DBPR ABT-6014 – Division of Alcoholic Beverages and Tobacco Change of Location/Change in Series or Type Application 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: Change of Location Increase in Series Series Requested Change of Business Name Decrease in Series / Change in Type Type Requested 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 # _______________________ Contact Person Phone Number Current License Number Series Type FEIN Number Business Telephone Number Location Address City County Check either: Location is within the city limits of ____________________ or State Zip Code Location is in the unincorporated county Mailing Address Section / Name (Attention: – Optional) City State Zip Code Do you wish to change the business name? Yes No If yes, please list new name below. New Trade Name (D/B/A) 1 American LegalNet, Inc. www.FormsWorkflow.com SECTION 3 - 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. DBPR Authorized Signature___________________________________________ Date_________________ Approved Disapproved Comments_____________________________________________________________________________ ______________________________________________________________________________________ 2 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/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 5 - ZONING TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION Trade Name (D/B/A) Street Address City County State Zip Code Are there outside areas which are contiguous to the premises which are to be part of the premises sought to be licensed?” Yes No If this application is for issuance of an alcoholic beverage license where zoning approval is required, the zoning authority must complete “A” A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series______________ license. Signed____________________________________________________Date_____________________ Title______________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com SECTION 6 - 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 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. Are there any persons 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 Co-signer Lender Interest Rate (List) These questions must be answered about this business for every person or entity listed. Copies of agreements must be submitted with this application. 2. Is there a management contract, franchise agreement, or service agreement in Yes connection with this business? 3. Are there any agreements which require a payment of a percentage of gross or net Yes receipts from the business operation? 4. Have you or anyone listed on this application accepted money, equipment or Yes anything of value in connection with this business from a manufacturer or wholesaler of alcoholic beverages? 4 No No No American LegalNet, Inc. www.FormsWorkflow.com SECTION 8 – SPECIAL LICENSE REQUIREMENTS (DOES NOT APPLY TO BEER AND WINE LICENSES) Please check the appropriate “Special Alcoholic Beverage License” box of the license for which you are applying. Fill in the corresponding requirements for each Special License type. Quota Alcoholic Beverage License Club Alcoholic Beverage License Special Alcoholic Beverage License This license is issued pursuant to __________, Florida Statutes or Special Act, and as such we acknowledge the following requirements must be met and maintained: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Please initial and date: Applicant’s Initials___________________________ Date______________ SECTION 9 - 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 cigarette 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. 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 5 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 for Filing Date Stamp 6 American LegalNet, Inc. www.FormsWorkflow.com