DCPLC-PatioRequestform Rev 3/11 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Fax: (860) 713-7235 Website: http://www.ct.gov/dcp PATIO REQUEST FORM PERMITTEE:___________________________________________________PERMIT #_____________________________ BACKER:____________________________________________________________________________________________ ADDRESS:___________________________________________________TOWN__________________________________ TRADE NAME:_______________________________________________________________________________________ BUSINESS PHONE:_____________________FAX #______________________HOME PHONE:_____________________ WILL PATIO BE PERMANENT: 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. 2. 3. 4. 5. The Patio in relation to the permit premises. List all dimensions of Patio in feet. All entrances & exits leading to and from the patio. Portion of sketch that shows Permit Premises must be labeled with all the Dining Rooms, Barrooms, Kitchen, etc Indicate all fences, railings, etc. surrounding patio area 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 $190.00 fee must be Submitted with this application. IF THIS SHEET IS NOT LARGE ENOUGH, CONTINUE SKETCH ON ONE ADDITIONAL SHEET. 1. 2. 3. 4. 5. 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. If access to Patio is through a Dining Room, the Patio is considered and extension of the Dining Room. a. 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). If Alcoholic Beverages are to be made from an Additional Consumer Bar Located on the Patio-Patio is considered Barroom-(NO MINORS ALLOWED) No alcoholic beverages are to leave the patio area (away from premises.) NO DEVIATIONS FROM THE PLAN SHOWN ON THIS FORM ARE ALLOWED WITHOUT WRITTEN APPROVAL FROM THIS DEPARTMENT. SIGNATURE:_______________________________________________________________ PERMITTEE _________________ DATE ---------------------------------------------------------------MUNICIPAL APPROVALS ZONING: SIGNATURE:______________________________________________________________DATE______________________ FIRE DEPT. SIGNATURE:_____________________________________________________________DATE_____________________ HEALTH DEPT. SIGNATURE:__________________________________________________________DATE_____________________ 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