For Official Use Only DCPLC – LWG App New 9/11 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 SALE OF WINE WITH GIFT BASKETS Please print clearly or type the information entered on this application. An application and permit fee is required. Please submit the required fee of $300.00. 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 1. Trade Name (DBA Name) 2. Business Address City 3. Is there currently a liquor permit at the proposed premises? YES NO 5. Business Telephone Number If yes, current permit number 6. Business Fax Number State Zip Code 4. Are you requesting a Provisional Permit? YES NO 7. Business Email Address Section B: APPROVAL/CERTIFICATION OF LOCAL OFFICIALS 8. Zoning Authority Approval: I certify that I am familiar with the zoning ordinances and bylaws of the city/town identified in item #2 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 ______ /______ /________ 9. 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 ______ /______ /________ Section C: PERMITTEE APPLICANT INFORMATION 10. Permittee Name (First, Middle, Last) 11. Permittee Residence Street Address City 12. Permittee Telephone Number 14. Permittee Email Address 13. Permittee Fax Number State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com DCPLC – LWG App New 9/11 2 Section D: PREFERRED MAILING ADDRESS Check () one box below and enter address if different than Business or Permittee Address BUSINESS ADDRESS PERMITTEE ADDRESS ADDRESS BELOW 15. Name 16. Address City State Zip Code 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 17. Backer: Please select the type of Backer (individual or legal entity that owns the business) below Please check () only one Sole Proprietorship/ Owner Corporation Partnership Limited Liability Company Limited Liability Partnership Unincorporated Association 18. Name of Corporation, LLC, Partnership, Sole Proprietorship, etc. 19. Street Address 20. Backer Telephone Number City 21. Backer Fax Number State Zip Code 22. Backer Email Address 23. 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 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. 24a. Does any Permittee or Backer currently hold a liquor permit? YES NO 24b. Has any Permittee or Backer held a liquor permit in the past? YES NO If yes, please complete the permit information for each past or present permit below American LegalNet, Inc. www.FormsWorkFlow.com DCPLC – LWG App New 9/11 25a. Type of liquor permit (e.g., cafe) 3 Liquor permit # Name of backer or permittee for the permit State in which issued Name of business Were/Are you a backer or permittee of the permit? Backer 25b. Type of liquor permit (e.g., cafe) Liquor permit # Name of backer or permittee for the permit State in which issued Were/Are you a backer or permittee of the permit? Liquor permit # Name of backer or permittee for the permit Permittee Name of business Backer 25c. Type of liquor permit (e.g., cafe) State in which issued Dates held Permittee Name of business Were/Are you a backer or permittee of the permit? Backer 26. Have any of the permits listed above been revoked, suspended or denied in CT or any other state? YES NO Dates held Dates held Permittee 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 27. Permittee Certification (To be signed by permittee applicant, identified Signed by Permittee Applicant in “Section A” of this application) Date I certify that the information provided in this application is true to the best of my X__________________________________________________ knowledge. 28. Backer Certification (To be signed by backer or the authorized representative of the backer) Signed by Backer or Authorized Representative of Backer Date I certify that the information provided in X__________________________________________________ this application is true to the best of my knowledge and that the permittee Print name of Backer or Representative Title of Backer or applicant identified in “Section A” of this Representative application is designated as my principal representative on the premises for which this application is being submitted. American LegalNet, Inc. www.FormsWorkFlow.com DCPLC - LWG INST New 9/11 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Web Site: www.ct.gov/dcp INSTRUCTIONS AND INFORMATION Sale of Wine With Gift Baskets Application PLEASE READ ALL INSTRUCTIONS AND INFORMATION BEFORE COMPLETING APPLICATION. APPLICATION WILL NOT BE ACCEPTED IF INCOMPLETE OR IF ANY REQUIRED DOCUMENT IS MISSING ABOUT THIS PERMIT This permit allows the retail sale and shipment of wine in gift baskets to both in-state and out-of-state consumers. The premises must be located in-state and the wine (1) must be purchased from a package store or farm winery, (2) cannot be consumed on the premises, and (3) can only be sold during the same hours a package store is allowed to sell alcohol. The sale of wine in gift baskets is not allowed on another’s alcohol permittee’s premises. Under this permit, the permittee may sell gift baskets that include (1) up to four bottles of wine per basket; (2) food