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. Incomplete applications will not be accepted. 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 all individual applicants, partners, corporate officers, managing members, stockholders owning .5 or more percent of stock, directors, and all general partners of a limited partnership. Fingerprints must be taken by a law enforcement agency and must be taken on fingerprint cards provided by the district office serving your area. You must submit the DBPR ABT-6021 Fingerprint Affidavit form with the fingerprint card, plus a $53.25 processing fee. Fingerprints must have been taken within the last 45 days before the date submitted to the Division. 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 or fees. 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 1 American LegalNet, Inc. www.FormsWorkFlow.com 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 within the past 15 years, 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. Copy of Arrest Disposition If the applicant answers “yes” to any of the criminal background questions asked in this application, provide a 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 copy of Arrest Disposition, if applicable Mitigation for Moral Character, if applicable If required, complete DBPR ABT-6021 Fingerprint Affidavit form, the official fingerprint card, and include a $53.25 fee for each officer/ stockholder Submit Secretary of State Certificate of Status, if applicable Submit 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 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 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: Initial Permanent License Do you wish to purchase a Temporary 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* 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 Does the applicant entity currently hold an alcoholic beverage license? If yes, complete the following information. Current License Number Series Yes No Type Current Business Name 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 of Applicant 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 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 within the past 5 years? Yes No If yes, provide the information requested below and provide a 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 within the past 15 years? Yes No If yes, provide the information requested below and a COPY OF THE DISPOSITION. Attach additional sheet if necessary. Date Location Type of Offense 5 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 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 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. 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 President Name Stock % 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. Interest Name Guarantor Co-signer Lender Rate 9 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. 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 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 DBPR ABT-6021 – Division of Alcoholic Beverages and Tobacco Fingerprint Affidavit STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 1940 North Monroe Street Tallahassee, FL 32399-0783 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 Please include your official fingerprint card and $53.25 fee with this affidavit. Do not staple anything to your fingerprint card or highlight any portion of the fingerprint card. Fingerprints must have been taken within the last 45 days before the date submitted to the Division. Please use black ink only when filling out this affidavit. AFFIDAVIT In compliance with Florida Beverage Laws and Regulations, I hereby certify: Full Applicant Name Mailing Address City State Zip Code The person stated above was fingerprinted by me for the State of Florida Division of Alcoholic Beverages and Tobacco, and that the attached fingerprints are his/hers. ____________________________________________________________________________________ Fingerprint Technician Name (please print) _______________________________________________________ _____________________________ Signature of Fingerprint Technician Department 13 American LegalNet, Inc. www.FormsWorkFlow.com