INSTRUCTIONS FOR COMPLETING DBPR ABT – 6034 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR A BOTTLE CLUB LICENSE AND RETAIL TOBACCO PRODUCTS DEALER PERMIT Application begins on page 4 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html GENERAL INSTRUCTIONS Submitting Your Application Applications for bottle club licenses and retail tobacco products dealer permits are filed with the Division of Alcoholic Beverages and Tobacco. Please complete all information. Incomplete applications will be returned. All questions are applicable and must be answered fully and truthfully. You must provide an original and a copy of the application and duplicate copies of all supporting documentation. All signatures must be original. If eligible, a temporary license may be purchased. Note: When applicable, you must submit two legible and executed copies of the following: Lease, Purchase Agreements, Franchise Agreements, Management Contracts, Service Agreements, and any agreements which require a percentage payment from the business operation, Certified Copy of Death Certificate, Letters of Administration, Certificate of Title, Certified Copy of All Court Orders pertaining to the alcoholic beverage license. Florida law prohibits transfer applicants from assuming operation of a licensed establishment and selling alcoholic beverages prior to obtaining a temporary or permanent license in the transferee's name. APPLICATION REQUIREMENTS AND INSTRUCTIONS FOR COMPLETING THIS APPLICATION Health Approval Health approval is required on all applications for consumption on the premises. Businesses that serve food or are located on premises licensed by the Division of Hotels and Restaurants, must obtain approval from that division. Businesses that do not serve food must contact the County Health Authority or the Department of Health. Food service establishments located in grocery and convenience stores, bakeries or delicatessens must contact the Department of Agriculture and Consumer Services. Applications must be submitted within 90 days of receiving this approval. Zoning Approval Zoning approval is executed by the city or county zoning authority in which the business to be licensed is located. Zoning approval is required on all new and change of location applications unless the applicant is a state college or university located on State owned property. Zoning approval may also be required for certain change in series applications. If this application is for the transfer of an existing bottle club license with no change of the location address, zoning approval is not required. Applications must be submitted within 180 days of receiving this approval. 1 American LegalNet, Inc. www.FormsWorkflow.com Department of Revenue Clearance Department of Revenue clearance is required on applications for all new, transfer, change of location, and correction of information applications which change the licensee’s name. Applications must be submitted within 90 days of receiving this approval. Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, all partners of a general partnership, all general partners of a limited partnership, all managing members of a limited liability company, or one of the officers of a corporate applicant. Affidavit of Transferor The affidavit of transferor must be completed for all transfer applications. The affidavit must be signed by the individual owner, all partners of a general partnership, all general partners of a limited partnership, all managing members of a limited liability company, or a corporate officer of record. If the transfer is pursuant to operation of law or judicial proceedings, certified copies of court order(s) in which the applicant is named may be accepted in lieu of signature(s) of seller. Fingerprints Fingerprints must be submitted by each individual applicant, all corporate officers, all managing members, all general partners of a limited partnership, all partners of a general partnership, each individual stockholder owning more than .5 percent of stock, and all directors. Each applicant shall submit electronic fingerprints through the department’s vendor PearsonVue. Costs associated with the fingerprint process will be collected by PearsonVue. You may contact PearsonVue at www.pearsonvue.com or by calling 1-877-2388232. At the time application is made to the Division of Alcoholic Beverages and Tobacco, you will need to submit your PearsonVue receipt. The receipt serves as proof of the fingerprint requirement and includes information necessary to process your application. Failure to provide this receipt will delay the processing and/or denial of your application. Note: If you are a current licensee or have been fingerprinted by this division in the past three (3) years, you are not required to submit this fingerprint information. Partner, Officer, Stockholder Personal Data - Section 4 This section of the application must be completed with original signatures for each applicant or person(s) directly connected with the business, unless they are current licensees. This will include the sole proprietor, all partners, officers, directors, individual share holders owning more than .5% of stock in nonpublic corporations, general partners of general partnerships, general partners of a limited partnership, and the managing partners of a limited liability company. Directly interested persons include anyone that is connected with the business who has a beneficial interest. It is important that each individual disclose any arrests they have had, even if they were charged, but not formally arrested, and regardless of the disposition. Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes. Corporate and Limited Partnership Registration All corporations, domestic or foreign; general partnerships; limited liability corporations; and limited partnerships are required to be registered with the Florida Secretary of State, Division of Corporations. If you have not already registered, you will need to contact the Department of State at (850) 488-9000 for further information. Your application cannot be accepted by this division without this registration. 