items; (3) nonalcoholic beverages; (4) concentrates used to make mixed alcoholic beverages; (5) winemaking kits and related products; (6) ice; (7) clothing with advertising related to the alcoholic liquor industry or the permittee’s business; (8) flowers, plants, and garden-related items: (9) drinking glasses, bottle openers, and literature related to wine; or (10) gift certificates. Fees and Form of Payment: The total filing fee of $300.00 is required for successful submission of this application. Checks and/or money orders should be made payable to “Treasurer, State of Connecticut” and must accompany this application. The application filing fee of $100.00 is included in the total filing fee and is not refundable. If you are filing the application in person with the department, cash may be accepted. You may not submit cash via mail. The Application Process **Once we are in receipt of your complete and correctly executed application and filing fee, a Liquor Placard will be mailed to you with additional instructions for public notification. The placarding process is critical to application approval. A placarding error can delay a permit approval at least two additional months. A Liquor Control Agent will then be assigned to your file and will contact you to begin the remainder of the new application process. If you have requested a Provisional Permit, please refer to the page entitled “Provisional Permit” in this application packet. If for any reason a Final Liquor Permit is not issued within a period of one year, you will be required to file another application.** Definitions Permittee – The permittee is the applicant for the liquor permit. The permittee is a person designated as the representative of the backer for the permit premises. The permittee must be able to read and understand English. The permittee can be the owner/backer of the business that holds the permit. Backer – An individual or legal business entity that owns the business to which the liquor permit is issued. American LegalNet, Inc. www.FormsWorkFlow.com DCPLC - LWG INST New 9/11 Authorized Backer Representative – An individual who is legally authorized by the nature of the position held (i.e. corporate officer) in the business, or through a power of attorney to sign documents and make decisions related to the liquor permit. **Section 30-45 of the Connecticut General Statutes prohibits the following individuals and officer holders from obtaining a liquor permit. Section 30-45 appears below and the prohibited individuals are noted. If you are a prohibited individual, you may not apply for a liquor permit. CT General Statutes, Section 30-45: The department of consumer protection shall refuse permits for the sale of alcoholic liquor to the following persons (1) Any sheriff, deputy sheriff, judge of any court, prosecuting officer or member of any police force, (2) any first selectman holding office and acting as a chief of police in the town within which the permit premises are to be located, (3) a minor, and (4) any constable who performs criminal law enforcement duties and is considered a peace officer by town ordinance pursuant to the provisions of subsection (a) of section 54-1f, any constable who is certified under the provisions of sections 7-294a to 7-294e, inclusive, who performs criminal law enforcement duties pursuant to the provisions of subsection (c) of section 54-1f, or any special constable appointed pursuant to section 7-92. This section shall not apply to out-of-state shippers', boat and airline permits. As used in this section, "minor" means a minor as defined in section 1-1d or as defined in section 30-1, whichever age is older. APPLICATION INSTRUCTIONS AND DOCUMENTS REQUIRED FOR A SALE OF WINE WITH GIFT BASKETS PERMIT APPLICATION TO BE ACCEPTED 1. APPLICATION FOR SALE OF WINE WITH GIFT BASKETS PERMIT Complete all three pages of application. Every question must be answered, and all necessary approvals obtained (zoning and town clerk) If left blank, the application will not be accepted. If the question does not apply, enter the word “none”. Completing the Application Section A: Business Information Item #1 through #7 – Complete this section with type of permit selected, trade name and business information. If you are applying for a provisional permit, please complete the Provisional Permit and Credit Waiver Request form (DCPLC-Provisional Permit Request) included in this application package. Section B: Approval of Local Officials Items #8 and #9 need to be signed and completed by your local public officials. No applications will be accepted without local zoning approval and town clerk certification. Section C: Permittee Applicant Information Item #10 through #14 please enter name, address and contact information for permittee. Section D: Preferred Mailing Address Items #15 and #16 Indicate the preferred mailing address for all correspondence. If you would like correspondence mailed to an address other than the business or permittee home address, specify in #15 and #16. Section