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Application For Liquor Permit Form. This is a Connecticut form and can be use in Department Of Consumer Protection Statewide.
Tags: Application For Liquor Permit, Connecticut Statewide, Department Of Consumer Protection
OR FILING APPLICATION FOR LIQUOR PERMIT
INSTRUCTIONS If
1. Please read all questions carefully. All questions, including each separate part, must be answered. If a question or one of its parts does not apply,
fill in the word "NONE".
2. FEE. The application must be accompanied by the proper permt fee and fiing fee in the form of a CERTIFIED PERSONAL OR
CORPORATE CHECK. BANK CHECK. MONEY ORDER OR CASH (IF HAND CARED). A personal or corporate check which is NOT
certified cannot be accepted under the statute.
3 . ATTACH EXTR sheets if space allowed under any item is inadequate or inconvenient. Write "see attachment" in any such space, and show
name of permttee and date of application at the top of each sheet. Identify subject of attachment by letter and number as shown on this form (e.g. C,
2) for each such subject.
4. Please note the term "APPLICANT" as used in this application designates the person in whose name the permit wil be issued if
the application is
approved. It does not refer to backers of any kind.
SECTION A
permit desired (example: Restaurant Liquor, Restaurant Wine & Beer, Package Store, Grocery Beer, Cafe, etc. See permit fee schedule
for complete list). Check appropriate box for patio. List type of1ive entertainment (be specific) Le., exotic dancers, comedians, bands, etc.
Fil in type of
SECTION B
Fi\ in business telephone and trade name.
Line 1. Fí1 in complete business address.
Line 2. Fil in mailing address if different from line 1 address.
Line 3. Check appropriate box and necessary permt information.
Line 4. Fire Marshal's dated signature required for all on premises applications.
Line 5. Must be completed by Zoning Offcial for all applications.
Line 6. Must be completed by TownCity Clerk for all applications.
SECTION C
Fil in permittee's home phone number.
Line 1. Fi\ in your last, first and middle names.
Line 2. Fi\ in month, day, and year of
your birth.
SECTION D
(For Manufacturers and Wholesalers only)
Fill in permit number issued by A.T.F. and amount of
bond posted with the Connecticut Department of
Revenue Services.
SECTION E
Fill in Federal Employer Identification Number (F.E.LN.) issued by the Internal Revenue Service.
SECTION F
Check appropriate box for type of ownership.
SECTION G
Lines 1 through 4. Fil in name and date ofbiith for each individual owner or partner.
SECTION H
Line 1. Fil in name of corporation, unincorporated association, or limited liability company (LLC)
Line 2. Fil in state of organization for entity listed in line 1.
Line 3. Fil in date of organization (month, day, year).
Line 4. If out-of-state entity, fill in date authorized to do business in Connecticut (month, day, year).
birth (month, day, year).
Line 5 & 6. Fil in name, number of shares he~ and date of
SECTION I
Fil in name and date of
birth (month, day, year) for all general and limited partners. Include corporations if applicable and complete Section H.
SECTION J
Lines 1-3. Fil in all requested information for present or previous liquor permts held by any individual or corporation listed or by the
immediate family member of any individual or corporate member listed.
SECTION K
Right to Occupy the prellses for which you are applying. If there is a percentage clause in the lease produce copy of lease.
SECTION L THROUGH N
Signatures and notarizations as required for type of ownership requested.
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DOCUMENTS NEEDED FOR FILING
APPLICATION FOR LIQUOR PERMIT
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1. SKETCH. A diagram, sketch, plan or blueprint of the layout of the premises, including patios,
maximum 17"x 21" in size showing all dimensions e.g., height of separations, outside measurements of
bars, measurement of doorways separating the barroom from the other rooms, etc. and all rooms
labeled, e.g., dining room, Iockable storage area, barroom etc., for all applications except for grocery
beer, airline, boat, railroad, out-of-state shippers, uúlitary, brokers and warehouse pennts.
If your proposed preuúses has access to other areas withi the building, provide us with a separate
the building labeling the other areas.
the layout of
diagram, sketch, plan or blueprint of
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2. HEALTH CERTIFICATE.** All on preuúses locations. Signatures must be less than 60 days old at
time of
receipt by the Liquor Division.
3. SALES TAX NUMBER. Copy of
receipt, stamp, letter or blue card required as proof.
4. PERSONAL HISTORY AND INFORMATION RELEASE AUTHORIZATION.** The
applicant/pennttee and backers (individuals, parters, general parter and liuúted parters in a L TD
partership, offcers, directors and a LLC manager and members in a LLC, corporate offcers and
stockholders) must complete a personal history affdavit and an informtion release authorization
affdavit.
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5. CORPORATION. LLC AND LTD INFORMATION RELEASE AUTHORIZATION.** Only
authorized individuals may sign on behalf of the above listed entities.
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6. FINANCES.** A completed Liquor Division financial affdavit. Additional documents may be
required.
CORPORATIONS & L.L.C. The application wil not be approved until the incorporation or
organization papers have been fied with the Secretary of the State. Corporation papers may be
transferred from an existing fie, if applicable.
