HomeMy WebLinkAboutLiquor License Feb, 9, 2016 2:26PM N t REC DEPT No- 5578 P. .6
DBPR ABT-6003-Division of Alcoholic Beverages and Tobacco
Application for One/Two/Three Day Permit or Special Sales License
STATE OF FLORIDA DBPR Form
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6003
Revised 081207q
If you have any questions or need assistance in completing this application,please contact the Division of
Alcoholic Beverages&Tobacco's(AB&7)local district office. Please submit your completed application to
your local distract office at least(7)days prior to the first date of the event to insure the permit is issued by
the event date. This application may be submitted by mail,or it can be dropped off. A District Office
Address and Contact Information Sheet can be found on AB&T's page of the DBPR web site at the link
provided below.
SECTION C.'.H-ECK TRANSACTION!_REQU.t-STED
Transaction Type:
E59�0n2LwL6e Day Permit El 82ecial Sales License
SSNION 77 PERMIT or LICENSE INFORMATION
if the applicant is a corporation or other legal entity,enter the name and the document number as registered with-the
Flo6da Department of State Division of Ca orations on the line below.
FEIN Number Business Telephone Number E-Mail Address(Optional)
79—
Full Name of Applicant(s);(This is the name the permit or license will beDepartment of State Document#
Business Name(D/B[A)or Name of Event
Location of Event(Street and Number)
city County State z;p Codi
e-
Mailing Address(Street or P.O.-Pox)
city State Zip Code
Contact Person-This section is optional,see application instructions for details
Contact Person Telephone Number
x:14 Q7
ext.
Email Address(Optional)
.. �J-
F
Mailing Address(Street or P.O. Box)
City State Zip Code
Qate(s)Perm It Desired.
ABT District Office Received Date Stamp
Auth: 61A-5.0013,FAG
I vu. )F.. LV IV L L ++y+ +r i nw vu + [IV. 7710 � V
91.1a SALESS T AX
TO BE COMPLETED BY THE DEPARTMENT OF REVENUE
Full Name of Applicant Organization s 7
The named applicant for a license/permit as complied with the Florida Statutes concerning registration for Sakes and
Use Tax and has agreed to pay any applicable takes due.
Signed Date
Title
Department of revenue Stamp.
SECTION; -BONING
TO BE COMPLETED BY THE ZONI G•AUTHORITY GOVERNING THE EVENT LOCATION
Location of Event(Street and Humber)
Cit County,.� i
The location complies with zoning requirements for the temporary sale of alcoholic beverages pursuant to this
application for a One/Two/Three Day Permit
Signed Date
T'r�e
Note:- College fraternities and sororities must meet certain additional conditions
which can be found in the application instructions and requireme its.
Auth_ 69A-5.0023,FAG 2
1 GU. J.. LV IV L•LIIIYI tY ! 1XLV VLI I tYU. JJIV I, 7
11anf o a n s T .��UCENSE
::��"AB& --AUniQPJZEDZIG3 "URE
R1~�£2U11�A" a=:
Business Nsme(1}BtA)or Name of Even t
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 speciftG areas-which are part of the premises-sought to be licensed. A muiti-story building where
the entire building is to be licensed must show each floor lan.
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z�
V
Auth: 61A4013,FAC- 3
h
Feb, 9. 2016 2:26PM N I REC DEPT No. 5578 P. 4
sr:C.Ti6-N-7-AFFIDAVIT OF APPLICANT
FOR SPECIAL SALES LICENSE
NOTARIZATION REQUIRED
Ful! Name of Applicant Organization
the undersigned individual, or if a corporation, its authorized representative,hereby swear or affirm that I am duly
authorized to make the above and foregoing application for et special sales license which authorizes the sale of
alcoholic beverages for period of up to three(3)days-I understand this license does not permit the sale of alcoholic
beverages for consumption on the premises and only allows package sales in sealed containers and acknowledge that
the location may be inspected and searched during the hours that the special sale is being conducted without a search
warrant by authorized agents or employees of the Division of Alcoholic Beverages and Tobacco,the Sheriff, his
Deputies,and Police Officers for purposes of determining compliance with the beverages laws.
