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Liquor License
i "� 4M PLANNING AND DEVELOPMENT SERVICES DEPARTMENT * Building and Code Regulations Division 2300 Virginia Ave Fort Pierce,FL 34951 772-462-1553 APPLICATION FOR ZONING COMPLIANCE—BUSINESS (Not in ho e) r /t..,� � G"�f� Name of Business:,. Au0th VA tJ a Type,and description of business: 1 C__dv�\o Number of Employees 10 / Number of Parking spaces available for business Address of Business: `W(S s Ct4tW &t, 0 S A J—'al`6 F Zip Name of Shopping Center,if applicable:. T-Sc " Name of Applicant: 1(k _� Mailing Address: _ / _,,,2 Contact Phone: :772 --Z7-9— 0246, Email- �9Sd9-�cp�, t� 6 &f_;CofM Property Tax ID#:(Available from the Property Appraiser's Office) s 0 -= L- 1� - l Is this a restaurant?Yes"No—If yes,will alcohol be served?Yes No` Comply with distance req: Yes✓Noy If yes,need a copy of License from ATF Is this a conditional Use?Yes fNo �f yes,please att h Conditional use document with conditions of approval. I understand it is my responsibility to contact the Fire" partment prior to the issuance of the Zoning Compliance. This application certifies that the property on which the abo described business will operate is properly zoned for that purpose pursuant to applicable county land development cod -/z�h l�5 Nuc Ap licant's Signature /arn Date Please Print Name �FF10E[TSE`QNLY� Zoning: SIC Code: Landscaping Req.:Yes/ s/No Notes: Name&type of previouSite Plan Name: Verify if proposed use ggers a Change in Occupancy"? Yes/No;$uilding permit needed:Yes/No RECEIVED PDS Staff Date f SEP 2 3 .2015 F } Revised 5/28/2015 —I�VLy t..V oil- 1 Ems: 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&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: http://www.mvfloridalicense.com/dbpr/abt/district offices/licensina.html fl SECTION 1 —LICENSE TRANSACTION{ S � . ,Y> ® 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: N Transfer of Ownership Do you wish to purchase a ❑ Change of Location Temporary License? ❑ Change of Business Name ❑ Change in Series N 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) ❑Pi es Only []Over the Counter E]Vending 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 C, Nl=ORMAT[QN 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 ' Telephone Number E- it Address (Optional .7 '4soawt Full Name of Applicant(s): (This is the name the license will be issued in) Department of State Document# SEA ENTERPRISES LLC L15000073604 Business Name(D/B/A) SAUDERS LANDING Location Address (Street and Number) 9815 S OCEAN DR City County State Zip Code NSEN BEACH ST LUCIE I FL 134957 Mailing Address (Street or P.O. Box) 28 LAWERNCE LAKE DRIVE City State Zip Code BOYTON BEACH I FL 133436 _. . -. tiGontct#?erson. Thrssection fsotional;see=a lacaon:rias#r0cit1onsxfar,detaiT,sE ' . „ Contact Perso Telephone Number zol t 09-0' 0 M'e— 72-37 ext. E-Mit Address (Optional) 'MailZi gg Addr s� s (Street or P.O. Box) l�� ftt-c .lam City State r r zip Code3 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 XNO Ilf yes, explain the relationship: Auth.61A-5.010&61A-5.056,FAC 2 LATED.PARTY PERSONAL INFORMATION'.._.. Thissecf�onmust be cornpletedfor eachperson dre�ctly connect�edrNith the business, unles �they� are a�cglrrent,lrcensee � . , ,.4 . ,, a. .._ . .. .. . 1. Business Name (D/B/A) SAUDERS LANDING 2. ull Name of Individ I c4¢ b 0_ ocial Security Number* Home Telep one Number Date of Birt -3763 ��- 6 �-�r� - � s , 1 I S S� Race Sex Height Weight Eye Color Hair Color S ,r1nj 3. Are you a U.S. citizen? Yes ❑ No If no, immigration card number or passport number: 4. Florrie Address (Street and Number) r1t-tl�FCe2 City State Zip Code 6 �� B ( - 3 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 yesprovide 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 rbv`ide 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 El 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? ❑ YesNo 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? lxcYes F1 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 [ No ,a r ' "NO'CARt2AT10N STATEMENT w "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 OFLi COUNTY OF APPLICANT SIGNATURE The foregoing wasb() Sworn to and