21711 Louisiana Alcohol & Tobacco Control 8585 Archives Ave., Suite 220 Baton Rouge, LA 70809 Message of Importance to All Applicants: The application process to receive an alcohol or tobacco permit is not an easy one. The laws that demand the applicants maintain certain qualifications make it, to many, cumbersome. However, we are committed to make the process as painless as possible. The State has 35 days to investigate and review all applications and many times the process will take the full 35 days and more, if there are any problems with the application. All problems we find, are caused from the applicants not reading and understanding that we have to have all documentation that is required. There are no exceptions. Please begin by locating the checklist furnished with the application and follow the instructions. This will assure you that we will process this application in the shortest possible time frame. Thank you for choosing Louisiana in which to do business. Troy Hebert, Commissioner Office of Alcohol & Tobacco Control American LegalNet, Inc. www.FormsWorkFlow.com CHECK LIST – Requirements for all Alcoholic Beverage Permits Notice of Intent (NOI) Poster Application {RS 26:77(E) / 277(E)} - Posters are valid for 90 days and must be displayed in plain view outside the business front of the location for 15 consecutive days before submitting the alcoholic beverage permit application. HOWEVER …If you are acquiring an on-going business and this location has held a valid, state-issued alcoholic beverage permit within the last six months, the NOI application may be submitted at the same time as the alcohol application. In this case, you are still required to post the NOI posters for the mandatory 15 days. Fingerprint Cards - May be obtained from ATC or your local police department or sheriff’s office, and must be completed for all Owners and their Spouses for the purpose of conducting a background check. The completed fingerprint cards, 2 disclosure forms, and processing fee, must be submitted to ATC, as specified below. See (*) and (**). The processing fee amount is $45.25, and should be made payable to Louisiana State Police. Acceptable forms of payment are money order, cashier’s check, and certified check. * IF YOU ARE APPLYING AS A NEW BUSINESS, the completed fingerprint cards, 2 disclosure forms, and processing fee must be submitted to ATC at the same time that you apply for your Notice of Intent (NOI) Posters. ** IF YOU ARE ACQUIRING AN ON-GOING BUSINESS, and this location has held a valid, state-issued alcoholic beverage permit within the last six months, your fingerprint cards, 2 disclosure forms, and processing fee must be submitted to ATC at the same time that you apply for your alcoholic beverage permit. Alcoholic Beverage Permit Application {RS 26:78 / 278} - Double-check your paperwork to be certain that the owner name, trade name, mailing address and location address match exactly on ALL paperwork submitted. Legal names are required. No nicknames are accepted. The document MUST be signed by the Applicant. Proof of Publication and Newspaper Ad {RS 26:77(A) / 277(A)} - The Proof of Publication document, along with the newspaper ad showing that the “Notice of Application” was run in the city or parish’s local newspaper (official journal) where your business will be located. These documents can be obtained from the publisher. See example included in the application packet. The newspaper ad is required to run only one time, and it is valid for 90 days. Schedule A - Must be completed for each owner, partner, officer, director, and stockholder or member owning more than 5%, and for any appointed managers or other individuals who are responsible for the operation of the business. Schedule F (if required) - Must be completed by applicants and their spouses who have been convicted of a felony and seek lawful issuance of an alcoholic beverage permit under the provisions of R.S. 26:80F and R.S. 26:280F. This includes any convictions that have been adjudicated under Article 893 or for which a pardon or expungement was received. Corporate Documents (RS 26:80 / 280) - The applicant must attest on the application that they are the true owner(s) of the business seeking to be permitted and that they are not seeking the permit as a means to allow any other person(s) to benefit. If you are applying as Corporation or LLC, you must also include Articles of Incorporation and a copy of the Secretary of State certificate. If applying as a Partnership, you must submit a notarized Partnership Agreement, list all partners, and a percentage of ownership in the partnership. If applying as any other entity type than those listed above, corporate paperwork is required. Lease (RS 26:80 / 280) - If applicant is not the owner of the premises, a copy of the signed and dated written lease