Illinois Liquor Control Commission Pat Quinn Governor 100 W. RANDOLPH ST. SUITE 7-801 CHICAGO, ILLINOIS 60601 TELEPHONE: 312-814-2206 FAX: 312-814-2241 TDD: 312-814-1844 101 W. JEFFERSON ST. SUITE 3-525 SPRINGFIELD, ILLINOIS 62702 TELEPHONE: 217-782-2136 FAX: 217-524-1911 WEB SITE: www.state.il.us/LCC APPLICATION FOR STATE OF ILLINOIS RETAILER’S LIQUOR LICENSE REMEMBER: YOU CANNOT PURCHASE OR SELL ALCOHOL WITHOUT A VALID STATE LIQUOR LICENSE! DEFINITION: A Retailer’s Liquor License shall allow the licensee to sell and offer for sale at retail, only at the premises specified in such license, alcoholic liquor for use or consumption, but not for resale in any form; provided that any retail liquor license issued to a manufacturer shall only permit such manufacturer to sell alcoholic beverages at retail on the premises actually occupied by such manufacturer [235ILCS 5/5-1(d)], the only exception being a wine-maker’s retail license—2nd location [235 ILCS 5/5-1(i)]. All applicants for licensing as a liquor “retailer” must complete this application form. Respond to all questions on the application and furnish all required supporting documents. Failure to do so will result in the rejection of the application and non-issuance of a state liquor license. FEE: RETAILER’S LIQUOR LICENSE $500.00 The following documents and information are REQUIRED prior to receiving for your state license: 1) Photocopy of Certificate of Insurance (not the “Policy Declaration”) if alcohol will be consumed on-premise; 2) Photocopy of Current Local Liquor License (contact your local liquor commission); 3) Prior State Liquor License (if applicable); 4) Bulk Sales Release Order—Address Release (call IL Dept. of Revenue at 312-814-3063 if applicable); 5) Proof of Purchase, ie, bill of sale, closing statement, or lease (the closing on the purchase of business MUST occur prior to applying for your state license); IMPORTANT: You must also present proof that the applicant (ie, Corporation, LLC, Partnership, or Sole-Proprietor) has the right to possession of the property (ie, Deed or Lease). If there is an existing state liquor license on the premise, this license should be surrendered (if available); 6) Federal Employer Identification Number (FEIN) (call 800-829-3676 to apply for number); 8) Illinois Business Tax (IBT or Sales Tax) Number (if applicable, call 800-732-8866 to obtain number); 9) Check or Money Order payable to the “Illinois Liquor Control Commission” (the Commission does NOT accept U.S. currency/cash as payment); 10) This application with the information requested printed or typed in the spaces provided. This form MUST bear an Original Signature. NOTE: The date of expiration of your initial State license will coincide with the 12-month period that begins on the issue date of your local liquor license. In some cases, the term of your first year’s State liquor license may be less than a full year in duration. IMPORTANT NOTICE: THE I.L.C.C. IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY UNDER THE ILLINOIS LIQUOR CONTROL ACT (235 ILCS 5/1 ET SEQ.). DISCLOSURE OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE ANY INFORMATION WILL RESULT IN THE NON-ISSUANCE OF YOUR LICENSE. FORM APPROVED BY THE STATE FORMS MANAGEMENT CENTER. IL 567-0015 (03/2009) Printed on Recycled Paper PAGE 1 OF 6 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICE USE ONLY LICENSE NO. DATE ISSUED SIGNATURE OF AUTHORIZED PERSONNEL EXPIRATION DATE COUNTER Application for State of Illinois Retailer’s Liquor License If you want your renewal application, your license certificate and other ILCC correspondence sent to your “corporate” address, please check the box at left. 1. APPLICANT - CORPORATE INFORMATION A. FEIN Enter your Federal Employer Identification Number (FEIN) in this box. The FEIN is a nine-digit number issued by the U.S. Internal Revenue Service. This number is used for verification purposes only. If you do not have an FEIN number, call 1-800-829-3676 for general information on how to apply and to obtain the forms you will need. FEIN # B. ILLINOIS BUSINESS TAX NUMBER (IBT OR SALES TAX NO.) Enter the eight-digit Illinois Dept. of Revenue Business Tax (Sales Tax) Number. YOU MUST HAVE THIS NUMBER IN ORDER FOR A LICENSE TO BE ISSUED. If you need to obtain this number, call the Illinois Department of Revenue in Chicago at 312-814-5232 or in Springfield at 217-785-3707. Or call toll-free at 800-732-8866. ILLINOIS BUSINESS TAX # C. TELEPHONE Enter the area code/telephone number/extension of the sole proprietorship, corporation, etc. AREA CODE/TELEPHONE NO. EXT. D. COUNTY Enter the county where the sole proprietorship, corporation, etc. is located. COUNTY E. NAME Enter the name of the