Address(Optional) no Full Name of Ap licant(s): (This is the ame the license will be issued in) Department of State Document# e Business Name(D/B/A) r _ Location A d ess(Street and Number) . r► •1st City �.: 4 County State Zip Codez)r Q Mailing Address(Street or P.O. Box) Ci � � i a �� State Zip;C�e Ct Y,=ContacfPerson is,,section,iso}tional;see`a 'Iicar on instructuons#o details fy _ _. Contact Person Telephone Number E-Mail Address (Optional) an Mailing Address(Street or P.O. B0X9 \ � Lj City• Mate Zi C. C-r �` - - �. w 77 APT p�st►i�t Q'ffIc9 R�reivOO�4f1'81 rP Auth.61A-5.010&61A-5:056,FAC i, ,� .k x ., .,,,.`�::�... .'., :SECTION 3;-�RELATED�,P�►RTY;PE�SON�1t,'1L�FORMATION "_>,,�'. . �. -.a., ..;,.'„ This sectio43" must be completedtfor e�ch person d�rect(y connected with the bus�nes,�unless they.; 1. Business Name (D/B/A). - - W. �f 2. Full Name of Individual,- - Socia Se;u ' Number* Home Tele hone Numbs Dae ofrth . Race,-,, SexHeigh Weight E ve Color Hair Color 3. Are Wylou a U.S.citizen? es ❑ No If no, immigration card number or passport number: -4. Home Addre�(St end Number), L4L4G a� qty��,. - � Stade ,�p -� E. L 5. Do-you currently own or have an interest in any business selling alcoholic beverages, wholesale Vreesrftk2r�obacco products, or a bottle club? No If yes, provide the information requested below. The location address should include the city and state. usiness Name (D/p/A), 1� License Nu be Loca i n Address 6. Have you had any type of alcoholic beverage; or bo tle club license, or cigarette, or tobacco permit refused, rev ked or suspended anywhere in the past 15 years? ❑ Yes M 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?, Li Yes L9 No If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as request d in the Application Re uirements checklist. Date Location Type of Offense 8. Have you been convicted of an offense volving alcoholic beverages or tobacco products anywhere within the past 5 years? ❑ Yes VNNo If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Ap lication Requirements checklist. Date Location Type of Offense Auth.61A-5.070&M-5.056,FAC 2 9. Have you been arrested or issued a n ice to appear in any state of the United States or its territories within the past 15 years? ❑Yes , 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. Doyou meet the standards of the moral character rule? - Yes _ No i-1-7 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 est powers,whose certification is current and active? ElYes M No NOTARIZATION STATEMENT r "I swear under oath or affirmation under penalty ofperjuryas 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. -1 further swear-or-affirm-that-the foregoing information is true and correct."- STATE OF COUNTY OF c�Gi-j'►f C-VLi`e- APPEIC SIGNATURE The foregoing was Swom to and Subscribed OR(4Acknowledged before me this O$4t" Day Of �'� 20 15 , BY �o"`� I` J��(2� who is(personally (print name of person making statement) kn to me R( )who produced as identification. ,•,� LEMUEL K.JUMNbUN III Notary Public-State of Florida 't ice. ate;My (res J�!30 2018 01 Notary Public .,,, �;,,.• O VIVIFF'7'MS: . 3 c9 8 (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 identifylicensees 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. Asti;A A '69r;,phd 3 r SECTION 4 DESCRIPTtON�bF,,PREMISES--TO BE-UCENSEDu T,OdaBEEGO1kIPLETED BYTfEAPt?LICANT£ Y< ,,.. x,, ;, kx '4 . , . 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 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. 1-61 of 6r U C> ' Iwo n Ile ewl t Ock a � ; i n i SEGTIONA�PLIC► fON1PPROVACSk f< Fjjll Name of AQplicant: (This is the name the license will be�ssued irA `�� l5tsiness Name(D/B/A) J \e Street A dress. / c� -- - V-- a 0D 015.3. cityCounty , State Zip Code G E- FL 3LI9 IN NIS 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: 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 th sk tc ?" J] Yes HINo Check either: a do not skip;this is important for license fee sharin ❑ Locations it i h city limits or❑.Location is in the unincorporated conn Fylr� Signed Date �/ l� Title Gin/ / / This approval is valid fo ��days. ' IEE SDq7EFAXR TMENTpOF RE1lES�UE _ u , t� _ k The named applicant for a license/permit has complied with the Florida Statutes con 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. MM HEALTI� Lam, h � TO4BEtCOMPLETE�B�(YTHE`D]VIS�ON OFiiOTEL$AVID T�1URANTS yrs O COxZ UNTY HEALTH AUT}iORITYi s , r � �h f _ }(3R„13EPIRTMENT,DF.AGRfCULTURE#CONSUMER SER�/ICES _ The above establi nt complies with the requirements of the Florida Sanitary Code. Signed Date IV 17 1 Irl� Title_ _Agency. This approval is valid for days. Auth.61A-5.010$61AS.056,FAC 5 SECTtONu APPLICANT ENTIT1l FELt3NY CONViCTlON Business Name (D/B/A) Has the applica entity been coni ed-of a felony in this state, any other state, or by the United States in the last 15 y s? _ -E]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). SECTIONS" SRECIAL'LICENSEGREQUIREMENTS t ' - - - -Please-check-the_appropriate-box of-the_license for_which-you are applying.~ FiA 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 pate AUth.61A-.010&61A-5.066,FAC 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, seethe fingerprint section in the application instructions. --Business-Name(D/B/A) • � ,� l�.-t !. �� .�� 1. When applicable, complete the 6ppropriate 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 managers(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 erson or entity listed.as the applicant 1. Are there any persons or entities not disclosed who have loaned money to the business? ❑ Yes 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 ElL/Yes Ivo 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 El 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 aright 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 "' No 7. Is there a management contract,franchise agreement, or concession agreement in connection 0 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 dNo Florida Administrative Code? If yoq.answered yes to any of the above—questions, a copy of the agreement must be.submitted with this Ap'plication'. The.terms of the agreement may require.th&interested persons or parties relayed to an entity to submit fingerprjrtts and'a related,pa;►ty pe►spnal informatiort sheet.. , Auth.61A-5:Oi0 8 MA- AFFIDAl/IT QFxAPPLICANT� ` f NOTARIZATION REQUIRED,„ v+ Business Name(D/B/A) "I;-the undersigned individually, or on behalf-of aiegal 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 d i G. dam, c l COUNTY OF .v APPLICANT/AUTHORIZED REPRESENTATIVE NAME APPLIC T/AUTHORIZED REPRESEATIVE SIGNATURE The foregoing was (✓)Sworn to and Subscribed OR(Acknowledged before me this 0� Day 20—LG—, By No-44, 0- /" 41140-d who is (Vj'/p`ersonally (print name(s) of person(s).making statement) known e ( )who produced -0 LEMUEL 11.jOHNSON as identification. Notary Public-State, Florida Z , Zo M hi smogYFx19H �s Q(a 30 ao/� Notary Public """' ANfh,614-5.gip&f -5,056,FAC 8 CURRENTkLICENSEE UFDAT!, T�I SHEET This section is to be completed for all current alcoholic beverage and/or tobacco license holdets listed on the application to ensure the most up to.date information is captured. __-- —Business_Name_(D/B/A -_ ___ Last N e First \� M -- Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Securltv Number* Street Address , A Cit State Zi .,C d c_ L Last Name Current Alcohol(Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* r dJ_ Street Address Y�Ab - -Y- (-=n CityState 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-5.010&61A-5.056,FAC 9