Subscribed OR ( )Acknowledged Before me this Day Of l - 20 15 , By ���01 ' �1 -A . GUd� who is ( ) personally (print name of person making statement) known to me OR ( )who produced as identification. ro4'91 ft *� State of Florida -7,o` Commission Expires 1010312QAmmission Expires: Nota °FFA Commission No.EE 849823 (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 tq 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 r E j; hisPra�n`rnist b��l�oeld ilf'orYeirso�ndirtly°,connected wfththe btisi<ress;`uniessthnr a'ffi>-a t�S '74-0 � 1. Business Name�(D6) LAWO cb 2. Full Baa�off Individual Social Security Number* Home Telephone Number Date of j3ift W— v 1G j--3 C_ .SS S Race Sex Height Weight Eye Color Hair Oblof b— 5—�r IZ-S -� e erica 3. Are you a U.S.citizen? a Yes ❑ No If no, immigration card number or passport number: 4. HQme Address(Street and Number) City State Zi FC �3 e 36 5. Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or to�cco products, or a bottle dub? ❑Yes [9-No If yes, provide the information requested below. The location address should include the city and state. Business Name(13/131A) License Number Location Address 8. Have you had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit refused, revolmd or suspended anywhere in the past 15 years? ❑ Yes E3No If yes, rovide the information requested below. The location address should include the d and state. Business Name(D/B/A) Date Location Address 7. Have you been convicted of a felony within the past 15 years? Ll Yes o. 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 [9-flo" 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 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 2'1Go 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 you meet the standards of the moral character rule? LW-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 ED-go' °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 �� m 0O-) APPL CANT SIGNATURE The foregoing was( )Sworn to and Subscribed before me thispp 2 Day of 37V�Q 20 15 . By �W) d&_G SJ U c _.— who is( ) personally (print name of person making statement) known to me OR(A)who produced -:l✓ 171 1 'fi1�GLC e-o as identification. ?fit' pneWilRinson 4,,, Ch State of Florida My n Egres 1 5Commission Expires: 22,.20 Nota 'c orifiNo,EE JHQQ (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.1.93,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 ftensees for tax administration purposes. This information is used to identify lienees for tax administration purposes, and the division will redact the information from any public records request. F .t, ¢t x 3 FIS r'['1t?1 —NEI. T D PARTYP RSONA1.INFORNC MON x � 3 , �. [s'� h 5'a> bs�cd"mpts#�drfor�, ,Psrsoih��Iirectly� tt»acted_ twrl��the bdsineuatless'th 1. Business Name(D/B/A p c' .S' 2. Full Nj@me of Individual ,Da" A- ,�->A" n ividual "444- So ial Securi Number* Home Telephone Number Date of Bih 56f— 3-36— * 5-5 v z— Race Sez Height S d Wei ht Eye Color Hair Color 3 1 A .5---1 t / c,cq Q l 3. Are you a U.S. citizen? L-'Yes ❑ No If no, immigration card number or passport number. 4. Home Address(Street and Number) City � 4 Stat ZipCode � 5. Do you currently own or have an interest in any business selling alcoholic beverages, wholesale ci arette or tobacco products, or a bottle club? Yes El-Wo 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 [0-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 LJLNCII— If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date I Location Type of Offense 8. Have you been convicted of an offense involving aicohotic beverages or tobacco products anywhere within the past 5 years? ❑Yes G-Ma 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 t. t. issued a no Ce ries 9. Have you been arrested or i ti to appear in any state of the United States or its territories within the past 15 years? 0 Yes L!