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HomeMy WebLinkAboutLiquor License 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 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 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 web site at the link provided below. hftp://www.mvfloridalicense.com/dbpr/abt/distdct offices/licensing.html ,SECTION.. f CHECK TRANSACTIOM:RE4UESTED. ` ransact ype. One wo hree Day Permit ❑ Special Sales License SECTlON;2 PERMITror<L IRMATI ,5 -�2 (CENSE INFOON 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 the nameAn p rmor license will be issued in) Department of State Document# AID Business Name(D/B/A)or Name of Event Location of Event(Street and Number) D Sn O &LOD City County' State Zi Codes I` . T k0e/ r IFL Mailing Address(Street or P.O. Box) City State Zip Code Contact Person-This section is optional,see application instructions for details Conttqct Yf'Pers Tele"hone umber 14/ t'J � ext. Email Address(Optional) �Tb S Wlq Mailing Address(Street or P-0. Box) City State Zip Code Date(s)Permit Desired ABT District Office Received Date Stamp Auth: 61A-5.0013,FAC 1 iSECT[O,N 3.' SAFES TAX' T.HEO�P�4RTMENT,QF.REVENUE Full Name of Applicant Oapizatio� ki c—gJs cjo 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 ©1_i R--1 Title ' RECEIVED Department of Revenue Stamp: FLORIDA DEPT OF REVENUE FLORIDA DEPARTMENT OF REVENUE JAN 18 2017 GTA-COMPLIANCE ENFORCEMENT 337 NORTH U.S. HIGHWAY ONE,SUITE 8 FORT PIERCE SERVICE CENTER FORT PIERCE,FLORIDA 34950-4206 SECTION 4°ZONING ,{ F TO'BE COMPLETED BY THE ZONING AUXHORITY GOUERNINGTHE,EVENT LOCATION Locationf E rent(Street and Nu er) City � /✓ � .�- County ell . The location complies ing requirements for the temporary sale of alcoholic beverages pursuant to this applicatio or a nelfwogrhree Day Permit. Signed g Date Title bh �I"11? �L 5a2 Note: College fraternities and sororities must meet certain additional conditions which can be found in the application instructions and requirements. Auth: 61A-5.0013,FAC 2 i f: , EG'1'#ONS;-="IriESGRIG� �ON,.O.1wF�MiSEfi;f--SE EM i'�At�#ORI2.EU�.,�rIGNAtUIt�•REt�t}tRE�"-�=.."'.:c: Business Name(D/B/A)or Name of Even A)eTt4-0 sr . ,'/�'�, A�- Neatly draw a floor pian 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 each floor plan. r OL Auth. 82A 5,00'3,FAC. 3 i 'SECT110%`,4AFFIDAVIT OF APRLICANT FOR NON PROFIT CIVIC ORGANIZATION ALCO�OLIC BEYERAGf`PERMIT , f F f } x t ,V; - `NOTARIZATIQN REQULRED: t '` Full Name of Applican OrganizationSfooa -7 / "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. This is 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 Alcoholic'Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for purposes of determining compliance with the alcoholic beverage laws. I,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.pedury as provided for in Sections 559.791, 562.45, and 837.06, Florida Statutes, that the foregoing information is true to the best of my knowledge." STATE OF L COUNTY OF T ORIZED REPRESENTATIVE NAME PLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE . The foregoing was( )Sworn to and Subscribed before me this 1?>4h Day of, , 20 By lI 1 _�3ae-C, who is( ) personally known to me (print name4)of person making statement) OR )who produced as identification. ' P Commission Expires: Notary Public CARLA NELSON �'s= Notary Public-State of Florida �' Commission WFF 985535 '•.,;;�o���... My Comm.Expires Feb 28,2020 Auth: 61A-5.0013,FAC 4 ������ ,F.,{" _ 2^s'��( -s$ ,�.� �- rye Y�+- T�v-�`'``✓ < � �ss S �" Full Name of Applicant Organization r � �� "I, the undersigned individual, or if a corporation for itself, its officers and.directors, hereby swear or affirm that I am duly authorized to make the above and foregoing application for a 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 agree 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 affirmation 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 FL COUNTY OF_S1 A ac4 APPLIC PRESENTATIVE NAME APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE The foregoing was( ) Sworn to and Subscribed lbefore Mme this Day o6knQW., 20 `'� , By who is personally known to me (print name(s) o� f person making statement) OR( )who produced as identification. t^- aod:t M Commission Expires: a 8 h��a Notary Public >"'"�e'•. CARLA NELSON �-; • ���. -Notary