6606 Tussing Road, P.O. Box 4005 Reynoldsburg, Ohio 43068-9005 http://www.com.ohio.gov/liqrThis application MUST BE NOTARIZED and must be completed in its entirety and signed by the permit holder of record. If the permit holder is a corporation, it must be signed by an officer or majority stockholder(s) of the corporation. If the permit holder is a Limited Liability Company("LLC"), it must be signed by an officer or Managing Member of the LLC. If necessary please attach any documents that may assist the Division ofLiquor Control ("Division") in processing your request.1)2)Do you still have tenancy rights?If NO, explain circumstances which resulted in loss of tenancy:Type of Request: (See attached Information Sheet to determine what type of request you qualify for):Section B - Temporary Closing Authority Information: DLC 4214 EOE/ADA SERVICE PROVIDERFOR TTY USERS DIAL ORS 1-800-750-0750 Section A Section C - Safekeeping Information:1)2)Do you still have tenancy rights?3)Please indicate the reason for requesting Temporary Closing Authority.4)APPLICATION FOR SAFEKEEPING OR TEMPORARY CLOSING AUTHORITY(Please print or type all information except signatures) Note, if you have lost tenancy you only qualify for Safekeeping. Safekeeping (Fill out Section A, C & D only) Temporary Closing Authority (Fill out Section A, B & D only) YES NO NO YESDBA (doing business as): Name of Permit Holder: Permit Premises Address: City: State: Zip Code: Permit Number: Permit Class(es): Indicate the number of days the premises is expected to be temporarily closed, (cannot exceed 180 days). Give exact last date of operation: Name of Real Property Owner: Real Property Owner Address: Phone Number: Rev. 5/2019 American LegalNet, Inc. www.FormsWorkFlow.com Is your request due to a fire?Please indicate how long you anticipate on being closed to renovate, as this time frame may qualify you for Temporary Closing Authority. You must provide a mailing address, (OTHER THAN PERMIT PREMISES) where the permit holder will receive mail, as you are required to renewyour permit while in safekeeping. Please be advised that the information you provide will be subject to public disclosure.Section DThe following must be completed by the person(s) making the request: Signature(s) Printed Name(s) (If a corporation, LLC or club, indicate officer's title and name of corporation or LLC)Sworn to before me and subscribed in my presence this day of , 20 .(Notary Public)(Notary Expiration) 6)To be approved for safekeeping, you must submit your current, original Permit and Permittee Identification Card, OR the original OperatingReceipt if your permit has not been issued. If you can not submit this documentation, explain why: (e.g., lost, stolen, etc.). 3)4)DELIBERATE FALSIFICATION OF ANY OF THE INFORMATION IN THIS REQUEST CAN RESULT IN THE DIVISION'S REFUSAL TOAPPROVE THIS REQUEST AND MAY JEOPARDIZE THE RENEWAL OF THIS PERMIT. NO YES5) Give effective date of loss of tenancy, if applicable: Give exact last date of operation: If YES, please submit a copy of the fire report or news article. Mailing Address: (Name, Street Address, City & Zip): Telephone Number between 8:00 a.m. and 4:30 p.m. -State of Ohio, County, ssbeing first duly sworn, according to law, depose and say(Printed Name)that the statements and answers made in the foregoing application are true.I, American LegalNet, Inc. www.FormsWorkFlow.com DIVISION OF LIQUOR CONTROLINFORMATION SHEET ONSAFEKEEPING & TEMPORARY CLOSING AUTHORITYSAFEKEEPINGThis is to advise you that Section 4303.272 of the Ohio Revised code provides:Any permit holder whose permit premises are destroyed or made unusable for any cause,or whose tenancy is terminated for any cause, shall deliver his permit to the Department ofCommerce-Division of Liquor Control for safekeeping until such time as the originalpermit premises are made available for occupancy or new premises are secured by thepermit holder or until new premises are secured by the permit holder outside the precinctaffected by a local option election.TEMPORARY CLOSING AUTHORITYThis is to advise you that Section 4301:1-1-16 of the Ohio Administrative Codeprovides:If a permit holder is unable to operate or desires to discontinue the operation of the permitbusiness for a period in excess of thirty days, the permit holder, a majority of the officers,partners, shareholders, or managing members shall notify the division, by affidavit, givingthe reason for the request, specifying the last date of operation of the business, and indicatingthe period of time the permit holder wishes to remain closed. When the permit holderdiscontinues operation in excess of thirty days it must be for a bona fide reason. Thepermit holder must also be a bona fide operator. 223Bona fide224 operator means substantialservice, as distinguished from incidental, sporadic, or infrequent service. No closing authorityshall extend beyond one hundred eighty days from the last date of operation of thebusiness, except for good cause. During the period of closing authority, the permit premisesshall not be used for any other purpose. At the end of the closing authority period,the permit holder shall resume operation. If the permit holder is unable or unwilling toresume operation and no extension of closing authority has been granted, the division shallnot renew the permit. Noncompliance with the above provisions shall be grounds forsuspension, revocation, or rejection of the permit.If the division determines the permit business has been closed in excess of thirty days andthe permit holder has not notified the division of the closing within thirty days of the lastdate of operation of the business, the division shall issue a citation to the permit holder forfailure to exercise permit privileges and for being closed more than thirty days without theconsent of the division.This rule is only applicable to a permit holder who has operated its permit business for atleast six months, unless the permit holder can show a mental illness, physical disability orother just cause necessitating closure of the permit business prior to six months ofoperation. American LegalNet, Inc. www.FormsWorkFlow.com