I swear under oath or affin-nafion under penalty of perjury as provided for in Sections 559.791, 562.45,and 837.06,
that the foregoing information is true to the best of my knowledge and that no other person or entity except as
indicated herein has an interest in the special sales license and that all of the above listed persons or entities meet the
qualifications necessary to hold this special sales license."
STATE OF
COUNTY OF
APPLICA "D-,
EL' PRESENTATIVE NAME
APPIRCANT/AUTHORIZED REPRESENTATIVE SIGNATURE
A
The foregoing was e\ Sworn to and Subscribed before me this 2, Day
of By 51
who personally known tome
i11
(print name(s)d person making statement)
OR who produced _as ideriffication.
Commission Expires;
DOLORES C DIBENEDICTIS
MyCOMMISWN#FFIU7339
EXPIRES January 5,2019
(407)356-0153 FiQrkiallotsrY$erviCe.c0M--—
Auth: 6IA-5.0013,FAC 5
Feb. 9. 2016 2;27PM N I REC DEPT No, 5578 P. 10
ATTESTATION
This form is to be completed by the alcoholic beverage license holder ONLY when the event of the non profit .
organization is being held at a location that is licensed by the Division of Alcoholic Beverages&Tobacco for the sale
of alcoholic beverages.
Note,This attestation must have the original signature of the alcoholic beverage license holder(only persons on
file with the division may sign)and must be submitted by the non-profit group along with the application for the
One/Two/Three Day Permit_
Licensee:
Business Name(DBA): -
License#: Series of Permanent License:
Type:
Contact Person Telephone Number
ext.
E-Mail Address(Optional)
Name of Non-Profit roup:
bate(s)of Event
A One/Two/Three Day permit is being requested for an event to be held on your licensed premises. During
the event, no sales.or service of alcoholic beverages may be made under your alcoholic beverage license in
the area identified for use by the nonprofit organization. Failure to comply will result in administrative
charges being filed against your license.
Signature of Licensee:
Date:
Auth: SIA-5.0013,FAC
Feb. 9. 2016 2:26PM N I REC DEPT No, 5578 P. 7
DBPR ABT-6003—Division of Alcoholic Beverages and Tobacco
Application for One/Two/Three Day Permit or Special Sales License
STATE OF FLORIDA DBPR Form
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6003
Revised 0$/2013
If you have any questions orneed assistance in completing this application,please contact the Division of
Alcoholic Beverages& Tobacco's(AB&7)local district office. Please submit your completed application to
your local district office at least(7) days prior to the first date of the event to insure the permit is issued by
the event date. This application may be submitted by mail, or it can be dropped off. A District Office
Address and Contact Information Sheet can be found on AB&T's page of the DBPR website at the link
provided below.
http://www.oMoridalleense.com/dbor/abt/distdct offices/licensing.htmI
SEETI.ON;,I; CHECKTRANSACTION REQIJES'fED77
Transac' Type:
On w' hree Day Permit ❑ S ecial Sales License
SECTION:2:-,RERMIT;a�l[CITNSE INFORIitIATION.::•:
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(Optionaq
4,6— 51 '7
Full Name of A'plicant(s):(This is the name the permit or license will be issued in} Department of State Document#
� s —A!:'4 0
Business Name(DIB/A) or Name of
Event
rr ZL 5 /r r Pr61/ ! C 7 v
Location of Event(Street and Number)
City , County State Zip Code
FL ;S77
Mailing Address(Street or P.O. 139 0_
51 /tee efX43® Vd:
City State Zip Code
Contact Person -This section is optional,see application instructions for details
Contact Person Telephone Number
u3(I L(_-4 .66 S 77' 2. ext.
