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: American LegalNet, Inc. www.FormsWorkFlow.com 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 American LegalNet, Inc. www.FormsWorkFlow.com