Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For Off Premise Caterer Permit Form. This is a Connecticut form and can be use in Department Of Consumer Protection Statewide.
Loading PDF...
Tags: Application For Off Premise Caterer Permit, Connecticut Statewide, Department Of Consumer Protection
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
Liquor Control Division
Telephone: (860) 713-6210
Fax: (860) 706-1345
Website: http://www.ct.gov/dcp
APPLICATION FOR OFF PREMISE CATERER PERMIT
Section A: BUSINESS INFORMATION
1. Trade Name (Name of Business)
3. City:
2. Street Address & Number:
State:
Zip Code:
7. If yes, current permit
number:
6. Is there currently a liquor
permit?
YES
NO
4. Business Telephone:
(
)
5. Business Fax:
(
)
8. Will you provide food and beverages at private
gatherings or special events?:
YES
NO
Section B: APPLICANT INFORMATION
9. Permittee Name (First, Middle, Last)
10. Date of Birth
11. Residence Street Address
13.Home Telephone Number
(
)
12. City
14. Home Fax Number
(
)
State
Zip Code
15. E-mail:
Sections C, D, E: BACKER/OWNER INFORMATION
* Each backer must also complete the “Personal History Form” that accompanies this application
16. Business Structure: Please select the box that best describes how your business/organization is structured:
Sole
Proprietorship
Partnership
Corporation
17. Name of backer individual or business entity:
19. City:
State:
Zip Code:
Limited
Liability
Company
Limited
Liability
Partnership
Unincorporated
Association
18. Street address & number:
20. Telephone:
(
)
Fax:
(
)
21. Backers: List individuals associated with ownership of backer business/organization (i.e. sole owner/corporate
officers/partners/LLP members)
a. Name: (First, Middle, Last)
Title:
% of ownership or # of
shares:
b. Name: (First, Middle, Last)
Title:
% of ownership or # of
shares:
American LegalNet, Inc.
www.FormsWorkFlow.com
c. Name: (First, Middle, Last)
Title:
% of ownership or # of
shares:
d. Name: (First, Middle, Last)
Title:
% of ownership or # of
shares:
e. Name(First, Middle, Last)
Title:
% of ownership or # of
shares:
f. Name: (First, Middle, Last)
Title:
% of ownership or # of
shares:
Section F: CURRENT LIQUOR PERMITS WITH WHICH PERMITTEE,
BACKER, OR IMMEDIATE FAMLY ARE ASSOCIATED
This section applies to the permittee applicant, and to each backer who is a sole proprietor, partner or a
member of a partnership organization, corporations, members of a limited liability organization or
unincorporated associations. In the case of package store permits, it also applies to ownership by members
of the permittee applicant’s or backer’s immediate family. Immediate family includes parents, children
and spouse – Attach a separate sheet if needed.
22a.Type of other liquor permit
held: (i.e. cafe)
Liquor permit number:
Name of backer or permittee or immediate family
associated with other permit:
Name of business:
Are you a backer or permittee of other business?
Backer
22b. Type of liquor permit held:
(i.e. cafe)
Liquor permit number:
Name of backer or permittee or immediate family
associated with other permit:
23. Have any of the previous permits listed above been
revoked, suspended or denied in CT or any other state?
YES
NO
Permittee
Name of business:
Are you a backer or permittee of other business?
Permittee
Backer
If yes, attach a statement detailing the enforcement
action(s) taken including violations, dates, and the
circumstances involved.
Section G: PREVIOUS LIQUOR PERMITS WITH WHICH PERMITTEE OR BACKER WERE
ASSOCIATED
This section applies to the permittee applicant, and to each backer who is a sole proprietor, partner or a
member of a partnership organization, corporation, limited liability organization or unincorporated
association.
24a. Type of liquor
Liquor permit
State in which
Name of business:
permit held: (i.e. cafe)
number:
issued:
Name of backer or permittee associated with
previous permit:
Were you a backer or permittee of previous business?
Backer
Permittee
List all liquor permits previously held in CT or any other state - Attach a separate sheet if needed.
American LegalNet, Inc.
www.FormsWorkFlow.com
24b. Type of liquor permit
held: (i.e. cafe)
Liquor permit
number:
Name of backer or permittee associated with
previous permit:
State in which
issued:
Name of business:
Were you a backer or permittee of previous business?
Backer
25. Have any of the previous permits listed above been
revoked, suspended or denied in CT or any other state?
YES
NO
Permittee
If yes, attach a statement detailing the enforcement
action(s) taken including violations, dates, and the
circumstances involved.
Section H: APPOINTMENT OF APPLICANT AS PRINCIPAL REPRESENTATIVE
(If applicant is not to be sole backer)
The backers of the proposed applicant agree to appoint him as principal representative on the premises where the
sale of alcoholic liquor is to be and to vest in him/her the same full authority and control of these premises and of
the conduct of all business therein relative to the sale of alcoholic liquors backers could in any way have and
exercise; and the applicant agrees to accept such authority and control.
26. Name of backer or authorized representative of the backer:
27. Street Address:
City:
State:
Zip code:
Section I: CERTIFICATION OF PERMITTEE APPLICANT AND BACKER OR
AUTHORIZED REPRESENTATIVE OF BACKER
28. Permittee Certification: (To be signed
by permittee applicant, identified in “Section
B” of this application) I certify that the
information provided in this application is
true to the best of my knowledge.
29. Backer Certification: (To be signed by
backer or the authorized representative of
the backer) I certify that the information
provided in this application is true to the best
of my knowledge and that the permittee
applicant identified in “Section A” of this
application is designated as my principal
representative on the premises for which this
application is being submitted.
Signed by Permittee Applicant:
Date:
X______________________________________
Signed by Backer or Authorized Representative
of Backer:
Date:
X______________________________________
34. Print name of Backer or
Representative:
35. Title of Backer or
Representative:
Subscribed and affirmed before me:
Signed X
(Commissioner of Superior Court, Notary Public, Justice of Peace)
Date
American LegalNet, Inc.
www.FormsWorkFlow.com