This means the following are required:
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A. Certificate of incorporation and proof of filing (if incorporated within 1 year) or certificate of good
standing (if incorporated more than 1 year).
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An information release authorization for corporations must be subuútted with the aforementioned
corporate documents. **
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7. GROCERY SALES FIGURS. ** For grocery beer pernts. The 9 item "Breakdown of Sales" form
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8. FEDERA BASIC PERMIT. All wholesale and manufacturer pernts require a copy of the federal
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should be completed for a one month period. Estimates are not acceptable. Do not round off figures.
Includes gas sales under #9.
basic pernt issued by the Bureau of Alcohol, Tobacco & Firearm.
that a tax bond has
9. TAX BOND. All wholesale, warehouse and manufacture pernts require proof
been posted with the Departent of
Revenue Services.
CLUB PERMITS.
a. Copy of Charter Incorporation
by-laws
b. Copy of
c. Proof of the existence of the club as a bonafide organization for at least three years in this state or
proof that the club is a bonafide national or international fraternal or social organization in existence
for at least one year in this state (e.g.: miutes).
o 10. PHOTOGRAHS. 8"x 10" in size (any photos smaller than this required size wil not be acceptable).
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A. One taken from a position directly across the street or highway from the proposed location.
B. One taken from a position 300 feet to the rightofthe proposed location showing the front and side
of
the preuúses.
C. One taken from a position 300 feet to the left of
the proposed location showig the front and side of
the preuúses.
D. Applicants for tavem pernts must fuish a photo taken immediately inside the front entrance
showing the entire interior of the proposed tavern.
E. All exterior photos should be marked with a "X" showing the location of the preuúses in the photos
and the name of the pennittee and address of the pernt preuúses must be printed on the back of each
photo.
Applicants for restaurant, cafe, theater, special outing facilty, special sporting facilty, farm winery,
airort, brew pub, coliseum, art museum, racquetball, and resort pernts, bowling alley, hotel, tavern
and university pernts must fuish photographs showig the full interior of the barroom, dining rooms,
lounge and kitchen, where applicable. Also, grocery beer applicants must subuút a photo showing the
the regulations for exact photo
the store. Please refer to section 30-6-Al of
entire interior of
requirements for each pernt. Photos must be 8"x 10". The applicant's name and business address
should be on the rear of all photographs.
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11. MENU. STAFF & EQUIPMENT, Proposed menu, staff & equipment, for all restaurant and hotel
applications.
12. BUYER/SELLER AFFIDAVITS. If a business or equipment was purchased from the previous
permit holder. These must be signed at closing.
13. ADDITIONAL CONSUMER BAR** If
you have more than one consumer bar, please cornplete the
Additional Consumer Bar Permit application.
** See attachments
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DEPARTMENT OF CONSUMER PROTECTION
LIQUOR DIVISION
PERMIT FEE SCHEDULE
A fee of $100.00 in the form of a bank or certified check, money order, or cash (if carried by hand) must
accompany the application along with the necessary pernt fee.
FULL YEAR
ADDITIONAL CONSUMER BAR (NO FILING FEE)
AIRLINE
AIRPORT AIRLINE CLUB
AIRPORT BAR
AIRPORT RESTAURANT
BOAT
BOWLING ALLEY
BOWLING ALLEY BEER
BREW PUB
BROKER
CAFE
CLUB
CLUB NON-PROFIT
COLISEUM CONCESSION (BEER ONLY)
COLISEUM
CONCESSION
CONCESSION (ONE DAY)
DRUGGIST LIQUOR
FARM WINERY
GOLF COUNTRY CLUB
GROCERY BEER
HOTEL BEER
HOTEL LIQUOR
10,000 OR LESS POPULATION
50,000 OR LESS POPULATION
50,000 OR MORE POPULATION
HOTEL MINI BAR (NO FILING FEE)
MANUF ACTURR APPLE BRANDY
MANUACTURR BEER
MANUFACTURR CIDER
MANUFACTURR LIQUOR
MILIT AR Y