2 American LegalNet, Inc. www.FormsWorkflow.com Federal Employer's Identification Number (FEIN) All licensees who pay wages to one or more employees must have a Federal Employer's Identification Number. Contact the Internal Revenue Service (IRS) at 1-800-829-3676 and request Form #SS4. Sketch of Premises Draw, in ink, a complete sketch of the premises which includes all walls, doors, counters, sales areas, storage areas, etc. No architectural drawings are accepted. Certified Copy of Arrest Disposition If the applicant answers “yes” to any of the criminal background questions asked in this application, provide a Certified Copy of the Arrest Disposition to ensure the applicant is qualified, pursuant to Statute and Rule. Mitigation for Moral Character If the applicant is required to submit an arrest disposition, they may also be required to submit mitigation under the moral character rule. A copy of the rule and requirements can be found on AB&T’s page of the DBPR web site. APPLICATION CHECKLIST Select the appropriate Transaction below and comply with the corresponding application requirements. TRANSACTION New License Transfer of Ownership Correction of Information APPLICATION REQUIREMENTS Pay $125 fee if requesting an initial temporary license (make check payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6034 Division of Alcoholic Beverages and Tobacco Application for Bottle Club License and Retail Tobacco Products Dealer Permit Certified copy of the Arrest Disposition, if applicable Mitigation for Moral Character, if applicable Contact the department’s vendor for electronic fingerprinting, PearsonVue at www.pearsonvue.com or call 1-877-238-8232 to arrange for fingerprinting. Submit the receipt issued by PearsonVue with your application. Submit Secretary of State/Certificate of Status, if applicable Pay $100 fee if requesting a temporary license (make check payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6034 Division of Alcoholic Beverages and Tobacco Application for Bottle Club License and Retail Tobacco Products Dealer Permit Certified copy of the Arrest Disposition, if applicable Mitigation for Moral Character, if applicable Contact the department’s vendor for electronic fingerprinting, PearsonVue at www.pearsonvue.com or call 1-877-238-8232 to arrange for fingerprinting. Submit the receipt issued by PearsonVue with your application. Submit Secretary of State/Certificate of Status, if applicable Complete DBPR ABT-6034 Division of Alcoholic Beverages and Tobacco Application for Bottle Club License and Retail Tobacco Products Dealer Permit 3 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6034 – Division of Alcoholic Beverages and Tobacco Application for Bottle Club License and Retail Tobacco Products Dealer Permit STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 1940 North Monroe Street Tallahassee, FL 32399-0783 NOTE – This form must be submitted as part of an application packet If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T’s page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district_offices/licensing.html SECTION 1 - CHECK TRANSACTION REQUESTED Transaction Type: Do you wish to purchase a Temporary License? New License Transfer of Ownership Yes No Change of Location Change of Business Name Change of Officers/Stockholders Correction SECTION 2 - CHECK LICENSE CATEGORY Bottle Club License Retail Tobacco Products Dealer Permit SECTION 3 – LICENSE INFORMATION Full Name of Applicant (If this is a corporation or other legal entity, enter the name as registered with the Secretary of State) Trade Name (D/B/A) FEIN Number or Social Security Number* Business Telephone Number Contact Person Phone Number Location Address (Street and Number) City County State Zip Code State Zip Code Mailing Address (Street or P.O. Box) Section / Name (Attention: – Optional) City 4 American LegalNet, Inc. www.FormsWorkflow.com SECTION 3 – LICENSE INFORMATION **If this application is for a New license or permit, the following questions are not applicable. Current Business Name Current License Number Is the transfer of this license due to revocation proceedings? Yes No If yes, is there any personal relationship to the transferor? Yes No If yes, explain the relationship: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 5 American LegalNet, Inc. www.FormsWorkflow.com SECTION 4 – PARTNER, OFFICER, STOCKHOLDER PERSONAL INFORMATION This section must be completed for each applicant or person(s) directly connected with the business, unless they are current licensees. 1. Trade Name (D/B/A) 2. Full Name Social Security Number* Race Sex Home Phone Number Height Weight 3. Hair Color Are you a U.S. citizen? Yes No If no, immigration card number or passport number: 4. Eye Color Date of Birth Home Address (Street and Number) City 5. State Zip Code Do you currently own or have an interest in any business selling alcoholic beverages, wholesale cigarette or tobacco products, or a bottle club? Yes No If yes, provide the information requested below. The location address should include the city and state. Trade Name (D/B/A) License Number Location Address 6. Have you ever had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit refused, revoked or suspended anywhere in the past 15 years? Yes No If yes, provide the information requested below. The location address should include the city and state. Trade Name (D/B/A) License Number Location Address 7. Have you been convicted of a felony or an offense involving alcoholic beverages anywhere? Yes No If yes, provide the information requested below and provide a Certified Copy of the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense 8. Have you ever been arrested or issued a notice to appear in any state of the United States or its territories? Yes No If yes, provide the information requested below and a CERTIFIED COPY OF THE DISPOSITION. Attach additional sheet