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Temporary Liquor Permit Application Form. This is a Connecticut form and can be use in Department Of Consumer Protection Statewide.
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Tags: Temporary Liquor Permit Application, CPLTP-01, Connecticut Statewide, Department Of Consumer Protection
DCPLC-Temp Permit App Rev 9/09
For Official Use Only
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
LIQUOR CONTROL DIVISION
Telephone: (860) 713-6200
Web Site: www.ct.gov/dcp
TEMPORARY LIQUOR PERMIT APPLICATION
INSTRUCTIONS:
Your application must be completed, signed and accompanied by a check or money order made payable to
“Treasurer, State of Connecticut.” An application for a temporary liquor permit must be filed with the Department
of Consumer Protection at least ten (10) days prior to the date of the event and returned to:
Î Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT
06106
Î FEES:
A $10.00 non-refundable filing fee, in addition to the permit fee noted below, must accompany this application
Please check (3) the permit type for which you are applying (check only one box)
Special Club
Available to club or golf
country club liquor permit
holders for outdoor picnics
$50.00 per day
TIME & PLACE
of EVENT
Charitable
Organization
Noncommercial
Organization
Alcoholic Beverages
Nonprofit
Corporation
Retail Sale of Wine at Auction
including Beer
$50.00 per day
$50.00 per day
1. Name of Event
2. Date of Event
3. Rain Date
City/Town
6. Will event be held indoors or outdoors? (If indoors, complete item 27).
INDOORS
OUTDOORS
$25.00 per day
$30.00 per day
5. Street Address of Event
PERMITTEE
APPLICANT
of EVENT
Noncommercial
Organization
Beer Only
4. Proposed time of event
State
Zip Code
7. Attach an 8 ½” x 11” sketch showing the exact locations
within the event area where alcoholic beverages will be
dispensed and specify the manner by which service of such
beverages to minors will be controlled.
BOTH
8. Name of Applicant (Last, First, Middle)
9. Date of Birth
11. Home Street Address
City/Town
10. Telephone Number
State
Zip Code
12. Have you ever been convicted of a felony crime?
YES
NO If yes, please attach a statement including the date(s) of
the conviction(s), the court(s) where the case(s) were disposed of and a description of the circumstances involved.
13. Have you previously been a liquor permittee?
YES
NO
If yes, please specify the liquor permit type(s) and permit number(s)
14. Are you a minor or a person who holds a position that would prohibit you from obtaining a liquor permit?
YES
NO
*(See item #3(a) in instructions for listing of persons who are prohibited from acting as permittee or backer on a liquor permit)
15. If applying on behalf of a noncommercial organization – will all of the profits derived from the sale of alcoholic beverages be
retained by the organization?
YES
NO If no, briefly explain the distribution of profits:
16. As the applicant, I assume responsibility as manager and principal representative of the backer for the event to be held on the
premises described in this application. I certify that all information contained in this application is true.
Signature of Applicant x _____________________________________________________ Date ______________________
BACKER
ORGANIZATION
SPONSORING
EVENT
17. Name of club/organization that is acting as backer
18 Business address of club/organization (Street, City, Zip)
19. Enter State sales tax number of organization
20. If the organization is a charity, enter the Federal tax identification
number of the charitable organization: (Or attach a copy of tax
identification letter)
21. In boxes below provide names(s) of the officer(s) of club/organization that is sponsoring event:
Officer #1. Name: (Last, First)
Officer #1 address: (Street, City, Zip)
Officer #2. Name: (Last, First)
Officer #2 address: (Street, City, Zip)
22. Has the club/organization/officer previously been a backer or
owner of an entity with a liquor permit?
YES
NO
If yes, please specify the liquor permit type(s) & number(s)
23. Has the organization appeared as backer on other temporary
permit(s) in this calendar year?
YES
NO
If yes, please specify the number of permits obtained:
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24. I appoint the applicant named in item #8 above, as my principal representative to be in charge of the premises and the event
described in this application. Signature of authorized backer’s representative or officer of club/organization.
x _____________________________________________________________
CITY/TOWN
CERTIFICATION
(To be completed by
the city/town clerk
where event
is to be held)
Date
25. Name of City/Town:
26. I certify that I am aware of the city ordinances and there is no ordinance prohibiting the dates and times of sale of alcoholic
liquor as requested in this application.
Signature of City/Town Clerk
Date signed
x __________________________________________________________
Date signed
LOCAL FIRE
MARSHAL’S
CERTIFICATION
27. This certifies that the premises described in this application complies with the required fire
code. Signature of local Fire Marshal (or attach a signed certification to this application)
(If event is held
indoors or in a tent)
x __________________________________________________________
CITY/TOWN
ZONING
(To be completed by
the zoning official
where event
is to be held)
Rank/Title of Fire Control Official
28. Name of City/Town:
29. I certify that the location in Item #5 of this application is located in the town or city where stated; that I am acquainted with the
zoning ordinances and bylaws of said town or city; and that, at this location said town or city does not prohibit the sale of alcoholic
liquor under the type of permit here applied for.
Signature of Zoning Official
Date signed
x __________________________________________________________
PRINCIPAL
POLICE
AUTHORITY
APPROVAL
(Town in which
event is to be held)
Where there is no local police department, this section must be signed by State Police.
30. Do you approve of the issuance of this permit?
Signature of Police Authority
YES
NO If no, please explain.
Rank/Title of Police Authority
Date signed
xPERMITTEE
APPLICANT’S
SUITABILITY
(To be completed by
police authority in
city/town where
applicant resides)
31. Has the applicant whose name appears in item #8 of this application been convicted of a felony crime?
YES
NO If
yes, please attach a statement including the date(s) of the conviction(s), the court(s) where the case(s) were disposed of and a
description of the circumstances involved.
32. Do you believe the applicant named in item #8 of this application is suitable to be a liquor permittee?
If no, please attach a statement supporting your reasons for this decision
Signature of Police Authority
Rank/Title of Police Authority
YES
NO
Date signed
x
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