NONPROFIT GOLF TOURAMENT ($10 FILING FEE)
NONPROFIT PUBLIC ART MUSEUM
NONPROFIT PUBLIC TELEVISION ($10 FILING FEE)
OUT OF STATE SHIPPER (CONNECTICUT)
OUT OF STATE SHIPPER (OTHER)
PACKAGE STORE LIQUOR
PROVISIONAL PERMIT (90 DAY RENEWABLE)
RACQUETBALL FACILITY
RAILROAD
RESORT
RESTAURNT BEER
RESTAURANT CATERER
RESTAURNT LIQUOR
RESTAURNT WINE & BEER
SPECIAL OUTING FACILITY BEER
SPECIAL OUTING FACILITY LIQUOR
SPECIAL SPORTING FACILITY BAR
SPECIAL SPORTING FACILITY CONCESSnON
SPECIAL SPORTING EMPLOYEE RECREATION
SPECIAL SPORTING FACILITY GUEST
SPECIAL SPORTING FACILITY RESTAURNT
TAVERN
THEATRE
UNIVERSITY BEER ONLY
UNIVERSITY LIQUOR (UCONN ONLY)
UNIVERSITY WINE & BEER
WAREHOUSE BOTTLING
WAREHOUSE STORAGE
WHOLESALE BEER
WHOLESALE LIQUOR
ONLY REQUIRES $10 FILING FEE:
CHARITABLE ORGANIZATION (PER DAY)
SPECIAL CLUB (PER DAY)
TEMPORARY ALCOHOL (PER DAY)
TEMPORAY BEER (PER DAY)
SIX MONTHS
. $ 150.00
$
400.00
650.00
300.00
1,200.00
400.00
2,000.00
350,00
240.00
160.00
1,750.00
240.00
650.00
1,000.00
2,000.00
240.00
25.00
425.00
240.00
800.00
85.00
240.00
1,200.00
1,600.00
2,400.00
50.00
320.00
800.00
160.00
1,600.00
15.00
200.00
200.00
25.00
45.00
1,000.00
425.00
500.00
2,000.00
400.00
1,700,00
240.00
1,200.00
1,200.00
560.00
240.00
1,200.00
300.00
240.00
240.00
240.00
1,200.00
240.00
200.00
240.00
240.00
560.00
160.00
35.00
800.00
2,400.00
266.67
266.67
1,333.33
233.33
160.00
106.67
1,166.67
160.00
666.67
1,333.33
160.00
283.34
533.33
56.66
160.00
800.00
1,066.67
1,600.00
213.33
533.33
106.67
1,066.67
133.33
283.34
1,333.33
266.67
. 160.00
800.00
800.00
373.33
200.00
160.00
160.00
160.00
800.00
160.00
133.33
160.00
106.67
533.33
1,600.00
25.00
25.00
25.00
15.00 .
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STATE OF CONNECTICUT
Application for Liquor Permit
DEP AR1lMENT OF CONSUMER PROTECTION
LC28 Rev 11/97
BEFORE THE LIQUOR CONTROL COMMISSION
DO NOT WRITE HERE, FOR USE OF LIQUOR DIVISION ONLY
State of Connecticut
Department of Consumer Protection
Liquor Division
Room 110
165 Capitol Avenue
Hartford. CT 06106-1630
RETURN TO
AMOUNT OF FEE RECEIVED
DATE APPLICATION RECEIVED
DATE FEE RECEIVED
ATTORNEY:
ADDRESS:
TELEPHONE:
RECEIPT
NO.
A. THIS SECTION MUST BE COMPLETED PRIOR TO OBTAINING LOCAL SIGNATURS.
ENTER HERE THE TYPE OF PERMIT DESIRED PATIO YES
-
NO
List tye of live entertainent (be specific)
B. BUSINESS TELEPHONE NO.
2. MAILING ADDRESS (if different).
1. ADDRESS AT WHICH BUSINESS WILL BE CONDUCTED (No., S1., Town or City, Zip Code)
If
3. IS THERE NOW A PERMIT ON THE PROPOSED PREMISES?
YES
0
Proposed
Present
TRAE NAME
yes, give pennit number and pennittee name.
NoD
4. FIRE MARSHAL APPROV AL DATE
signature of FIRE MARSHAL
Signature must be Jess than 60 days old, to certify that thc premises identified in item I are physically constituted
business for which this penn~ sought.
so as to be safe for the type of
this section is located in the town or city there stated; that I am acquainted with
5. CERTIFICATE OF ZONING AUTHORITY: This is to certfy that the building in item I of
the zoning ordinances and bylaws of said town or city; and that, at this location, said town or city does not prohibit the sale of alcoholic liquor under the tye of pennithere applied for.
Signature must be less than 60 days old.
Name of
Name of
TOWll or City
Zoning Authority
Signature of Authorized Offcer
Date
I Tm,
6. CERTIFICATE OF TOWN CLERK (Signature must be less than 60 days old)
Date
a. Said town or city has no ordinance reducing the hours of sale of
alcoholic liquors except as stated below:
Signature of
Town or City Clerk
HOME TELEPHONE NO. (
C. FOR APPLICANT ONLY (Pennittee)
Town or City
Name of
)
DATE
1. NAME AND HOME ADDRESS OF APPLICANT
OF
BIRTH
(Last, First. Middle) include Maiden, previous marred, and any NKA
D. WHOLESALERS AND
A TF PERMIT #
AMT OF BOND POSTED E. FEDERA EMPLOYER IDENTIFICATION
NUMBER (FEIN)
MANUFACTURRS
F. TYPE OF OWNERSHIP
o
o
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i. INDIVIDUAL
(COMPLETE SECTION G)
2. PARTNERSHIP
(COMPLETE SECTION G)
3. CORPORATION
(COMPLETE SECTION H)
D
4. UNINCORPORATED ASSOCIATION
D
5. LIMITED PARTNERSHIP
(COMPLETE SECTION H)
OR LLC/LIMITED LIAILITY COMPANY
(COMPLETE SECTION I)
',.
