Liquor License Application Form. This is a Idaho form and can be use in State Police Statewide.
Tags: Liquor License Application, Idaho Statewide, State Police
Idaho State Police Liquor License Application 1. □ New □ Change 2. License Type and Fees □ Transfer Premise File Number _________ Proposed Opening Date_____________________________ □ On Premise Consumption □ Restaurant (Must Qualify) □ Keg Beer (Kegs to Go) $20 □ Beer $50 ($20 for Transfer) □ Liquor by the Drink (Includes Wine)$ ____________ Total Fee Enclosed $__________ ! Place of business qualifies for a liquor by the drink license per Title 23 Chapter 9, Idaho Code, as listed: □ Incorporated City □ Golf Course □ Waterfront Resort □ Continuous □ Ski Resort □ Airport Restaurant □ Airline □ X-Country Operation Facility □ Common Carrier Boat □ Convention Center □ Theme Park □ Split Ownership Ski Resort Facility □ Equestrian □ Gondola □ Railroad □ Racing Facility □ Club ! Business is located □Inside or □Outside of City Limits. 3. Applicant Information License to be issued to: _____________________________________________________ (Applicant Name: Individual(s), Corporation, LLC or Partnership) Doing Business As: ________________________________________________________________ Located At: ________________________________________________________________ City, County, Zip: ________________________________________________________________ Former Business Name: _______________________________________________________________ Mailing Address: ________________________________________________________________ Daytime Telephone: ___________________ Nighttime Telephone: _____________________________ Federal or State Tax I.D. Number: ________________________________ Liquor License Proprietor:_____________________________________SSN___________________ 4. List all individuals, partners, officers, directors, 10 primary stockholders with percentages of stock held and LLC/LLP members. (Corporations must include an in-state manager) Attach additional list as needed. Officer or stockholder updates must include signed meeting minutes. (Name)___________________________(Title)_________ (Home Address)___________________________ (SSN)____________________(DOB)_____________(Contact Phone Number)_______________________ (Name)___________________________(Title)_________ (Home Address)___________________________ (SSN)____________________(DOB)_____________(Contact Phone Number)_______________________ (Name)___________________________(Title)_________ (Home Address)___________________________ (SSN)____________________(DOB)_____________(Contact Phone Number)_______________________ (Over) Alcohol Beverage Control, P O Box 700, Meridian, ID 83680-0700 (208) 884-7060, Toll Free (888) 222-1360 American LegalNet, Inc. www.FormsWorkflow.com ! Does anyone listed have any direct or indirect interest in any other business licensed for the sale of beer, □ □ NO YES (Explain. Include Premise Number) wine or liquor by the drink? ___________________________________________________________________________ □ □ ! Has anyone listed ever had an alcohol license denied, suspended or revoked? NO YES Explain: _____________________________________________________________________ ! Has anyone listed ever been convicted of a felony or an alcohol related misdemeanor? □ NO Explain: ______________________________________________________________ □ YES 5. Applicant Financial Information ! Attach a list of all assets and liabilities of the applicant. You may attach a financial statement as long as the assets and liabilities are clearly listed. ! Does anyone not previously listed have any financial interest (direct or indirect) in the business? □ No □ Yes (explain) (Name) (Address) (Explanation) ________________________________________________________________________________ ________________________________________________________________________________ ! Business Bank Name and Address: ________________________________________________ ! Persons Authorized to sign on bank account: ____________________________________________ ! Building: □Leased (Attach a copy of the valid lease) ! Liquor License: □ Owned-Purchase Price________ □ Leased (Attach a copy of the valid lease) □ Owned- Purchase Price_________ ! Did you pay for Goodwill (Good name, patronage, reputation)? _______ Purchase Price________ 6. Premise Diagram/Floor Plan (No architectural blue prints) Attach a sketch of the entire area proposed to be licensed, all entrances, exits, locations of bars, back bars, bar stools, booths, tables, coolers (for off premise), coin operated amusement devises and the place where the licenses are regularly displayed. Indicate in the margin the direction and distance to the nearest school, church or other places of worship measuring from the nearest entrance of the licensed premises to the school, church or other place of worship if within 300 feet. Include a copy of your permits for health, safety and zoning from the governmental agency with zoning jurisdiction over the facility’s location. 7. Read the following, Sign and have notarized. The applicant hereby affirms that he/she is the bona fide owner of the business, is eligible and has none of the disqualifications for a license as provided by Title 23, Chapter 9, 10,11, 13, 14, Idaho code or any amendments thereto. I/we hereby certify that there have been no changes in the above named business, ownership, directors, stockholders, partners or members during the past licensed year, except as indicated herein. An application for and acceptance of a license by a retailer shall constitute consent to, and be authority for, entry by the director or his authorized agents, upon any premises related to the licensee’s business, or wherein are or should be, kept, any of the licensee’s books, records, supplies or other property related to said business, and to make the inventory, check and investigations aforesaid with relation to said licensee or any other licensee, as per Idaho code sections 23-1006, 23-907 and 23-1314. I/we have also read all of the above and declare under penalty of perjury that each and every statement is true and correct. ____________________________________ ____________________ _______________ Applicant Signature Title Date Subscribed and sworn to before me this ______ day of ______________, 20____. __________________________________________ Notary Public (Seal) Residing At_____________________________________ My Commission Expires: ________________________ American LegalNet, Inc. www.FormsWorkflow.com