sole proprietorship (assumed name), partnership, corporation (Illinois, national, or foreign), or limited liability company in this box. Note! This name must be consistent with the name printed on your local liquor license and on your Illinois Department of Revenue Sales Tax Registration Certificate. NAME F . ADDRESS Enter the street address, city, state, and Zip Code of the sole proprietorship, corporation, etc.. ADDRESS IL 567-0015 (03/2009) CITY STATE ZIP CODE PAGE 2 OF 6 American LegalNet, Inc. www.FormsWorkflow.com 2. STATUS OF BUSINESS Check the applicable box (assumed name/sole proprietorship, partnership, Illinois corporation, foreign corporation, limited liability company) which corresponds to your business’ official papers filed with the Office of the Secretary of State. Based on the box that you check, provide the date of the filing of the sole proprietorship/assumed name with the county clerk; in the case of a copartnership, the date of formation of the partnership; in the case of an Illinois corporation, the date of its incorporation; in the case of a foreign corporation, the foreign state where it was incorporated and the date, as well as the date of its becoming qualified under the “Business Corporation Act of 1983” to transact business in the State of Illinois; in the case of a limited partnership, the date of formation of such partnership; or in the case of a limited liability company, the date of formation of such entity. NOTE! In the case of a sole proprietorship, Section 5/6-2 of the Illinois Liquor Control Act requires that the business owner reside within the jurisdiction that grants the local liquor license. A. B. C. D. E. SOLE PROPRIETORSHIP DATE FILED WITH COUNTY CLERK: PARTNERSHIP DATE OF FORMATION: ILLINOIS CORPORATION DATE OF INCORPORATION: FOREIGN CORPORATION STATE OF INCORPORATION: LIMITED LIABILITY COMPANY DATE FORMED: DATE QUALIFIED TO DO BUSINESS IN ILL: If “C” or “D” is checked, indicate your current Secretary of State file number here (If you do not have this number available, please contact the Secretary of State’s office at 312-793-3380) 3. OWNERSHIP INFORMATION Provide the owner/officer/partner information in accordance with the business status described under Question 2. This information must be submitted for all owners/officers/partners. The same information must be submitted for shareholders with interests equal to or exceeding 5%. The following information must be provided for each individual applicant, sole proprietor, partner, corporate officer or director (whether or not they own any stock), shareholder owning in the aggregate stock equal to or more than 5% , (including officers, directors and shareholders with stock equal to or more than 5% for all corporate shareholders), and/or manager or agent conducting the business. Indicate the total percentage of stock of the corporation, if any, which is held by persons who hold less than a 5% interest. All Not-for-profit organizations and associations must provide the requested information for all corporate officers, directors and managers. If additional space is needed, provide information on a separate sheet(s) in the same format as this application requires. BEFORE COMPLETING THIS SECTION, CHECK QUESTION NO. 6 - ELIGIBILITY. For each owner/officer/partner/5% shareholder, provide full name, home address, city, state, Zip Code, social security number, date of birth, sex, title/position, home telephone number, and percentage ownership. Percentage ownership should equal 100%. If there are a number of shareholders owning less than 5%, indicate the aggregate total of ownership under E. A. NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. B. DATE OF BIRTH SEX AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. CITY TITLE/POSITION AREA CODE/TELEPHONE NO. HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. E. DATE OF BIRTH TITLE/POSITION HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. D. DATE OF BIRTH CITY HOME ADDRESS SEX NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NO. C. DATE OF BIRTH HOME ADDRESS CITY TITLE/POSITION AREA CODE/TELEPHONE NO. TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% INTEREST IL 567-0015 (03/2009) STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED STATE ZIP % OWNED % PAGE 3 OF 6 American LegalNet, Inc. www.FormsWorkflow.com 4. BUSINESS PREMISE INFORMATION If you want your renewal application, your license certificate and other ILCC correspondence sent to your business premise address, please check the box to the left. A. NAME/DOING BUSINESS AS (D/B/A) Enter the name of the business which will be selling or serving alcoholic beverages at the licensed premises. Note! This name must be consistent