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G. EACH INDIVIDUAL LISTED MUST SUBMIT A COMPLETED PERSONAL HISTORY FORM
NAME (Include Maiden or previous married)
BIRTH
DATE
NAME (Include Maiden or previous married)
BIRTH
DATE
BIRTH DATE
NAME (Include Maiden or previous married)
BIRTH
NAME (Include Maiden or previous married)
DATE
NAME (Include Maiden or previous married)
BIRTH DATE
NAME (Include Maiden or previous married)
BIRTH DATE
H. FOR BACKER IF CORPORATION, UNINCORPORATED ASSOCIATION, OR LLC
NAME OF CORPORATION OR ASSOCIATION
DATE OF ORGANIZATION
STATE WHERE ORGANIZED
DATE AUTHORIED TO DO BUSINESS IN CT
OFFICERS AND DIRECTORS, LLC MANAGERS
NUMBER OF SHAS
D/O/B
NUMBER OF SHAS
NAME & TITLE
D/O/B
SHAREHOLDERS, LLC MEMBERS
NAME
PLEASE ATTACH:
Certificate of incorpoTtion and proof of fiing (if incorporated within 1 year) OR certificate of good standing (if incorporated more than lyear)
1. L TD partnership (list names and D/O/B)
DATE ORGANIZED
GENERAL PARTNERS
L TD PARTNERS
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J. FOR APPLICANT, BACKERS (including Corporations or Unincorporated Associations)
AND FORPACKAGE STORES ONLY IMMEDIATE FAMILIES OF APPLICANT AND BACKERS.
Complete the following lines i through 3, as they apply to the applicant, to each backer who is an individual owner or partner, to corporations or unincorporated
such applicant or backer must also complete (Immediate family includes father,
the immediate family of
associations. For Package Stores Only, members of
mother, son, daughter, husband, wife).
i. LIQUOR PERMITS HELD NOW OR PREVIOUSLY (As permittee or backer, in CT or elsewhere)
a. By applicant, individual backers, LLC members, general partners (Give name, class of
permit, dates held, address of
business)
b. By corporation, LLC, offcers or direc,tors of corporation or L TD Partnership (Give class of permit, dates held, name of corporation, name of
stockholder and shares held)
2. PREVIOUS LIQUOR PERMITS REFUSED, REVOKED, FORFEITED, OR SUSPENDED (In CT or elsewhere). Give names and dates.
3. LOANS OR CREDITS RECEIVED FROM MAUFACTURERS OR WHOLESALERS OF ALCOHOLIC LIQUORS. In this section list all cases in which
the above persons, or any employee or agent ofthese persons, has borrowed money or received credit in any form for a period in excess of thirty (30) days, directly
or indirectly, from any manufacturer permittee of alcoholic liquors or backer thereof. or from any wholesaler permittee of alcoholic liquor or backers thereof, or
from any member ofthe family of such manufacturer permittee or backer thereof, or from any stockholder in a corporation manufacturing or wholesaling alcoholic
liquors. Give the name of any person to whom money was loaned or credit extended, date, and amount for each such case.
have rented the premise located at
K. I1we
Name of
business premises
lessee place of
-
yes, provide copy oflease.
Is there a rent percentage contained in the lease? Yes _ No _ If
L. APPOINTMENT OF APPLICANT AS PRINCIPAL REPRESENTATIVE (Ifap¡ilicant is not to be sole owner)
By signature on this application, the backers of
the proposed applicant agree to appoint him as principal representative on the premises where the
the conduct of all business
these premises and of
sale of alcoholic liquor is to be permitted and to vest in him the same full authority and control of
therein relative to the sale of alcoholic liquor as said backers could in any way have and exercise; and the applicant agrees to accept such authority
and control.
SIGNING AUTHORITY FOR CORPORATE OFFICIALS
INSTRUCTIONS
Prepare and submit to the State of Connecticut, DepaLtment of Consumer Protection, Liquor Control Commission. This must be signed in ink by a corporate
offciaL. This form may be used to list the corporate offcials, or employees (if any), who are authorized by the articles of incorporation, the bylaws, or the board of
directors in adopted resolutions or motions, to act on behalf of the corporation or to sign its name. If the authorization to sign is granted by position title, rather
than to specific individuals by name, a new authorization wil not be needed each time a change of incumbent occurs. WHERE THE AUTHORIATION IS NOT
GRATED BY THE ARTICLES OF INCORPORATION, THE BYLAWS, OR ACTION BY THE BOAR OF DIRECTORS, POWER OF ATTORNEY MUST
BE SUBMITTED.
NAME AND COMPLETE ADDRESS OF CORPORATION
DATE MEETING HELD
BOARD MEETING
IJ DIRECTORS IJ TRUSTEES
C MAAGERS C GOVERNORS
THE FOLLOWING CORPORATE OFFICIAS, EMPLOYEES, OR INCUMBENTS OF THE OFFICES LISTED ARE AUTHORIED TO SIGN, OR TO
documents) SUBMITTED ON THE CORPORATION'S BEHALF TO THE
APPOINT PERSONS AUTHORIED TO SIGN, DOCUMENTS (Specif type of
STATE OF CONNECTICUT, DEPARTMENT OF CONSUMER PROTECTION, LIQUOR CONTROL COMMISSION.