E: Backer Information Item #17 through #23 – Provide correct backer name in #18. Backer name is the name of the Limited Liability Company or Corporation that is registered with the Secretary of the State or the individual name of the Sole Owner that has not formed a LLC or Corporation or the individual names of a Partnership that has not formed a LLC or Corporation, etc. American LegalNet, Inc. www.FormsWorkFlow.com DCPLC - LWG INST New 9/11 Section F: Current or Previous Liquor Permits Held By Permittee or Backer Item #24 through #26 – List current or previously held liquor permits. Include any permits held by permittee, backer, sole proprietor, partner or a member of a partnership organization, corporation, limited liability company etc. If there are none, check “NO” in #24a and #24b. Section G: Certification of Permittee Applicant and Backer or Authorized Representative of Backer Items #27 and #28 - The permittee listed in Section C #10 of the application must sign #27. The backer/owner listed in Section E or authorized backer representative must sign #28. 2. FEE AND FORM OF PAYMENT: The total filing fee of $300.00 is required for successful submission of this application. Checks and/or money orders should be made payable to “Treasurer, State of Connecticut” and must accompany this application. The application filing fee of $100.00 is included in the total filing fee and is not refundable. If you are filing the application in person with the department, cash may be accepted. You may not submit cash via mail. 3. SALES TAX NUMBER Submit copy of Connecticut Sales and Use Tax Permit, or copy of receipt as proof of filing from the Connecticut Department of Revenue Services. 4. LEASE / DEED / EVIDENCE OF RIGHT TO OCCUPY Provide a copy of the lease. The tenant listed on the lease needs to be the backer entity indicated on the application. Any assignment needs to be the backer entity indicated on the application with written consent of the landlord. If the backer entity is the owner of the property, provide a copy of the deed or a town property record card for the property. If you cannot provide a lease or deed at the time of application, the Department would accept other documentation showing evidence of the intention of the right to occupy the property. 5. AUTHORIZATION FOR RELEASE OF FINANCIAL INFORMATION AND STATEMENT OF PERSONAL HISTORY The applicant/permittee and backers (individuals, partners, general partner and limited partners in a limited partnership, officers, directors and limited liability company (LLC) manager/members in a LLC, corporate officers and stockholders) must complete an authorization for release of financial information and statement of personal history for each person. 6. AUTHORIZATION OF THE BACKER LEGAL ENTITY FOR RELEASE OF FINANCIAL INFORMATION Only authorized individuals of the backer may sign on behalf of the entity. 7. BACKER’S FINANCIAL STATEMENT Complete this form which is attached to the application. 8. CORPORATIONS & LLC Provide proof of filing of organization papers with the Connecticut Secretary of State. Printout verification from the C.O.N.C.O.R.D. system would be acceptable. 9. PARTNERSHIP Provide partnership agreement if backer/owner is a formal partnership or limited partnership. If no agreement exists, provide a letter to that effect that there is no such agreement. 10. FRANCHISE OR MANAGEMENT AGREEMENT Provide any franchise or management agreement if applicable. American LegalNet, Inc. www.FormsWorkFlow.com DCPLC - LWG INST New 9/11 11. CRIMINAL CONVICTION WORKSHEET If the permittee or any member of the backer has a felony conviction, complete the Criminal Conviction Worksheet, pursuant to Section 46a-80(b) of Connecticut General Statutes. (DCPLC-CHRO) 12. SIGNED STIPULATION FOR NEW CONTRUCTION If you are applying for a permit for a building that has not been constructed, you shall provide to the Department a signed stipulation setting forth a time limit for the construction and occupancy for the proposed permit premises. Please note that the date of filing an application, as defined in section 30-39(a) CGS, to the date of the issuance of a final permit shall not exceed one year, regardless of whether a provisional permit has been applied for, approved, or issued. After one year, a new liquor application will be required. 13. PHOTOGRAPHS One 8” x 10” photo taken from a position directly across the street or highway (any photos smaller than this required size will not be accepted). **Please Note**  Photos must be 8”x 10”. The applicant’s name, business address and date photo taken shall be on the back of all photographs.  For premises which has not been constructed, the submission of photographs are not required for the acceptance of a new application. (see #11) ONCE THE APPLICATION IS RECEIVED AND ACCEPTED BY THE DEPARTMENT OF CONSUMER PROTECTION, ADDITIONAL DOCUMENTS AND/OR INFORMATION MAY BE REQUIRED OF YOU BY A LIQUOR CONTROL AGENT AS PART OF THE REVIEW AND INVESTIGATION PROCESS American LegalNet, Inc. www.FormsWorkFlow.com