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. American LegalNet, Inc. www.FormsWorkflow.com DOCUMENTS NEEDED FOR FILING APPLICATION FOR LIQUOR PERMIT o 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 o o o 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. D 5. CORPORATION. LLC AND LTD INFORMATION RELEASE AUTHORIZATION.** Only authorized individuals may sign on behalf of the above listed entities. o 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: o A. Certificate of incorporation and proof of filing (if incorporated within 1 year) or certificate of good standing (if incorporated more than 1 year). o An information release authorization for corporations must be subuútted with the aforementioned corporate documents. ** o 7. GROCERY SALES FIGURS. ** For grocery beer pernts. The 9 item "Breakdown of Sales" form D 8. FEDERA BASIC PERMIT. All wholesale and manufacturer pernts require a copy of the federal o 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). o o o o o 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. American LegalNet, Inc. www.FormsWorkflow.com o o D 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 American LegalNet, Inc. www.FormsWorkflow.com 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 . American LegalNet, Inc. www.FormsWorkflow.com 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 o 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) ',. American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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: American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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 ) American LegalNet, Inc. www.FormsWorkflow.com 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: American LegalNet, Inc. www.FormsWorkflow.com ..."'.",',"',.._.....~,."",..."._."".",............"....".."..""..,,............".....,.-.-..."...."............,..,,,....,........ 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: American LegalNet, Inc. www.FormsWorkflow.com