I certify that this is true and complete and that the above authorization was granted at the cited meeting
of the board.
CORPORATE SEAL
SIGNATURE
TITLE
-
DATE
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M. SIGNATURES
This application must be signed and sworn to by the applicant and all backers. If backer is a corporation or an unincorporated
association, application must be signed and sworn to by an authorized agent. If permittee is sole backer, permittee must sign
line I K only. ALL PARTNERS MUST SIGN.
4. BACKER-OWNER (Partner/or General Partner)
I. APPLICANT (Permittee and/or sole owner)
2. BACKER-OWNER (Parner/or General Parner)
5. BACKER-OWNER (Partner/or General Parner)
3. BACKER-OWNER (Parner/or General Partner)
6. BACKER-OWNER (Authorized Agent of Corporation or
Unincorporated Association or LCC Member or Manager)
N. SIGNATURES
PERSONALLY APPEARD the above named .................................................................................. and
made oath to the truth of the statements contained in his/her answers to the foregoing questions.
i. FOR APPLICANT
BY (Signature)
COUNTY OF
-
C
Notary Public
Justice of
C
BY (Signature)
Comm. of Superior Court
the Peace
ALL Y APPEARD the above named .....................................................................................and made oath
to the truth ofthe statements contained in his/her answers to the foregoing questions.
3. FOR BACKER
PERSON
SS. (Date)
,
BY (Signature)
COUNTY OF
-
IJ
IJ
IJ
Notary Public
Justice of the Peace
Comm. of
Superior Court
PERSONALLY APPEARD the above named .....................................................................................and made oath
to the truth of the statements contained in his/her answers to the foregoing questions.
4. FOR BACKER
STATE OF
Comm. of Superior Court
IJ
SS. (Date)
,
COUNTY OF
STATE OF
Justice of the Peace
PERSONALLY APPEARD the above named .....................................................................................and made oath
.
to the truth of the statements contained in hislher answers to the foregoing questions.
2. FOR BACKER
STATE OF
Notary Public
IJ
SS. (Date)
,
IJ
IJ
STATE OF
SS. (Date)
,
BY (Signature)
COUNTY OF
-
IJ
IJ
IJ
Notary Public
Justice of the Peace
Comm. of
Superior Court
5. FOR BACKER
PERSONALLY APPEARED the above named .....................................................................................and made oath
to the truth of the statements contained in his/her answers to the foregoing questions.
STATE
SS. (Date)
COUNTY OF
-
Justice of the Peace
Comm. of Superior Court
PERSONALLY APPEARD the above named .....................................................................................and made oath
to the truth ofthe statements contained in his/her answers to the foregoing questions.
6. FOR BACKER
STATE OF
Notary Public
C
BY (Signature)
C
IJ
OF
,
SS. (Date)
BY (Signature)
COUNTY OF
IJ
IJ
Notary Public
Justice of the Peace
IJ Comm. of Superior Court
AFFIX SEAL BELOW
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4
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
BEFORE THE LIQUOR CONTROL COMMISSION
PERSONAL HISTORY DATA
If
the application process
the application and this form are not completely filled out, they must be returned resulting in a delay of
and this application's approvaL.
PERMIT NUMBER
APPLICANT
Print or type carefully all the information requested below. Please give complete answers to those questions that pertain to you. If
a question does not pertain to you, print "N/A". The infonnation you provide wil be used to evaluate the pennit application. All
information submitted may be investigated. The application wil not be processed without this completed form. IF YOU NEED
ADDITIONAL SPACE, USE AN ADDITIONAL SHEET.
First name
Last name
1.
.
1 Middle
Title
I Shares
Aliases, other names known by, maiden name
.
Marital status
I Age
I Place of
Birh
I Driver's Lic # & State
Social Sec. #
U.S. Citizen
Birh
I Date of
yes
0
no 0
If no, alien reg #
I Sex
MD
F
D
natualization
Date & place of
I Business Phone #
Home Phone #
I Since( date ì
Present home address
2. CRIMINAL RECORD: List any convictions of a Federal or State law, including motor vehicle violations. Include any
pending charges, and/or matters in which you were granted a not yet disposed of accelerated rehabiltation, or alcohol
you have no
incarceration, probation, fine, license suspension or revocation, etc. If
education program, and include periods of
such record, indicate by using the word "NONE". List any statutory citation of any charge or conviction.
CONVICTION/PENDING CHARGE DATE DISPOSITION
3. Public offices now held by applicant, individual backers, shareholders, corp. offcers, LLC. Give name of offce holder and
town, city, state or federal agency.
identify by title, place and name of
no
Are you able to read and understand English?
yes
I,
, do hereby swear or affrm that the information herein contained is true to
NAME
Signed Date
the best of
my abilty and that I personally completed or directed completion of
Personally appeared the signer of
this form.
the foregoing statement and made oath before me to the trth of
Signed (Commissioner of Superior Court, Notary, Justice of
Peace)
the matters contained therein.
