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HomeMy WebLinkAboutLiquor License r tOffice Use Only Permit# - ? � � ;���=Date of Apphcafion �' ''' eyes PLANNING AND DEVELOPMENT SERVICES DEPARTMENT Building and Code Regulations Division RECEIVED 2300 Virginia Ave - Fort Pierce,FL 34951 JUN , 2015 772462-1553 APPLICATION FOR ZONING COMPLIANCE—BUSINESS (Not in ome) s ►�o ar2S L0 4 r 4-2 Name of Business: Type and description of business: cr--: - Www�•� S'`�?nt t�-rl�b�-T Number of Employees / Number of Parking spaces available for b ness gg,am�; Address of Business: �. �� S �'"FL� Zip17 Name of Shopping Center,if applicable: p Name of Applicant: 3Y Mailing Address: ( fid Contact Phone: ME-72-3 Email: Property Tax ID#:(Available from the Property praiser's Office) Is this"a restaurant?Yes✓No_If yes,will a ohol be served?Yeg�No_ Comply with distance req:Yesl�No_ If yes,need a copy of License from ATF Is this a conditional Use?Yes /No If yes,please attach Conditional use document with conditions of approval. I_understand it is my responsib' ty to contact the Fire Department prior to the issuance of the Zoning Compliance. This application certifies that the p perty on which the above described business will operate is properly zoned for that purpose pursuant to applicable con land development code. 14 j4_, pplicant's Signa re Date Please Print Name Q,F11<CEU ONLY _ Zoning: Da Land Use: SIC Code: Yl-2, Land aping Req.:Yes/No; Parking Req:Yes/No Notes: N e&type of previous business: Site Plan Name: erify if proposed use triggers a"Change in Occupancy"? Yes/No;Building.permit needed:Yes/No PDS Staff Date Revised 5/28/2015 DBPR ABT-6002—Division of Alcoholic Beverages and Tobacco Application for Transfer of Ownership of an Alcoholic Beverage License STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6002 Revised 0812013 If you have any questions or need assistance in completing this application, please contact the Division of Alcoholic Beverages& Tobacco's(AB&1)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.- hftp://www.mvfloridalicense.com/dbpr/abttdistrict offices/licensing.html ,'ter.,.�.n v.R�`..aaz ,,�} �k��.k ,_ �,,...�- :e-_a.�'T •z,".cr'r.a�a.,.ya.>ne�-'.�'.G'°..a,..e'°.4.as " ^mow>.w .. „mac ' �"",:.A ecu P... s,�w�`'.�'"'�'w..,�.,, .�', _aa ® Retail Alcoholic Beverages ❑ Alcoholic Beverage Broker Sales Agent ❑ Beer/Wine/Liquor Wholesaler ❑ Alcoholic Beverage Manufacturer ❑ Alcoholic Beverage Importer ❑ Passenger Waiting Lounge Seller's Business Name License Number LANDING THE 6602566 Transaction Type: ® Transfer of Ownership Do you wish to purchase a ❑ Change of Location Temporary License? ❑ Change of Business Name ❑ Change in Series ® Yes ❑ No ❑ Decrease in Series ❑ Increase in Series ❑ Change of Officer/Stockholder/Amended Corporate Name ❑ New Retail Tobacco Products(must check one or more of the below) []Pipes Only ❑Over the Counter EjVending Machine License Series Requested Type/Class Requested 2COP Child License Requested Number of Child Licenses Requested ABT District Office Received Date Stamp Auth.61A-5.010&61A-5.056,FAC 1 F'e ,„,'�.. .. '''q*x �'O W�7 I,,l_Qf i..It.G ,Nv„.... Ili, 11 1!l,1['►T�nQ � '' z .. s- w_� licant is a corporation or other legal entity, enter the name and the document number as registered Florida Department of State Division of Corporations on the line below. mbe Business Telephone Number E-Mail Address(Optional 0z�6 "' ,DY6 4�wn�a� ��dkV�rt.