DCPLC-Wine Festival Permit App Rev 6/09 For Official Use Only STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION Telephone: (860) 713-6200 Web Site: www.ct.gov/dcp WINE FESTIVAL 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 wine festival 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: Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT 06106 FEES: A $10.00 non-refundable filing fee, in addition to the permit fee noted below, must accompany this application Please check ( ) the permit type for which you are applying (check only one box) CT Farm Winery Wine Festival Available to farm winery liquor permit holders for wine festival Out of State Farm Winery Wine Festival Available to out of state farm winery liquor permit holders for wine festival $75.00 per event $75.00 per event 2. Date of Event City/Town 3. Rain Date State 4. Proposed Time Zip Code TIME & PLACE of EVENT 1. Name of Event 5. Street Address of Event 6. Will event be held indoors or outdoors? (If indoors, complete item 27). INDOORS OUTDOORS BOTH BACKER ORGANIZATION SPONSORING EVENT 7. Name of Organization (acting as Backer) 8. Business Street Address 9. Enter CT State Sales Tax # City/Town State Zip Code 10. 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. 11. Principal Authorized Backer Representative Name (Last, First, MI) 12. Residence Street Address 13. Has the organization/officer previously been a backer or YES NO owner of an entity with a liquor permit? 14. Has the organization appeared as backer on other temporary permit(s) in this calendar year? YES NO City/Town State Zip Code If YES, please specify permit type(s) and number: If YES, please specify permit type(s) and number: 15. I appoint the applicant named in item #11 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 organization. x _____________________________________________________________ CONNECTICUT FARM WINERY PARTICIPANTS (To be completed by Farm Wineries already licensed by the State of Connecticut) Date _____________________ PERMIT NUMBER 1. 2. 3. PERMITTEE NAME TRADE NAME American LegalNet, Inc. www.FormsWorkFlow.com PERMIT NUMBER CONNECTICUT FARM WINERY PARTICIPANTS (To be completed by Farm Wineries already licensed by the State of Connecticut) 4. 5. 6. 7. PERMITTEE NAME TRADE NAME (continued) 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. American LegalNet, Inc. www.FormsWorkFlow.com OUT OF STATE FARM WINERY PARTICIPANTS (To be completed by Farm Wineries already licensed by the State of Connecticut) PERMIT NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. PERMITTEE NAME TRADE NAME 16. Name of City/Town: CITY/TOWN CERTIFICATION (To be completed by the city/town clerk where event is to be held) 17. 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 __________________________________________________________ LOCAL FIRE MARSHAL'S CERTIFICATION (If event is held indoors or in a tent) Date signed 18. 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) Rank/Title of Fire Control Official x __________________________________________________________ 19. Name of City/Town: CITY/TOWN ZONING (To be completed by the zoning official where event is to be held) 20. 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. 21. Do you approve of the issuance of this permit? YES NO (If no, please explain) Signature of Police Authority Rank/Title of Police Authority Date signed x _____________________________________ PERMITTEE APPLICANT'S SUITABILITY (To be completed by police authority in city/town where applicant resides) 22. Has the applicant whose name appears in item #11 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) 23. Do you believe the applicant named in item #11 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