Date
rev 8/97
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STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
BEFORE THE LIQUOR CONTROL COMMISSION
FINANCIAL AFFIDAVIT
A. COST /EXPENSES
1. Purchase /sale price for business $
2. Cost of
real estate is being transferred) $
building (if
3. Leasehold/security deposit $
4. Renovations/alterations $
5. Franchisee fee (if
proposed owner is a franchisee) $
6. Existing beer/wine/liquor/food inventory $
7. Furniture, fixtures, equipment, etc. $
8. Other expenses (explain) $
TOTAL COST EXPENSES $
*************************************************************************************
B. SOURCE OF FUNS TO SATISFY THE TRANSACTION ($AMOUNTS). TOTAL(S)
(MULTIPLE OR SOLE SOURCE) MUST AGREE WITH TOTAL COST EXPENSES
1. CASH ON HAND
SEE (C)
$
2. SAVINGS ACCOUNT
SEE (C)
$
3. CHECKIG ACCOUNT
SEE (C)
$
4. CERTIFICATE OF DEPOSIT
SEE (C)
$
$
5. PROMISSORY NOTES
6. LOAN(S)
$
SEE (C)
$
7. OTHER
TOTAL SOURCE FUNDS
$
C. NOTE:
Funds dispersed to satisfy the transaction prior to the application must be accounted for.
NOTE TO APPLICANT:
This fonn must be completed for an new outlets and changes of ownership. ADDITIONAL DOCUMENTS MAY BE
REQUESTED BY THE DEPARTMENT.
Applicant signature
Subscribed and Sworn to before me this
day of
Notary/Commissioner of Superior Court/Justice of the Peace
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STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
LIQUOR DIVISION
INFORMATION RELEASE AUTHORIZATION
CARFULLY READ THIS AUTHORIZATION TO RELEASE INFORMATION ABOUT YOU, THEN
SIGN AND DATE IT IN INK.
I authorize any agent from the State of Connecticut, Departent of Consumer Protection, to obtain any information,
relating to my activities, from employers, crimial justice agencies, financial or lending institutions, credit bureaus,
consumer reporting agencies and retail business establishments, or individuals. This information may include, but is
not liuúted to, my residential, personal, or crimial history record, and financial and credit informtion.
I fuither authorize release of my crimnal history from crimial justice agencies for the purpose of determing my
eligibility for a liquor pernt as either a pernttee and/or backer.
I understand that the inormtion released is for offcial use by the State of Connecticut, Departent of Consumer
Protection, and that these users may redisclose this informtion as authorized by law.
liability for damages that may result to me because of
compliance, or any attempts to comply, with this authorization. This release is binding, now and in the future, on my
heirs, assigns, associates and personal representative( s) of any natue. Copies of this authorization that show my
signature are as valid as the original release signed by me.
I release any individual, including records custodians, from all
Failure to complete this form may result in delays of obtaining your pernt and may result in the peiTIt being denied
if
this information can not otherwise be obtained.
Signature
Full name tyed or printed
Other names used
Social security number
Other names used
Other names used
Current address
Home phone #
Subscribed and sworn to before me, this
Date
day of 199_"
N otary/Comnssioner of Superior CourtJustice of the Peace
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STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
LIQUOR DIVISION
CORPORATION, LLC AND LTD PARTNERSHIP
INFORMATION RELEASE AUTHORIZATION
authorization form about the corporation in which you have
authority to sign, then sign and date it in ink before a competent authority.
Carefully read this information release
,as
I,
,
(Title of signer in corporation, LLC, etc.)
having been duly authorized by the backer listed below. authorize any agent from the State of
Connecticut Department of Consumer Protection to obtain any information, relating to
(Name of corporation, LLC etc.)
from financial or lending institutions, licensing agencies, credit bureaus, consumer reporting
agencies, and retail business establishments, or individuals, etc.
I Understand that the information released is for official use by the State of Connecticut
Department of Consumer Protection, and that these users may re disclose this information as
prescribed by law or when involved in a joint investigation.
liabilty for damages that may
result to my corporation because of compliance, or any attempts to comply, with this authorization.
This release is binding, now and in the future, on my heirs, assigns, associates and personal
representative(s) of any nature. Copies of this authorization that show my signature are as valid
as the original release signed by me.
I Release any individual, including records custodians, from all
Failure to complete this form may result in delays of obtaining your permit and may result
in the permit being denied if this information cannot otherwise be obtained.
Signature
Full name typed or printed
Title
Federal
Backer's name
Other names used
Current address
Home telephone
Identification number
Subscribed and sworn to before me, this day of
Date
,199 .
Notary/Commissioner of Superior Court/Justice of the Peace
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STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
LIQUOR DIVISION
TO: THE DIVISION OF LIQUOR CONTROL
165 CAPITOL AVENUE
HARTFORD, CT 06106
I CERTIFY THAT
NAME OF PERMITTEE
NAME OF ESTABLISHMENT
STREET
TOWN OF CITY
PATIO: Yes No
COMPLIED WITH THE REQUIREMENTS OF THE STATE PUBLIC HEALTH CODE ON PLACES
DISPENSING FOOD AND BEVERAGES AT THE TIME OF INSPECTION.