if necessary: Date Location Type of Offense 6 American LegalNet, Inc. www.FormsWorkflow.com 9 Are you an official with State police powers granted by the Florida Legislature? Yes No If yes, provide details: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ NOTARIZATION STATEMENT “I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in Section 11 of this application. I further swear or affirm that the foregoing information is true and correct.” STATE OF___________________ COUNTY OF_________________ _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day of______________, 20_____, By_____________________________________ who is ( ) personally known to me OR ( ) who produced ______________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public (ATTACH ADDITIONAL COPIES AS NECESSARY) * Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(I). This information is used to identify licensees for tax administration purposes. 7 American LegalNet, Inc. www.FormsWorkflow.com SECTION 5 – DESCRIPTION OF PREMISES TO BE LICENSED AB&T AUTHORIZED SIGNATURE REQUIRED Trade Name (D/B/A) 1. Yes No 2. Yes No 3. Is the proposed premises movable or able to be moved? Is there any access through the premises to any area over which you do not have dominion and control? Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the premises, walls, doors, counters, sales areas, storage areas, restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show each floor plan. No architectural drawings are accepted. AB&T Authorized Signature___________________________________________ Date_________________ Approved Disapproved Comments_____________________________________________________________________________ _____________________________________________________________________________________ 8 American LegalNet, Inc. www.FormsWorkflow.com SECTION 6 – SALES TAX TO BE COMPLETED BY THE DEPARTMENT OF REVENUE Trade Name (D/B/A) The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax. 1. This is to verify that the current owner as named in this application has filed all returns and that all outstanding billings and returns appear to have been paid through the period ending ___________________ or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not constitute a certificate as contained in Section 212.10 (1), Florida Statutes. (Not applicable if no transfer involved). 2. Furthermore, the named applicant for an Alcoholic Beverage License has complied with Florida Statutes concerning registration for Sales and Use Tax, and has paid any applicable taxes due. Signed____________________________________________________Date_____________________ Title______________________________________________________ Department of Revenue Stamp: SECTION 7 – ZONING TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION Trade Name (D/B/A) Street Address City County State Zip Code If this application is for issuance of a bottle club license where zoning approval is required, the zoning authority must complete “A” and “B.” If zoning is not required, the applicant must complete section “B.” A. The location complies with zoning requirements for a bottle club license permitting the consumption of alcoholic beverages on the licensed premises pursuant to this application for a Series 14BC license. Signed____________________________________________________Date_____________________ Title______________________________________________________ B. Is the location within limits of an “Incorporated City or Town?” Yes No If yes, enter the name of the city or town:___________________________________________ 9 American LegalNet, Inc. www.FormsWorkflow.com SECTION 8 – HEALTH TO BE COMPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS OR COUNTY HEALTH AUTHORITY OR DEPARTMENT OF HEALTH OR DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES Trade Name (D/B/A) Street Address City County State Zip Code The above establishment complies with the requirements of the Florida Sanitary Code. Signed_______________________________________________________Date____________________ Title________________________________________________ Agency____________________________ SECTION 9 – CONTRACTS OR AGREEMENTS These questions must be answered about this business for every person or entity listed. Copies of agreements must be submitted with this application. Trade Name (D/B/A) 1. Yes No 2. Yes No 3. Yes No Is there a management contract, franchise agreement, or service agreement in connection with this business? Are there any agreements which require a payment of a percentage of gross or net receipts from the business operation? Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from a manufacturer, wholesaler, or retailer of alcoholic beverages? 10 American LegalNet, Inc. www.FormsWorkflow.com SECTION 10 – CORPORATE FELONY CONVICTION Trade Name (D/B/A) Has the applicant corporation been convicted of a felony in this state, any other state, or by the United States in the last 15 years? Yes No If the answer is “Yes,” please list all details including the date of conviction, the crime for which the corporation was convicted, and the city, county, state and court where the conviction took place. 