STATE OF ALASKA ALCOHOLIC BEVERAGE CONTROL BOARD APPLICATION FOR RESTAURANT DESIGNATION PERMIT - AS 04.16.049 & 13 AAC 104.715-794 FEE: $50.00 The granting of this permit allows access of persons under 21 years of age to designated licensed premises for purposes of dining, and persons under the age of 20 for employment. If for employment, please state in detail, how the person will be employed, duties, etc. This application is for designation of premises where : 1 2 3 4 X (please mark desired items). Under 13 AAC 104.305 Bona fide restaurant/eating place. License Number __________ Persons age 16 to 20 may dine unaccompanied. Persons under 16 may dine accompanied by a person 21 years or older. Persons between 16 and 20 years of age may be employed. *(See note below). LICENSEE: D/B/A: ADDRESS: 1. Hours of Operation: to Telephone # 2. Have police ever been called to your premises by you or anyone else for any reason: If yes, date(s) and explanation(s). 3. * Duties of employment: 4. Are video games available to the public on your premises? 5. Do you provide entertainment: 6. How is food served? 7. Is the owner, manager, or assistant manager always present during business hours? [ ] Yes [ ] No Table Service [ ] Yes [ ] No If yes, describe. Buffet Service Counter Service Other* [ ] Yes [ ] No *** A MENU AND A DETAILED LICENSED PREMISE DIAGRAM MUST ACCOMPANY THIS APPLICATION *** I have read and am familiar with Title 4 of the Alaska statutes and its regulations. Applicant signature Local Governing Body Approval Subscribed and sworn to before me this day of Date: Notary Public in and for Alaska My Commission expires Director, ABC Board Date: *Employees 16 and 17 years of age must have a valid work permit and a letter maintained in your files from a parent or guardian authorizing employment at your establishment. ** If more space is required, to explain food service, entertaiment, etc., please add on back or attach additional page(s). Update: 3/29/12 ABC Board 5848 E Tudor Rd Anchorage AK 99507 PH: (907)269-0350 FX: (907)272-9412 American LegalNet, Inc. www.FormsWorkFlow.com