•C �'� e of Applicant(s): (This is the name the license will beissued in Department of State Document# TERPRISES LLC L15000073604 Name(D/B/A) RS LANDING Location Address(Street and Number) 9815 S OCEAN DR City County State Zip Code NSEN BEACH ST LUCIE FL 134957 Mailing Address(Street or P.O. Box) 28 LAWERNCE LAKE DRIVE City State Zip Code BOYTON BEACH I FL 133436 Contact Perso ol 0 9-ac 0 r� Telephone Number 5G I'�£rf - ?23 ext. E-M 'I Address(Optional) '50QjL -0A,1- On vttiakC .0 Maili g Addr ss(Street or P.O. Box) 22- city State Zip Code 3 3 36 If this application is for the transfer of this license, is the transfer due to revocation proceedings? ❑Yes ® No If yes, is there any personal relationship to the transferor? ❑Yes EWNo If yes, explain the relationship: Auth.61A-5.010&61A-5.056,FAC 2 �3� Th>ss sects n rr�ust be„cohipletI d fo each pe�on d rectly�co tnecteci wi h the bustnes nless th 3t -.IMF!” , i 3�' "' +.,... � {. eticense�e. ,m k��`. .` "`x�4 Linz. 3z' A _.. 3 ✓.5 v.s�,=.y .„ 1. Business Name (D/B/A) SAUDERS LANDING 2. ull Name of Individ I A E-f ocial Security Number* Home Telephone Number Date of Birt -gC)3 U£�Y Le 6 SC9 rr �� 'SE'S l s-& Race Sex Height Wei ht Eye Color Hair Color 3. Are you a U.S. citizen? Yes ❑ No If no, immigration card number or passport number: 4. ome Address(Street and Number) City State� Zip Code � 5. Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or tobacco products, or a bottle club? ❑Yes 4 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 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 [�'No If es, r vide 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 LXNo If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Re uirements 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 E 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-5.010&61A-5.056,FAC 3 9. Have you been arrested or issued a notice to appear in any state of the United States or its territories within the past 15 years? ❑ Yes ONo If yes, provide the information reque ted below and a Copy of the Arrest Disposition. Attach additional sheet if necessary. Date. Location Type of 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, 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 1XNo m "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 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-5.010&61A-5.056,FAC 4 Business Name(D/B/A) SAUDERS LANDING 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. (7-11 4 a _C, �f Auth.61A-5.010&61A-5.056,FAC 5 �� ` SEG ON`5f LAPP bhT10�1�►P `Rb� LS ' , '"4�..-�-va-r.�+.i�.. ,�sv'�'+.w:-aa✓c�.°�.,..'"nr. a�..m"',3��1'� ..� s°?,nu�.a ,.p__ _ ..... ..n...,.�-�+,�_�' w. r .�r ,..��, .,., ets....-,�Iw,,,.-��_o,w...ff��`a,-du€ Full Name of Applicant: (This is the name the license will be issued in) Business Name (D/B/A) SAUDERS LANDING Street Address 9815 S OCEAN DR City County State Zip Code JENSEN BEACH ST LUCIE FL 34957 i A. The location complies with zoning requirements for the sale of alcoholic beverages pursuant to this application for a Series: 2COP Type: B. license. C. 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 eNo L Check either: Please do not skip,this is i portant for license fee sharing ❑ Location ' wit in the city limits or[Location is in the unincorporated cou ty Signed Date Title his approval is valid for, days. �,+�.� ,�c,Aa� '�`4-`�N.��",y��4. �.n a�rY.::: .�a' ✓ Ed �. it q'�'"'y�"r �. s-' ;a,., �x&a ,`x L. y.'5.� `�' �:- . .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 S ` concerning registration for Sales and Use Tax, and has paid any applicable taxes due. 4 P' Signed Date Title Department of Revenue Stamp This approval is valid for days. i" �r�° �aut �� � ,s- a td i +�✓"a r'x 1'�e s �s„ � "�,a.?' r� ' � a x a�, T1i—e.ALTI �aC'r ha,'.,,.aa �d4Y D1V1SlON OF I ® tOtAMD#t STAUIZA TS 3 NO- 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 [CAN 1" I±tTilslf11(GIC} .. w Business Name(D/B/A) SAUDERS LANDING Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15 years? ❑Yes ® No 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) � SIECf