with the name printed on your local liquor license and on your Illinois Dept. of Revenue Sales Tax Registration Certificate. NAME (DOING BUSINESS AS D/B/A ) B. TELEPHONE Enter the area code/telephone number/extension at the business premise location. AREA CODE/TELEPHONE NO. EXT. C. ADDRESS In the next five boxes enter the address, city, state, Zip Code and county of the business premises. This address information must be consistent with information on your local liquor license and on your Illinois Department of Revenue Sales Tax Registration Certificate. Remember, you MUST close on the business purchase prior to applying for your state license. Proof of business purchase is required (ie, bill of sale, closing statement). IMPORTANT: You must also present proof that the applicant (ie, Corporation, LLC, Partnership, or Sole-Proprietor) has the right to possession of the property (ie, Deed or Lease). If there is an existing state liquor license on the premise, this license should be surrendered (if available). The applicant will also need to provide the State of Illinois Liquor Commission with a Bulk Sales Release Order (“Address Release”) if applicable, which can be obtained by contacting the Illinois Dept. of Revenue at 312-814-3063. ADDRESS D. CITY STATE ZIP CODE COUNTY BUSINESS TYPE Check the one box which best describes the type of business in operation. If the selections listed are inappropriate, describe the business under “other”. A. B. C. D. E. DRUG STORE/PHARMACY RESTAURANT CONVENIENCE SUPERMARKET E. F. G. H. LIQUOR STORE DEPARTMENT STORE BAR/TAVERN HOTEL/MOTEL I. J. K. L. CONVENIENCE & GAS SMALL GROCERY GAS STATION OTHER WAREHOUSING If any of your inventory is warehoused, provide the name, street address, city, state, Zip Code and county of the warehouse. ADDRESS F . CITY STATE ZIP CODE COUNTY LEASED PREMISES If you lease your premises, the lease must cover the full term of the license. If you lease, provide the landlord’s name, telephone number, street address, city, state, Zip Code and county. LANDLORD NAME ADDRESS IL 567-0015 (03/2009) AREA CODE/TELEPHONE NO. CITY STATE ZIP CODE COUNTY PAGE 4 OF 6 American LegalNet, Inc. www.FormsWorkflow.com 5. LOCAL LICENSE INFORMATION/LIQUOR LICENSE HISTORY A. LOCAL LIQUOR LICENSE INFORMATION YOU MUST PROVIDE A PHOTOCOPY OF YOUR LOCAL LIQUOR LICENSE Your local license must contain the expiration date, issue date, and license number. Please enter the local liquor license number, the date it was issued, the date it expires, the municipality or county that issued the license and the date you intend to begin selling alcoholic beverages at this business premise. Alcoholic beverages may not be sold or offered for sale prior to the date that the State liquor license is issued. If you have begun selling alcoholic beverage products before obtaining this license, you will be required to fill out a “deliquency affidavit” to explain the circumstances. Note! In unincorporated areas, the county acts as the local liquor licensing authority. MUNICIPALITY/COUNTY ISSUING LOCAL LIQUOR LICENSE LOCAL LICENSE NO. DATE ISSUED B. EXPIRATION DATE DATE YOU BEGAN LIQUOR SALES AT THIS PREMISE FIRST LICENSE APPLICATION - LICENSE HISTORY Indicate by checking the correct box whether or not this is the corporation’s, sole proprietorship’s, etc’s first application for a State liquor license at any premises. If you check “no”, indicate the date of your first State liquor license application. Also indicate whether the license was granted, denied or withdrawn. Provide the address of your first State liquor license application. If you have ever had a license application denied or if you ever withdrew an application, please provide a written statement describing the reason and circumstances. IS THIS YOUR FIRST STATE LICENSE APPLICATION? YES NO IF NO, PROVIDE DATE FIRST APPLIED: DISPOSITION: GRANTED DENIED WITHDRAWN ADDRESS OF FIRST STATE APPLICATION: C. FEDERAL REGISTRATION AND RETURN To sell alcoholic beverages, you are required to register with the Federal Alcohol and Tobacco Tax and Trade Bureau (TTB) on a yearly basis. HAVE YOU FILED TTB FORM 5630.5d “ALCOHOL DEALER REGISTRATION AND RETURN”? YES NO If NO is checked, TTB Form 5630.5d may be obtained from the National Revenue Center at 800-937-8864 or downloaded at www.ttb.gov. D. TYPE OF LIQUOR LICENSE Check the box which describes the manner in which you sell alcoholic beverages to consumers - “on-premise”; “off-premise”; or “combined”. This information must be consistent with your approval granted by the local liquor licensing authority. ON-PREMISE CONSUMPTION (PATRONS CONSUME ALCOHOLIC BEVERAGES ON PREMISE ONLY) OFF-PREMISE CONSUMPTION (CARRY-OUT PURCHASES ONLY) ON/OFF-PREMISE