�C If yes, provide the information requested below and a Copy of the Arrest Disposition. Attach additional sheet if necessag. Date Location Type of Offense 10. Do u meet the standards of the moral character rule? Nos El 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 arre-st powers, whose certification is current and active? [:]Yes 94o -.,'N0TA' RlZAX1Q"_ ul 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--CL COUNTY OF (CANT NATURE The foregoing was M Sworn to and Subscribed before me this 2 Day 20 By', 1-e—L6 A Sa udee- who is personally (print name of person making statement) known to me ORwh j Ch6stineV"nSon /.tC&-nSR,- as'idenfificarion. awle UT Flonal tar My Commission Expires 10/03/2015 Commission No.EE-8= Commission Expires: ON-'31' No 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 55.9.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Tide 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 inforrnation is used to identify licensees for tax administration purposes, and the division will redact the information from any public records request. - r.t�.z. ,'�<�.�.fi '1Ehisn�'mtist ii�r'° m eted forac# �soncllrec#ty"c�onnecteditwlthUje business,unietiiiey X#w lt�..ay■A `UG,Hv(„. /►tt�...5',+}drexr y(e '4” �p ,# rirsi#ji r��S:B_�,trl�l'!'t��i;C811l4@Q�.1.�.r ..,J� � �lt : b..'ia`.= t FiJRt�1 0- d. t.' h �l l'+G' k•i 1. Busin s Name(D/B/A) oAn.S 2. Full Name of Individual Soci I Security Number* Home Telephone Number Date of Bi zh� y7 3 �— — o3g" 561 33 ,sem Rac Sex Hei ht , Weight Eye Color Hair Cod rr c 3 r2cfwr� (S 3. Are you a U.S. citizen? D-'-Yes ❑ No If no, immigration card number or passport number. 4. Home Address(Street and Number) City WC- State Zip Code 36 5. Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or tobacco products, or a bottle dub? ❑ Yes ❑-N'o If yes, provide the information requested below. The location address should include thea 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 Sklo 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? Lj Yes o 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 o 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 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 94o 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 you meet the standards of the moral character rule? [ Yes ❑ No Ill. 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�arr�t powers, whose certification is current and active? ❑Yes [moo .S:.n "I swear under oath or affirmations 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 I reni.+C� L CANT G The foregoing was( )Sworn to and Subscribed before me this Day o , 20if�_, By-JAW kyA- ud-P'r, who is( ) personally (print name of person making statement) known to me ORP�)owt�PRroduced nh is rloal�illanserl 1�'I vim_ [ , as identification. State of Florida My Commission Expires 10/03l2015 Commission Expir ON.LO/V� Not No.IT$19823 is (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. M 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. £+ E i _ "+, 1i� i § K'� 9 ,�y} "fie* �s_ 2` RFs , -�a...., M NO Business Name(D/B/A) SAUDERS LANDING 1. Yes ❑ No 0 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 statu ❑ 561.20 2 1,F.S.or[I561.20 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. ,o r� r -LZ-- _ S Auth.61A-5.010&61A-5.056,FAC 5 , i, s SECTION 5 APPLICATION APPROVALS a y Full Name of Applicant: (This is the name the license will be issued in) I I Business Name (D/B/A) SAUDERS LANDING Street Address 9815 S OCEAN DR City County State Zip Code JENSEN BEACH ST LUCIE FL 34957 IA ZONING ., gE COMPLETED BY-THEZONiNG AUTHORITY_GOVERNINGYO,UR BUSINESS LOCATIQ,N,,. 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 ► No Check either: Please do not skip,this is important for license fee sharing ❑ Location ' wit in the city limits or Location is in the unincorporated cou ty Signed Date /J'r Title his approval is valid for days. 77 . SALES TAX t z .,A. . . „TO C, M' BY THE DEPARTMENT,OF REVENUE . ,, _,,, a 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 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. HEALTH% r TO BE COMPLETED BY THE Dl1/ISION OF HOTELS ANBD RESTAURANTS � F� �OR COUNTYHEALTHAUTHORITY � ; ����� - , . ,.. ,, �OR;DEP RTMENT OF AGRICULTURE,&CONSUMER SERVICES - n -,� �" � � ,,U, 1 The above a bli a plies with the requirements of the Florida Sanitary Code. ��kZ Sy `���- Signed Date Title '51 Agency-A-11,113.0-1, f This approval is valid for��days. Auth.61A-5.010&61 A-5.056,FAC . SEC,'T101 ,6�`APPi:1CA®r ENTITIELQIX.,CiaN1lI710N _' 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) nAl- VT SET©N7SPECIAL I=ICENSEREQUJREN[ENTS Fcoholic Lme(D/B/A) LANDING k the appropriate"Special Alcoholic Beverage License" box of the license for which you are ll in the corresponding requirements for each Special License type. 