INSTRUCTIONS FOR COMPLETING DBPR – ABT 6011 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR CATERER’S LICENSE 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 or your local district office. 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 caterers of alcoholic beverages are filed with the Division of Alcoholic Beverages and Tobacco. Please complete all information. 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. APPLICATION REQUIREMENTS Division of Hotels and Restaurants The applicant must obtain approval from the Division of Hotels and Restaurants as proof of compliance with Chapter 509, Florida Statutes. 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. 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 1.888.274.2020. 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. 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 1 American LegalNet, Inc. www.FormsWorkflow.com 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. Partner, Officer, Stockholder Personal Data - Section 3 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. 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. 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. 2 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION CHECKLIST TRANSACTION Initial License as Caterer (13CT) APPLICATION REQUIREMENTS Pay $455 fee if requesting an initial temporary license (make check payable to the Department of Business and Professional Regulation) Complete DBPR ABT-6011 Division of Alcoholic Beverages and Tobacco Application for Caterer’s License Certified copy of 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 1.888.274.2020 to arrange for fingerprinting. Submit the receipt issued by PearsonVue with your application. Submit Secretary of State Certificate of Status, if applicable Submit certified copy of the arrest disposition, if applicable 3 American LegalNet, Inc. www.FormsWorkflow.com DBPR ABT-6011 –Division of Alcoholic Beverages and Tobacco Application for Caterer’s License STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 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 or your local district office. Please submit your completed application 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? Initial Permanent License Correction Yes No SECTION 2 - LICENSE INFORMATION If the applicant is a corporation or other legal entity, enter the name as registered with the Secretary of State on the line below. Full Name of Applicant Corporate Document # _________________________ 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 County State Zip Code Mailing Address (Street or P.O. Box) Section / Name (Attention: - Optional) City Does the applicant entity currently hold an alcoholic beverage license? If yes, complete the following information. Current License Number Series Yes No Type Current Trade Name (D/B/A) 4 American LegalNet, Inc. www.FormsWorkflow.com SECTION 3 – 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. D/B/A Name Date 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 5 American LegalNet, Inc. www.FormsWorkflow.com 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 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 7 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. 6 American LegalNet, Inc. www.FormsWorkflow.com SECTION 4 – SALES TAX TO BE COMPLETED BY THE DEPARTMENT OF REVENUE Trade Name (D/B/A) The named applicant for a license has complied with the Florida Statutes concerning registration for Sales and Use Tax. Signed____________________________________________________Date_____________________ Title______________________________________________________ Department of Revenue Stamp: SECTION 5 – DIVISION OF HOTELS AND RESTAURANTS Full Name of Applicant The named applicant for a license has complied with the requirements of Chapter 509, Florida Statutes, and is currently licensed by the Division of Hotels and Restaurants to provide catering services and complies with the requirements of the Florida Sanitary Code. Signed_______________________________________________________Date____________________ Title________________________________________________ 7 American LegalNet, Inc. www.FormsWorkflow.com SECTION 6 – CORPORATE FELONY CONVICTION 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. (Attach additional sheets if necessary) 8 American LegalNet, Inc. www.FormsWorkflow.com SECTION 7 – 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 9 Co-signer Lender Interest Rate (List) American LegalNet, Inc. www.FormsWorkflow.com SECTION 8 - 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 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, agents of the Division of Hotels and Restaurants, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the beverage law. It is understood that we must maintain for a period of three (3) years all records required by the division by statute to demonstrate compliance with the requirements of the purchase of alcoholic beverages and records identifying each customer and the location and date of each catered event. 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 the foregoing information is true and that no other person or entity except as indicated herein has an interest in the license and that all of the above listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license." 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 10 American LegalNet, Inc. www.FormsWorkflow.com SECTION 9 - 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 M.I. Current License Number(s) Date of Birth Social Security Number* ________/______/_________ Street Address City State Last Name First Zip Code M.I. Current License Number(s) Date of Birth Social Security Number* ________/______/_________ Street Address City State Last Name First Zip Code M.I. Current License Number(s) Date of Birth Social Security Number* ________/______/_________ Street Address City State Last Name First Zip Code M.I. Current License Number(s) Date of Birth Social Security Number* ________/______/_________ Street Address City State 11 Zip Code American LegalNet, Inc. www.FormsWorkflow.com FOR DIVISION USE ONLY – DO NOT WRITE BELOW THIS LINE Trade Name (D/B/A) Approved by___________________________________________ Date_____________ Fee:____________ District Office Date Stamp 12 American LegalNet, Inc. www.FormsWorkflow.com