For Official Use Only DCPLC ­ On-Premises App Rev 1/11 1 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Email: liquor.control@ct.gov Web Site: www.ct.gov/dcp APPLICATION FOR ON-PREMISES LIQUOR PERMIT Please print clearly or type the information entered on this application. An application and permit fee is required. Please see fee chart for required fee. Checks and/or money orders should be made to "Treasurer, State of Connecticut" and must accompany this application. The application fee is non-refundable. Return your completed application, documentation and appropriate fee to: Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT 06106 Section A: BUSINESS INFORMATION ADDRESS AT WHICH BUSINESS WILL BE CONDUCTED 1. Type of Liquor Permit Applying for: 3. Trade Name (DBA Name) 4. Business Address 5. Business Telephone Number 6. Business Fax Number City 2. Are you requesting a Provisional Permit? YES NO State Zip Code 7. Business Email Address 9. Patio? (If yes, complete attached patio request form) YES NO 8. Is there currently a liquor permit at the proposed premises? YES NO 10. Type of Live Entertainment: Acoustics (Not Amplified) Concerts YES If yes, current permit number NO (If yes, please check () all that apply below) Live Bands Plays/Shows Comedians Sporting Event(s) Exotic Dancers Magicians Disc Jockeys Karaoke Section B: APPROVAL/CERTIFICATION OF LOCAL OFFICIALS 11. Zoning Authority Approval: I certify that I am familiar with the zoning ordinances and bylaws of the city/town identified in item #4 of this application and they do not prohibit the sale of alcoholic beverages under the type of liquor permit/establishment identified in this application and/or entertainment listed in #10. Signature of Zoning Official X _______________________________________Print Name ____________________________________ Title of Official ______________________________________________________________________ Date ______ /______ /________ 12. Fire Marshal's Approval: I certify that the premises identified in items #3 & #4 of this application is physically constructed in a manner that is safe for the type of business that will be operated there. Signature of Fire Marshal X _________________________________________Print Name ____________________________________ Title of Official ______________________________________________________________________ Date ______ /______ /________ 13. Certification of Town Clerk: The town in which the business identified in item # 4 of this application is to be operated, has no ordinance restricting the hours of sale of alcoholic liquors beyond those set forth in State law except as indicated in the box below. (If none, please enter "NONE") Additional Restrictions: Signature of Town Clerk X_____________________________________________________________ Date ______ /______ /________ American LegalNet, Inc. www.FormsWorkFlow.com DCPLC ­ On-Premises App Rev 1/11 2 Section C: PERMITTEE APPLICANT INFORMATION 14. Permittee Name (First, Middle, Last) 15. Permittee Residence Street Address City State Zip Code 16. Permittee Telephone Number 17. Permittee Fax Number 18. Permittee Email Address Section D: PREFERRED MAILING ADDRESS Check () one box below and enter address if different than Business or Permittee Address BUSINESS ADDRESS 19. Name 20. Address City State Zip Code PERMITTEE ADDRESS ADDRESS BELOW Section E: BACKER INFORMATION * Each backer must also complete the "Authorization for Release of Financial Information & Statement of Personal History" form that accompanies this application 21. Backer: Please select the type of Backer (individual or legal entity that owns the business) below Please check () only one Sole Proprietorship/ Owner Corporation Limited Liability Company Partnership Limited Liability Partnership Unincorporated Association 22. Name of Corporation, LLC, Partnership, Sole Proprietorship, etc. 23. Street Address City State Zip Code 24. Backer Telephone Number 25. Backer Fax Number 26. Backer Email Address 27. Backers: List individuals below (for example; sole owner, corporate officers, members, etc.) Attach additional sheet if needed. a. Name (First, Middle, Last) Title % of ownership or # of shares b. Name (First, Middle, Last) Title % of ownership or # of shares c. Name (First, Middle, Last) Title % of ownership or # of shares d. Name (First, Middle, Last) Title % of ownership or # of shares American LegalNet, Inc. www.FormsWorkFlow.com DCPLC ­ On-Premises App Rev 1/11 3 Section F: CURRENT OR PREVIOUS LIQUOR PERMITS HELD BY PERMITTEE OR BACKER 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, and members of a limited liability organization or unincorporated associations. Attach a separate sheet if needed. 28a. Does any Permittee or Backer currently hold a liquor permit? 28b. Has any Permittee or Backer held a liquor permit in the past? 29a. Type of liquor permit (e.g., cafe) Liquor permit # YES YES NO NO Name of business If yes, please complete the permit information for each past or present permit below State in which issued Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 29b. Type of liquor permit (e.g., cafe) Liquor permit # State in which issued Name of business Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 29c. Type of liquor permit (e.g., cafe) Liquor permit # State in which issued Name of business Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 30. Have any of the permits listed above been revoked, suspended or denied in CT or any other state? YES NO If yes, attach a statement detailing the enforcement action(s) taken including violation(s), date(s), and the circumstance(s) involved. Section G: CERTIFICATION OF PERMITTEE APPLICANT AND BACKER OR AUTHORIZED REPRESENTATIVE OF BACKER 31. Permittee Certification (To be signed by permittee applicant, identified Signed by Permittee Applicant in "Section A" of this application) I certify that the information provided in this application is true to the best of my X__________________________________________________ knowledge. 32. Backer Certification (To be signed Date by backer or the