DATE:
SIGNATUR OF DIRECTOR OF HEALTH
OR HIS AGENT
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CPLP-grocbeer Rev 2/05
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
Liquor Control Division
Telephone: (860) 713-6210
Fax: (860) 713-7235
Website: www.ct.gov/dcp
Grocery Store Beer Permit
Breakdown of Sales
This form must be completed if applying for a grocery beer permit in accordance with CGS Section 30-20(c)
Name of Permittee (Last Name, First Name, Middle Initial)
Name of Business
Business Street Address
I State
I City
I Zip
In order to determine your eligibilty to obtain a grocery beer permit you must provide the following sales data for thE
most recent month of business operation. This information should reflect accurate monetary sales (not estimates) foi
that month in each of the categories noted below. Please use whole dollar values.
Date of Sales - Beginning Date:
Ending Date:
Month's sales In dollars:
1. Dairy products: (I.e. butter, cheese, milk, cream, Ice cream and other milk products)
Month's sales in dollars:
2. Eggs & Poultry:
Month's sales in dollars:
3. Fruits & Vegetables:
Month's sales in dollars:
4. Seafood:
Month's sales in dollars:
5. Bakery products:
6. Grocery items: (all edible items other than those noted above including, but not limited to,
canned goods, dry goods, meats, tea, coffee, spices, sugar. flour, cereal, juices & drinks, frozen food)
Month's sales in dollars:
Month's sales In dollars:
7. Candies, Nuts and Confectioneries (Sweets):
Month's sales in dollars:
8. Food items consumed on premises:
Month's sales in dollars:
9. Take-out foods: (i.e. sandwiches, salads, coffee & rolls)
Month's sales in dollars:
10. Non-edible items; (I.e. tobacco, health/beauty aids, paper products, magazines. newspapers)
Month's sales In dollars:
11. Gasoline:
Month's sales In dollars:
12. Beer: (If grocery beer pennit Is active on premises)
I certify under penalty of law that the information provided in this statement is true to the best of my knowledge:
Signature of Permittee, Backer or Authorized Representative of the Backer:
x
Date:
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AFFIDAVIT OF BUYER
UNPAID OBLIGATIONS
THIS FORM is TO BE EXECUTED AT THE TIME OF THE CLOSING
STATE OF CONNCTICUT
DATE:
SS:
COUNTY OF:
(TOWN
,OF
THE UNERSIGNED
(NAME)
, CONNCTICUT,
(ADDRESS)
BEING DULY SWORN, DEPOSES AN SAYS:
1. I AM OVER THE AGE OF EIGHTEEN YEARS AND BELIEVE IN THE OBLIGATIONS OF AN
OATH.
2. I AM THE APPLICANT FOR A LIQUOR PERMIT AT
, CONNECTICUT.
(ADDRESS)
3. I HEREWITH FILE WITH THE DEPARTMENT OF CONSUMER PROTECTION AN AFFIDAVIT
EXECUTED BY THE PREDECESSOR PERMITTEE OR BACKER DATED
LISTING ALL UNP AID OBLIGATIONS (INVOICES) OF THE
PREDECESSOR FOR THE PURCHASE OF ALCOHOLIC LIQUOR AT THE SAID PREMISES
PRIOR TO CHANGE IN OWNERSHIP.
4. I HAVE EXAMINED THE AFFIDAVIT OF SAID PREDECESSOR PERMITTEE OR BACKER
AND ANY LISTED UNAID OBLIGATION FOR THE PURCHASE OF ALCOHOLIC LIQUOR.
ALL SUCH LISTED OBLIGATIONS HAVE BEEN PAID.
5. THIS AFFIDAVIT IS MAE IN COMPLIANCE WITH C.G.S. SECTION 30-48(c).
,CT.,
SUBSCRIBED AND' SWORN TO BEFORE ME IN
THIS THE
Comnssioner of
19
DAY OF
the Superior Court, Notary Public, Justice of
the Peace
rev 3/97
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AFFIDAVIT OF SELLER
UNPAID OBLIGATIONS
THIS FORM IS TO BE EXECUTED AT THE TIME OF THE CLOSING
,OF
THE UNERSIGNED
(NAME)
, CONNCTICUT,
(ADDRESS)
BEING DULY SWORN, DEPOSES AN SAYS:
1. I AM OVER THE AGE OF EIGHTEEN YEARS AND BELIEVE IN THE OBLIGATIONS OF AN
OATH.
2. I AM THE BACKER, PARTNER OR DULY AUTHORIZED OFFICER IN THE BACKER
CORPORATION OF THE LIQUOR PERMIT PREMISES LOCATED AT
, CONNECTICUT, PERMIT NUBER
3. ATTACHED HERETO AND MAE A PART HEREOF IN EXHIBIT A IS A LISTING OF ALL
UNP AID OBLIGATIONS (INVOICES) FOR THE PURCHASE OF ALCOHOLIC LIQUOR AT
SAID PERMIT PREMISES PRIOR TO CHANGE IN OWNERSHIP. (IF THERE ARE NONE
WRTE THE WORD "NONE".)