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&61 A-5.056,FAC 7 J ' ..:,.H_ ..w ..._. SECTIOi ,8 bISCLO,,SURE OFINTERESTED PARTIES w " 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 (D/B/A) SAUDERS LANDING 1. When applicable, complete the appropriate section below. Attach extra sheets if necessary. Title/Position IName Stock% CORPORATION—List all officers, directors, and stockholders GENERAL PARTNERSHIP List all qeneral Dartners LIMITED LIABILITY COMPANY—List all mana ers member&non-member),directors, officers, and members AMBR SAUDER,RANDOLPH j j AMBR SAUDER,BELYNDA -32,— AMBR 2,— AMBR SAUDER,DREW SAUDER,SAMANTHA 0 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 ® 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 ® 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 ❑ 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 ® 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&61A-5.056,FAC 8 w SETl+3t�9 AFFIDAVIT C1�APPLICAt�iT � 3 MY NQTARIZATIOMrRQU1RED , ,.. a ,b r w.. .. 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 'P0 I(� Q)M �tD� °S'NY NO Christine Wilkinson APPLICANT/AUTHORIZED REPRESENTATIVE NAME State of Florida My Commission Expires 10/03/2015 OFA'° Commission No.EE 849823 rl APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE n The foregoing was ( Sworn to and Subscribed OR ( )Acknowledged Before me this C— Day of � � , 20 , By 0 h A. &vd ter. who is ( ) personally (print name(s) of person(s) making statement) known to me OR who produced as identification. Commission Expires: Notary P Auth.61A-5.010&61A-5.056,FAC 9 FN 10 AFFIDAVITaO "TRA[�SFE,,, R QUIREame(D/B/A) LANDING , teunersigned, 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 y- '�0 COUNTY OF A 1A,a,no o.,rp TRANSFEROR OR AUTHORIZED SIGNATURE TRANSFERO OR AUTRORIZED SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR( )Acknowledged Before me this _Day ofv X 20 , By Ma,Y(' r� who is ( ) personally (print name(s) of persons) making statement) known a OR vj ho pro ce as identification. Comm' i �`3 o Publi ^� RpD1aLLA ERVIN MY COMk1SS10N EE127i19 � �qd' $X41RFS;g�bf t3.ZOl! j,��ART' PI.Ma1�7 p{�p�ra ArR O�. Auth.61A-5.010&61A-5.056,FAC 10 EMM ROM CURRENT iLICENSE UPDATE r 3!lTA SHEET . , 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 NameC' p`2rt_ First M.I. Current Alcohol Beverage and/or Tobacco License Per it/Number(s) Date of Birth Social Security Number* S - S 562 a R-.1 6 Street Address LA,^N"+-� l� City State Zip Cl� Last Name First M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth S ial Security Number* Street Address City StagZip Code 3 Y341 Last Name_ �rFirst � M.1. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) l� Date of Birth �^�U r Social Security N_qlumber* er _ 7C— Street —Street Address City }� Stag Zip Cod Last Name • First S M.I. + �-- Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social S my Number* r1 / Street Address City � Staff` 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 Oetail by Entity Name Page 1 of 2 i FLORIDA DEPARTMENT OF STATE Detail by Entity Name Florida Limited Llabilitv 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 ENSEN BEACH, FL 34957 Changed: 05/20/2015 Mailing Address 28 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Registered Agent Name&Address SAUDER, RANDOLPH A 8 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Authorized Persons Detail Name &Address Title AMBR SAUDER, RANDOLPH A 28 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 itle 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 Detail by Entity Name Page 2 of 2 8 LAWRENCE LAKE DR BOYNTON BEACH, FL 33436 Title AMBR Sh&&ER, SAMA1t MItiA E E-Filing Services Document Searches Forms Help 8 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 Coovriahl:C)and Privacy Policies State of Florida,Department of State http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 6/1/2015