11 American LegalNet, Inc. www.FormsWorkflow.com SECTION 11 – DISCLOSURE OF INTERESTED PARTIES Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your license. Trade Name (D/B/A) 1. List below the names, titles and percentage of stock held for all officers, directors, stockholders, managing members and general partners of the corporation or other legal entity for which this license or permit is being sought. Attach extra sheets if necessary. If the applicant is a limited partnership or limited liability company, attach a list of all limited partners and members. Title/Position Name Stock % President Vice President Secretary Treasurer Director(s) Stockholder(s) Managing Member(s) General Partner(s) 2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan, or any person or entity who has loaned money to the business that is not a traditional lending institution? Yes No If yes, you must list the person(s) or entity and indicate which of the below applies. Name Guarantor 12 Co-signer Lender Interest Rate (List) American LegalNet, Inc. www.FormsWorkflow.com SECTION 12 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED Trade Name (D/B/A) “I, the undersigned individually, or if a corporation for itself, its officers and directors, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch or blueprint is substantially a true and correct representation of the premises to be licensed and agree that the place of business, if licensed, may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the sheriff, his deputies, and police officers for the purposes of determining compliance with the beverage and retail tobacco laws.” “I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in section 11 of this application. I further swear or affirm that the foregoing information is true and correct.” STATE OF___________________ _________________________________________________ APPLICANT SIGNATURE COUNTY OF_________________ _________________________________________________ APPLICANT SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day of______________, 20_____, By _____________________________________ who is ( ) personally known to me OR ( ) who produced ____________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public 13 American LegalNet, Inc. www.FormsWorkflow.com SECTION 13 - AFFIDAVIT OF TRANSFEROR NOTARIZATION REQUIRED Trade Name (D/B/A) “I, the undersigned, hereby swear or affirm that I am duly authorized to make this affidavit and do hereby consent, on my behalf or on behalf of the transferor, to the above transfer, and represent to the Division of Alcoholic Beverages and Tobacco that the license which is being transferred is as shown in the application and that a bona fide sale in good faith has been made to the within applicant of the business for which the foregoing transfer of license is sought.” STATE OF___________________ _________________________________________________ SELLER OR AUTHORIZED OFFICER SIGNATURE COUNTY OF_________________ _________________________________________________ SELLER OR AUTHORIZED OFFICER SIGNATURE The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day of______________, 20____, By _____________________________________ who is ( ) personally known to me OR ( ) who produced ___________________________________________as identification. ________________________________________________ Commission Expires: ___________________ Notary Public 14 American LegalNet, Inc. www.FormsWorkflow.com SECTION 14 - CURRENT LICENSEE UPDATE DATA SHEET This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date information is captured. Trade Name (D/B/A) Last Name First Middle Current License Number(s) Date of Birth Social Security Number* _____/_____/_______ Street Address City State Last Name First Zip Code Middle Current License Number(s) Date of Birth Social Security Number* _____/_____/_______ Street Address City State Last Name First Zip Code Middle Current License Number(s) Date of Birth Social Security Number* _____/_____/_______ Street Address City State Last Name First Zip Code Middle Current License Number(s) Date of Birth Social Security Number* _____/_____/_______ Street Address City State 15 Zip Code American LegalNet, Inc. www.FormsWorkflow.com SECTION 15 - DEPARTMENT OF REVENUE CLEARANCE COMPLETE THIS SECTION IF APPLYING FOR A TRANSFER OF OWNERSHIP Trade Name (D/B/A) The following information is extremely important and should be read in its entirety. Because of restrictions placed on the Department of Revenue in divulging confidential tax information, the business activity of the previous owner cannot be discussed without expressed written consent. Therefore, if this application is for the transfer of an alcoholic beverage license, the following section of this form must be completed before the Department of Revenue can approve your application. If the owner is unwilling to complete this disclosure form, you may request a meeting with a Department of Revenue representative and the owner jointly to discuss any potential liability for which you could be held responsible. DO NOT RETURN THIS FORM TO AB&T WITH YOUR APPLICATION SALES TAX NOTARIZATION REQUIRED This section must be completed by the present owner of the alcoholic beverage license and must accompany your application for sales tax registration. Purchaser’s Name Business Name Sales Tax Number Location Address City State Zip Code __________________________________________________________________________ Signature of Owner, Partner or Principal Corporate Officer “I, the undersigned individually, or if a corporation, on its behalf and its officers, hereby authorize the Department of Revenue to release to the above purchaser, the Division of Alcoholic Beverages and Tobacco and ______________________________________________ the status of my account number__________________________________. Seller’s Name_____________________________________________________________________ STATE OF___________________ _________________________________________________ Signature of Owner, Partner, or Principal Corporate Officer COUNTY OF_________________ The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this __________day of____________, 20_____, By ____________________________________________ who is ( ) personally known to me OR ( ) who produced ______________________________________________ as identification. Notary Public Stamp: Commission Expires: ______________ 16 American LegalNet, Inc. www.FormsWorkflow.com FOR DIVISION USE ONLY – DO NOT WRITE BELOW THIS LINE Trade Name (D/B/A) CODE: City_____________ County___________________ TYPE FEIN NUMBER FEE TOTAL _________________________ Approved by______________________________ Date_________Audited:_________ Unaudited:________ District Office Received Date Stamp District Office Accepted Date Stamp 17 American LegalNet, Inc. www.FormsWorkflow.com