DEPARTMENT OF LIQUOR CONTROL · COUNTY OF MAUI 2145 Kaohu Street, Room 105, Wailuku, Hawaii 96793 · Phone 243-7030 788 Pauoa Street, Room 102, Lahaina, Hawaii 96761 · Phone 661-9581 INSTRUCTIONS FOR FILLING OUT APPLICATION FOR PERMIT All requests for permits must be submitted to the Department of Liquor Control no later than ten work days prior to any proposed modification, approval for music, dancing, and entertainment, or any other proposed changes, etc. All requests for permits must include a neat and legible 8½" x 11" floor plan of the premises drawn to scale showing the location of all areas for music, entertainment, dancing, game devices, etc. Label the floor plan with the premises name and include directional (mauka, makai, etc.) arrows. Licensee shall obtain necessary clearances from other governmental agencies and comply with all State and County laws, ordinances, and administrative rules. Modification of Premises: Furnish details on the modification(s). Indicate the location of the modification(s) on the floor plan. Submit a floor plan including the proposed modification(s). Installation of Game Device(s): Rescind all previous permits for game devices. Indicate quantity, name, and dimensions of game device(s) to be installed. Furnish brochures and details as to type, content, function and size. Indicate the location of the game device(s) on the floor plan. Casino Game Device(s) ­ Additional Requirements Indicate date, name of person contacted and details of information furnished to MPD Vice Division Gambling Section. Include response from Vice Division regarding the proposed function. Area(s) for Music, Entertainment, and Dancing: Rescind all previous permits for music, entertainment, and dancing. Indicate location and dimensions of the area(s) requested on the floor plan. Extension of Premises: Furnish details on reason for extension; plans on how supervision and control is to be carried out; and a lease, rental agreement or written authorization signed by the owner or representative of the property authorizing the licensee the use and exclusive control of the property for the sale, service and consumption of liquor and that the function will be subject to the liquor laws and inspection by investigators of the Department of Liquor Control. Caterer Permit Furnish the date, times, and location of the event; a floor plan showing the boundaries of the proposed catered event with the consumption area(s) outlined in red; a lease, rental agreement or written authorization signed by the owner or representative of the property authorizing the licensee the use and exclusive control of the property for the sale, service and consumption of liquor and acknowledging that the event will be subject to the liquor laws and inspection by investigators of the Department of Liquor Control, and a statement indicating that all required governmental clearances have been or will be obtained. A site plan may also be required. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF LIQUOR CONTROL · COUNTY OF MAUI 2145 Kaohu Street, Room 105, Wailuku, Hawaii 96793 · Phone 243-7030 788 Pauoa Street, Room 102, Lahaina, Hawaii 96761 · Phone 661-9581 APPLICATION FOR PERMIT Permit is hereby requested for the item(s) indicated below: 123Extension of Premises Modification of Premises Game Device(s) 456Area(s) for Music, Entertainment, and Dancing Outside Warehousing Note: (Type or print details of request.) I hereby certify all necessary clearances from other governmental agencies have been obtained in reference to this application. Licensee: Trade Name: Signature of CORPORATE OFFICER, AUTHORIZED AGENT, etc. (License Number) Print Name/Title Date (NOTE: APPLICANT WILL ALSO APPLY FOR DEPARTMENT OF HEALTH CLEARANCE WHEN ALTERATION AFFECTING HEALTH & SANITATION IS INVOLVED.) American LegalNet, Inc. www.FormsWorkFlow.com DLC-022 [rev 12/02]