CONSUMPTION COMBINATION (BOTH ON-PREMISE CONSUMPTION AND CARRY-OUTS) 6. CERTIFICATE OF INSURANCE ATTACH PHOTOCOPY OF YOUR “CERTIFICATE OF INSURANCE” (NOT THE “POLICY DECLARATION”) You MUST provide a copy of your Certificate of Insurance if alcohol is consumed on-premise (this certificate is not required for carry-out only establishments). The Certificate of Insurance must show that you have liquor liability insurance and must include the following: 1) The applicant named as the insured (e.g. if the applicant is a corporation, then the corporation’s name must be listed; if the applicant is a sole proprietor, then the sole proprietor’s name must be listed.); 2) The address of the location where the liquor is being consumed; and 3) The dates of coverage and the coverage limits. IL 567-0015 (03/2009) PAGE 5 OF 6 American LegalNet, Inc. www.FormsWorkflow.com 7. ELIGIBILITY QUESTIONS The questions below pertain to the applicant and any other person listed under “Corporate Officer/Ownership Information” listed on page 3 of this form. If any questions are answered with a “Yes” attach a full written explanation to this document. 7A YES NO Are you delinquent in the payment of any Illinois business taxes (sales, withholding, etc.)? [235 ILCS 5/6-3] 7B YES NO Are you delinquent under the “cash beer” law? 7C YES NO If retailer, are you delinquent under the “30-day credit” law? 7D YES NO Have you ever made application for a liquor license which has been denied? [235 ILCS 5/6-2(14)] 7E YES NO Have you ever had any previous liquor license suspended or revoked? [235 ILCS 5/6-2(7)] 7F YES NO Have you ever been convicted of a felony? [235 ILCS 5/6-2(4)] 7G YES NO Have you ever been convicted of a gambling offense as defined under section 5/6-2 of the Act which includes offenses enumerated in 720 ILCS 5/28-1(a).11, “gambling;” 720 ILCS 5/28-1.1(a)-(d) “syndicated gambling;” and 720 ILCS 5/28-3 “keeping a gambling place”? 7H YES NO Do you possess a current Federal Wagering Stamp? 7I YES NO Are you, or is any other person having a direct interest in your place of business, a public or law enforcing official with jurisdictional authority? [235 ILCS 5/6-2(14)] 7J YES NO Have you received or borrowed money or anything of value directly or indirectly from any other licensees, representatives of a licensee, or suppliers of alcoholic products? 7K YES NO Are you or any other person having a direct interest in your place of business more than 30 days delinquent complying with a child support payment order? [5 ILCS 100/10-65(c)] 7L YES NO Are you in violation of the required liquor liability insurance coverage stated in section 6-21(a) of the Liquor Control Act [235 ILCS 5/] regarding establishments that sell alcoholic liquors for use or consumption on the licensed retail premises? 7M YES NO If a Corporate Licensee, is your corporation ineligible to be issued this license? [235 ILCS 5/6-2(a)(10) and 5/6-2(a)(10a)] 7N YES NO Have you filed your annual Special Occupational Tax Form as required by the TTB? (1-800-937-8864 or ttb.gov) Note! If you answer “Yes” to this question, a written explanation IS NOT REQUIRED. 8. HOURS OF OPERATION List the daily hours open for business. This information will assist Commission field agents in choosing an inspection time which causes the least disruption to the business. MON TUES WED THURS FRI SAT SUN 9. SIGNATURE/TITLE/DATE Please sign and date the application form and provide your title with the organization. The application must be signed by an owner, an officer, a partner or an officially authorized agent of the business. The signature must be an original, rubber stamps are not accepted. I, THE UNDERSIGNED APPLICANT OR AUTHORIZED AGENT THEREOF, SWEAR OR AFFIRM THAT: THE MATTERS STATED IN THE FOREGOING APPLICATION ARE TRUE AND CORRECT; THEY ARE MADE UPON MY PERSONAL KNOWLEDGE AND INFORMATION; THEY ARE MADE FOR THE PURPOSE OF REQUESTING THE STATE OF ILLINOIS TO ISSUE THE LICENSE HEREIN APPLIED FOR; THE APPLICANT IS QUALIFIED AND ELIGIBLE TO OBTAIN THE LICENSE APPLIED FOR; AND THE APPLICANT WILL NOT VIOLATE ANY OF THE LAWS OF THE UNITED STATES OF AMERICA OR THE STATE OF ILLINOIS, IN PARTICULAR, THE ILLINOIS LIQUOR CONTROL ACT, RULES AND REGULATIONS, AND THE CIVIL RIGHTS SECTIONS THEREOF. FURTHER, I AGREE TO NOTIFY THIS COMMISSION WITHIN 30 WORKING DAYS OF CHANGES IN ANY OF THE ABOVE INFORMATION. (NOTE: IF THE PERSON SIGNING THIS APPLICATION IS NOT LISTED IN SECTION 3, THEY MUST PROVIDE THE STATE WITH THEIR PERSONAL INFORMATION AS INDICATED IN SECTION 3 EVEN IF THEY DO NOT OWN 5% OR MORE OF THE BUSINESS.) SIGNATURE OF APPLICANT/AUTHORIZED AGENT IL 567-0015 (03/2009) TITLE/POSITION DATE PAGE 6 OF 6 American LegalNet, Inc. www.FormsWorkflow.com