DCPLC ­ LGB Breakdown of Sales Rev 3/11 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 Î This form must be completed if applying for a grocery beer permit in accordance with CGS Section 30-20(c) Name of Permittee (First Name, Middle Initial, Last Name) Name of Business Business Street Address City State Zip In order to determine your eligibility 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 monetary sales for that month in each of the categories noted below. Please use whole dollar values. (Estimate Figures are NOT Acceptable) Date of Sales - Beginning Date: ____________________ Ending Date: ____________________ Month's sales in dollars: For Liquor Control Use 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 permit is active on premises) TOTAL 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