IONISPECIAI�LICENSEREQUIREME V= r DAESa NO,� 1,14P,LYYTQ,BEER AN-j D, Business Name(D/B/A) SAUDERS LANDING 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-5.056,FAC 7 F EGTION8�QtSCLOSUREQ {NTER1�DFAe to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your license. MUST list all persons and entities in the entire ownership structure. To determine which of those persons submit fingerprints and a Related Party Personal Information,sheet,see the fingerprint section in the cation instructions. ame(D/B/A) LANDING 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 qeneral partners LIMITED LIABILITY COMPANY—List all mans ers member&non-member),directors, officers, and members AMBR SAUDER,RANDOLPH AMBR SAUDER,BELYNDA AMBR SAUDER,DREW SAUDER,SAMANTHA 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 N No 12. 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 N 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 N 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 N 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 N No 6. Are there any persons or entities not disclosed who have co-signed the lease or loan? ❑ Yes N No 7. Is there a management contract, franchise agreement, or concession agreement in connection ❑ Yes N 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 N 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.61A-5.010&61 A-5.056,FAC 8 u �4 �ASCTJ1N9=KA' ID ►UtTOF A11� LANT M � AR�ZAhQNREQUIR � h sem ... , s - .._,- ....... ....*n. +'x... .. a�.,._.E a:,.� .....« ..« '.a.'aem:.,P. Business Name(D/B/A) SAUDERS LANDING 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.61A-5.010&61A-5.056,FAC 9 aN R u N SEeTt, 1 AF I' OV, OFA < IrIS RQ41 � j " v w NO' ARIfZ1�filON RfQ�1tRQ IV 9�„ , ., ... �, .. .��. �.o�...,., Business Name(D/B/A) SAUDERS LANDING 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 Y �ISO °SECS ION 11, C11._ iyT SIC. NSEE USP© T 3�!►MAWS.K 151- 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) SAUDERS LANDING 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-5.010&61A-5.056,FAC 11 VULU11 Dy JMIL1Ly INUMC xi, E .. STATE ft z DIVISION OF CORPORATIONS x Detail by Entity Name Florida Limited Liability Company JSEA ENTERPRISES LLC Filing Information Document Number L15000073604 FEI/EIN Number NONE Date Filed 04/27/2015 Effective Date 04/27/2015 State FL Status ACTIVE Principal Address 9815 S. OCEAN DR JENSEN BEACH, FL 34957 Changed: 05/20/2015 Mailina Address 28 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Re istered Agent Name&Address SAUDER, RANDOLPH A 28 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Authorized Persons Detail Name &Address Title AMBR SAUDER, RANDOLPH A 8 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Title AMBR SAUDER, BELYNDA G 28 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Title AMBR SAUDER, DREW A http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 6/1/2015 Letaii Dy rnnry ivame rage vl 28 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Title AMBR SMI&ER, SAMAiN Ms E E-Filing Services Document Searches Forms Help 28 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Annual Reports No Annual Reports Filed Document Images 04/27/2015-- Florida Limited Liability View image in PDF format CopvriohY.n and Privacy Policies State of Florida,Department of State http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 6/1/2015 x0I ETI:T lS$ECIC�I � �'Pt,Y1NG�FQR1�7 1Nsl411 �ES� IgPYNZs Fk� Business Name(D/B/A) SAUDERS LANDING The following information is extremely important and should be read in its entirety. Because of restrictions placed on the Department of Revenue in divulging confidential tax information,the business activity of the previous owner cannot be discussed without