. I, , do hereby swear or affrm that the information herein
contained is tre to the best of
my ability and that I personally completed/directed completion of
this form.
Date
Signed
Personally appeared the signed of the foregoing statement and made oath before me to the trth of the
matters contained therein.
Signed: Date
(Comnssioner of Superior Court, Notary Public, Justice of
Peace )
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STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
LIQUOR CONTRO DIVISION
165 CAPITOL AVE
HARTFORD CT. 06103
FAX (860) 713-7235
TEL: (860) 713-6210
PATIO REQUEST
PERMIT #
PERMITTEE:
BACKER:
ADDRESS:
TRADE
NAME:
BUSINESS PHONE:
HOME PHONE:
TOWN
FAX
#
WILL PATIO BE PERlIANENT: YES NO
If Patio is going to only be used Temporarily, List exact dates needed:
DIRECTIONS: ON THE BACK OF THIS SHEET MAKE A SKETCH OF THE
EXISTING PERMIT PREMISES AND INCLUDE THE FOLLOWING
1. The Patio in relation to the permit premises. List all dimensions of Patio in feet.
2. All entrances & exits leading to and from the patio.
3. Portion of sketch that shows Permit Premises must be labeled with all the Dining Rooms,
..
,
Barrooms, Kitchen, etc
4 Indicate all fences, railngs, etc. surrounding patio area
5 Indicate how alcoholic beverages are going to be served on Patio. Show all consumer bars
&Service Bars
NOTE: If a Consumer Bar is going to be used on the Patio, an application for
Additional Consumer Bar permit together with a $150.00 fee must be
Submitted witll this application.
IF THIS SHEET IS NOT LARGE ENOUGH. CONTINUE SKETCH ON ONE
ADDITIONAL SHEET.
NOTES: 1. If access to Patio is through the Barroon, the Patio is considered an extension of
the Barroom (NO MINORS ALLOWED) Unless accompanied by Parent or
Guardian.
2. If access to Patio is through a Dining Room, the Patio is considered and extension of
the Dining Room.
3 If Alcoholic Beverages are to be made from a Service Bar located on Patio-NO
additional fee if required. (Service must be made by Waitstaff only).
4. If Alcoholic Beverages are to be made from an Additional Consumer Bar Located
on the Patio-Patio is considered Barroom-(NO MINORS ALLOWED)
5. No alcoholic beverages are to leave the patio area (away from premises.)
6. NO DEVIATIONS FROM THE PLAN SHOWN ON THIS FORM AR ALLOWED
WITHOUT WRITTEN APPROVAL FROM THIS DEPARTMENT.
.. .... ..... ....... .n...... a......... ......... ...................... .... w.
SIGNATUR:
DATE
PERMITTEE
SIGNATUR:
DATE
BACKER/OWNER
..........................................................................
MUNICIP AL APPROVALS
ZONING: SIGNATUR:
DATE
FIRE DEPT. SIGNATUR:
DATE
HEALTH: SIGNATURE: DATE
................... ~................... ................................ w.
DEPARTMENT OF CONSUMER PROTECTION PATIO APPROVAL
THIS MUST BE DISPLAYED NEXT TO YOUR PERMIT OR PERMIT MUST BE ENDORSED.
LIMITATIONS OR CONDITIONS:
APPROVED BY:
DATE:
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..."'.",',"',.._.....~,."",..."._."".",............"....".."..""..,,............".....,.-.-..."...."............,..,,,....,........
FOR OFFICIAL USE ONLY
CPLP-03 Rev 10/01
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
Liquor Control Division
Telephone: (860) 713-6210
Fax No: (860) 713-7235
Web Site: www.state.ct.us/dcp
I APPLICATION FOR ADDITIONAL CONSUMER BARS I
Instructions: Please complete this application and submit it along with a check or money order for the total
number of consumer bar(s) for which you are requesting approval (! $150 each.
Mail this application with the appropriate fee to the Department of Consumer Protection, License
Services Division, 165 Capitol Avenue, Hartford, CT 06106-1630. Checks or Money Orders should be
made payable to "Treasurer, State of Connecticut".
Liquor Perrnit No.
Permittee Narne: (First, Last)
Narne of Business:
Business Address: (Street & number)
City:
State:
Business Telephone No. (w / area code)
Business Fax No: (w/area code):
Backer's Name:
Zip code:
Number of additional consumer bars requested t9 $150 each:
NOTE:
. This application must be accompanied by an 8.5 X J. i inch sketch of the entire licensed
premises, showing the location(s) of the additional consumer bar(s) for which you are
requesting approvaL. You must also submit a photograph(s) of these proposed location(s)
I have attached a sketch and photograph(s), as described above, related to the additional consumer bar(s) for
which I am requesting approval: Yes ( ) No ( ).
Signature of duly authorized representative:
Date:
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