Email Address(Optional)
Mailing Address(Street or P.U. Box)
City State Zip Code
Date(s)Permit Desired
�t A lR• �l� � �
ABT District Office Received Date Stamp
AUth: 61A-5.0013,FAC
Feb. 9. 2016 2;27PM N I REC DEPT No. 5578 P. 8
SECTI6N••3 T SALES TAX
TO BE COMPLETED BY THE DEPARTMENT OF REVENUE
Full Name of Applicant Organization �
The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and
Use Tax and has agreed to pay any applicable taxes due.
Signed Date
Title
Department of Revenue Stamp:
SECTION 4-ZONING
TO BE COMPLETED BY THEbNING.AUTHQRITY GOVERNING THE EVENT LOCATION
Location of Event(Street and Number)
1. -/D
city ' County _
The location complies with zoning requirements for the temporary sale of alcoholic beverages pursuant to this
application for a One/Two/Three Day Permit.
Signed -- - Date
Title
Note: College fraternities and sororities must meet certain additional conditions
which can be found in the application instructions and requirements.
Auth: 61A-5.0013,PAC 2
Feb. 9. 2416 2:27PM N I REC DEPT No. 551$ P. 9
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r'ti �.f :. .• G fQ11 {.� JCf\iR l5./IY1�L':.�, Srl'�1171:�1�w 1] Q•,�?�'��r".�:,'=.-art.:�r��'.`.'
..Al3&t' 13TIiORIZED SIGNAtURE-REQUIRED 7=
Business Name{D/BlA)or Name of Evert
Neatly draw a floor plan of the premises in ink,including sidewalks and other outside areas which are
contiguous to the premises,walks,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 each floor plan.
• L ter
Iz—
Y
Yfti
ry
CS
Auth: 61A-$,0013,FAC- 3
Feb. 9. 2016 2:26PM N I RIC DEPT No, 557$ P. 5
SECTION 6-AFFIDAVIT OF APPLICANT
FOR NON-PROFIT CIVIC ORGANIZATION ALCOHOLIC BEVERAGE PERMIT
NOTARIZATION REQUIRED
-gull—Name of Applicant Organization
A) V2rC- 5 Z��e/,_OZZD
"This is to certify that the applicant requesting the permit in the above and foregoing application is a non-profit civic
organization and that the permit,if used,will be used only by the organization making application, on the date(s)
requested and at the location stated.By acceptance of this permit,we agree that the applicant organization,as the
permit holder, is the ONLY entity that will receive any of the profits from the sale of alcoholic beverages on this permit_
Thisis to further certify that the applicant organization has not received more than three(3)permits within the calendar
year, unless otherwise authorized by law,and acknowledge that the location may be inspected and searched during
the time that the permit is issued and business is being conducted without a search warrant by authorized agents or
employees of the Division of Adcoholir.Beverages and Tobacco,the Sheriff, his Deputies,and Police Officers for
purposes of determining compliance with the alcoholic beverage laws,
1,the undersigned individual, hereby swear or affirm that I am an officer or authorized representative and am duly
authorized to make the above and foregoing statements on behalf of the applicant organization-Furthermore, I swear
under oath or affirmation under penalty of perjury as provided for in Sections 559.791,562.46, and 837,06, Florida
Statutes,that the foregoing information is true to the best of my knowledge."
X_
STATE 0 �_
IF I—
COUNTY OF
L/
APPLICANWAUT-R,
�EPRESENTATIVE NAME
"WIRLICANTIAUTHORIZED REPRESENTATIVE SIGNATURE
The foregoing wa$,Q< )Sworn to and Subscribed before me this Day
of
,20 By who i personally known to me
"P'
LLhefor�g
foregoing
f
(print name(s) of person making statemenO_
OR )who produced as identification,
-Commission Expires,
N N6ta
6tay Public
DOLORES C DIBENFOInS
r,4y r 87339
,OMMIS&ON#FF1
IREs JanuarY 5.201
AMth: 61A-5.0013,FAC 4