Public-Stab of Ftorlda Commission M FF 905535 "- OF My Comm.Expires Feb 20,2020 Auth: 61A-5.0013,FAC 5 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 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 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 web site at the link provided below. hftp://www.mvfloridalicense.com/dbpr/abt/district offices/licensing.html SECTION 1 ==•CHECK TRANSACTION REQUESTED kOne&nsact' ype: ;/ hree Day Permit ❑ Special Sales License SECTION 2-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 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 the narn e p rmit or license will be issued in) Department of State Document# Business Name(D/B/A)or Name of Event / Location of Event(Street and Number) O 9 04_: ak City County State Zip Codes L 34q Mailing Address(Street or P.O. Box) City State Zip Code Contact Person-This section is optional, see application instructions for details Cont'a�ct,Person �J� Tele hone Number P AL"t-r� V ext. Email Address(Otional) Mailing Address(Street or P-0. Box) City State Zip Code P rpt Desired ABT District Office Received Date Stamp Auth: 61A-5.0013,FAC 1 - `. TO BE COMPLETED-BY THE;DEPARTMENT OF REVENUE Full Name of Applicant Or�c apization 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 �Q Date ©I -� -1 -7Title �y le C I z_d RECEIVED Department of Revenue Stamp: FLORIDA DEPT OF REVENUE FLORIDA DEPARTMENT OF REVENUE JAN 1.8 2017 GTA-COMPLIANCE ENFORCEMENT 337 NORTH U.S. HIGHWAY ONE,SUITE B FORT PIERCE SERVICE CENTER FORT PIERCE,FLORIDA 349%.4206 SECTION* ZONING TO,BE COMPLETED BY'THE ZONING.AUTHORITY 6OVERNINGr.HE,EVENT LOCATION Location o of E ent(Street and Nu ber) City Al � County /v m The location complies ing requirements for the temporary sale of alcoholic beverages pursuant to this applicatio ora n wo hree Day Permit. Signed � —Date to 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,FAC 2 ON5:.='DES��i1L�T(Ot ,t}tPRMFSES;Ft} .[C 130-AUI'HfJRI2ED.SlGNAItIRI=t3EtttIRED Business Name(D/B/A)or Name of Evenjn 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 speck areas which are part of the premises sought to be licensed. A mufti-story building where the entire building is to be licensed must show each floor plan. L jjEE V Auth: 61A-6,0013,FAG. SECTION,6,=,AFFIDAVIT,OF APPLICANT, FOR'NON-PROFIT CIVIC,ORGANIZATION ALCOHOLIC BEVERAGE PERMIT 'NOTARIZATION REQUIRED Full Name of Applicant Organization / t S /S'Z4,r4 1/`9�L "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. This is 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 Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for purposes of determining compliance with the alcoholic beverage laws. I, 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, 562.45, and 837.06, Florida Statutes, that the foregoing information is true to the best of my knowledge." STATE OF L COUNTY OF T�� RIZEDREPRESENTATIVE NAME .16 PLICANT/AUTHORIZED REPRESENTATIVE SIGNATUREC The foregoing was( ) Sworn to and Subscribed before me this 1341 1 Day ofN-InQQT�T20 By �� ,I I\ 1 �OCes who is( ) personally known to me (print name4s) of person making statement) OR �)who produced as identification. 'Commission Expires: Notary Public .•�:�a ° ;•.y CARLA NELSON Notary Public-State of Florida =N' Commission N FF 965535 My Comm.Expires Feb 28,2020 Auth: 61A-5.0013,FAC 4 x y SECTION 7 `AFFIDAVIT"OF APPLICANTRV FOR SPECIAL SALES LICENSE NOTARIZATION, E"Q RU,IRED. Full Name of Applicant Organization "I, the undersigned individual, or if a corporation for itself, its officers and directors, hereby swear or affirm that I am duly authorized to make the above and foregoing application for a 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 agree 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 affirmation 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 EL COUNTY OF�,-- % APPLIPRESENTATIVE NAME APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE The foregoing was ( ) Sworn to and Subscribed before me this Day of f Jam, 20 By -1 1 1\ 1 fs who is (�) personally known to me (print name(s) of person making statement) OR ( )who produced as identification. 0l &o_ lJ Commission' Expires: Notary Public >a'"�e•., CARLA NELSON Notary Public-State of floride •. Commission e`FF 98SS3S •FOF F� �� M Comm.Ex Ires`Feb 20;2020 r p Auth: 61A-5.0013,FAC 5 ,