expressed written consent. Therefore,if this application is for the transfer of an alcoholic beverage license,the following section of this form must be completed before the Department of Revenue can approve your application. If the owner is unwilling to complete this disclosure form,you may request a meeting with a Department of Revenue representative and the owner jointly to discuss any potential liability for which you could be held responsible. DO NOT RETURN THIS FORM TO AB&T WITH YOUR APPLICATION Purchaser's Name JSEA ENTERPRISES LLC Business Name Sales Tax Number SAUDERS LANDING Street Address 9815 S OCEAN DR City State Zip Code JENSEN BEACH FL 34957 Signature of Owner, Partner, or Principal of Legal Entity This section must be completed by the present owner of this alcoholic beverage license and must accompany our application for sales tax registration. I, the undersigned individually, or if a corporation or other legal entity, for itself and its related parties, hereby authorize the Department of Revenue to release to the above purchaser, the Division of Alcoholic Beverages and Tobacco, and the status of my account number Seller's/Transferor's Name or Entity Signature of Owner, Partner, or Principal of Legal Entity STATE OF COUNTY OF The foregoing was( ) Sworn to and Subscribed OR ( )Acknowledged Before me this Day of 120 , 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 13 Department of Business and Professional Regulation RECORD OF INSPECTION Division of Alcoholic Beverages and Tobacco Bureau of Law Enforcement Case Number: Alcohol Inspection#: Tobacco Inspection#: r ' �S �Licensee/Permittee: `��suS(. \dAkIr `` 1\4. License/Permit Number: f Series: Type: _Alcoholic Beverage_Tobaccz) Dual .Address:q(,:�k`.-, Q1, oc iu\— 1 City: -QR2. rl'•1..- 1 . C�, County: 1 E s '"' Zip: �;. {`J Telephone( ) Inspection Date:(_),,q /.0 / L > Time started: :1 s AMI N Time completed: AM/PM lY OFFICIAL NOTICE—Violation Observed Informational purposes Notice to produce records Record of inspection/,visit-no violation observed WARNING: Notice of noncompliance[refer to comments/instructions section]. No administrative or criminal charges are being filed at this time. Intent to file Notice to Show Cause for violation(s)specified below CASE#: Violation of s.562.11 and/or s.569.101, Florida Statutes: It is unlawful for any person to sell,give,serve or permit to be served alcoholic beverages to a person under 21 years of age or to permit a person under 21 years of age to consume such beverages on.the licensed premises and/or to sell,deliver,barter,furnish or give,directly or indirectly,to any person who is under 18 years of age,any tobacco product(refer to the comments/instructions section). Other: Comments/Instructions: u. Do a -�S5 VV k)&6,n >ji l 9� �t�e�i` 1� aj Ce-?l tk. i`iti i'� i 1 i _ J 31f�-SPY` . jt� I� I ( ~ l V�w1/�_ —%) .1&�v/�/1�'1 3 � rti ) 1 ter. i' - rt1�.... �"_'E ! i'l y 1..�e�I��f I ��' �S I �t ���'i^4��1� h'� ll<<.d �'� '=3`���/F V�—�\ —i.•,A�.�' 1. Failure to comply with the instructions specified on this official notice may result in criminal andlor administrative charges being filed against the viola�or(s}and the referenced alcoholic beverage/tobacco'licensea y/j•a� k l2�� .���tJ�y f i l�J � ��.� 1, iai7/t #:i ./� Telephone Li/c•-ens'e/en/0e,rmitrt}ee/Representati�v+e(Print Name) Signature J a� moi!< 3..,./i=- O y�-q V\. �.L Li N 'IBJ Y •:S i al.ti? �f 1 SIV 1 l.'1 / i . ABT InvestigatoWEmployee(Print Name) `Signature Date CONTACT INFORMATION: �7 Office: 't-4 �Lfi - Telephone('LL }d4LI '� - q?� t www.myftoridalicense.com Name of District Supervisor(or designee): _ � � Telephone"(`� ) 0 -�1�. Original: Case file Yellow Copy: Licensee BLE-320(0712013) Slate Accredited Law Erofomement Agency