or management agreement must be submitted. State and Local Sales Tax Clearances (RS 26:78 / 278) - A copy of your State and Local Sales Tax Clearance Certificates must be submitted, unless otherwise noted. The State sales tax clearance may be obtained from the nearest office of the Louisiana Department of Revenue. The local sales tax clearance may be obtained from your local municipality. Local Alcohol Permit {RS 26:79 / 279} - Proof of submitted application for a local alcoholic beverage permit, or a copy of the valid local permit must be submitted. Diagram - A detailed and exact diagram of the premises must be submitted. The diagram must include all entrances, exits, restrooms, bar, tables, kitchen, storage, office, etc. Your diagram will only be accepted in 8-1/2”x11” (letter-size) or 8-1/2”x14” (legal-size) format. Proper Application Fees {RS 26:71 / 271} - Fees will be processed immediately upon receipt. If your application is rejected or denied, fees will NOT be returned or refunded. Acceptable methods of payment are money order, cashier’s check, or bank certified check. Department of the Treasury – Alcohol and Tobacco Tax & Trade Bureau - Please download and fill out form OMB NO. 1513-0112 from http://www.ttb.gov and submit to the proper authorities. If you have any questions regarding the Special Occupational Tax (SOT), please contact the TTB National Revenue Center at 1 (800) 937-8864 or (513) 684-2979. QUALIFICATIONS American LegalNet, Inc. www.FormsWorkFlow.com Applicants for all state and local alcoholic beverage permits shall meet the following qualifications and conditions under Louisiana Revised Statutes 26:80 and 280: 1. Be a person of good character and reputation, and over 18 years of age. 2. Be a citizen of the United States and the State of Louisiana and a resident of the State of Louisiana continuously for a period of not less than two years next preceding the date of the filing of the application. However, the requirements as to Louisiana citizenship do not apply to wholesalers or retailers who, on or prior to January 1, 1946, held permits for high alcohol content and July 26, 1944, for low alcohol permits. 3. Be the owner of the premises or have a bona fide written lease. In cases in which the applicant holds a bona fide written lease, the name and current address of the lessor shall be shown on the application form filed with the Commissioner. 4. Have not been convicted of a felony under the laws of the United States, the State of Louisiana, or any other state or country. 5. . Have not been convicted in this or in any other state or by the United States of soliciting for prostitution, pandering, letting premises for prostitution, contributing to the delinquency of juveniles, keeping a disorderly place, or illegally dealing in controlled or dangerous substances. 6. Have not had a license or permit to sell or deal in alcoholic beverages, issued by the United States or any other states, or by any political subdivision of a state authorized to issue permits or licenses, revoked within two years prior to the application, or been convicted, or had a judgment of court rendered against the applicant involving alcoholic beverages by this or any other state or by the United States for two years prior to the application. 7. Have not been convicted of violating any of the provisions of Title 26 of the Louisiana Revised Statutes. 8. Have not been convicted of violating any municipal or parish ordinances adopted pursuant to the provisions of Title 26. If the applicant has been so convicted, the granting of a permit or of a renewal shall be within the discretion of the commissioner. 9. Not be the spouse of a person who does not meet the above-listed qualifications except for the citizenship requirements listed in number 2 above. An alternative is referenced in R.S. 26:80(G) and 280(G). 10. Not owe the state or the local government subdivisions in which the application is made any delinquent sales taxes, penalties, or interest excluding items under formal appeal pursuant to applicable statutes. PARTNERSHIPS: If the applicant is a partnership or anyone in partnership with or financed by another, all members of the partnership or all the persons furnishing the money shall also possess the qualifications required of the applicant. The application shall name all partners or financial backers and furnish their proper addresses and social security numbers. CORPORATIONS/LLCs: If the applicant is a corporation or limited liability company (LLC), all officers and directors and all stockholders or members owning in the aggregate more than five percent of the stock or membership interest in a limited liability company and the person or persons who shall conduct or manage the business shall possess the qualifications required of an applicant. However, the requirements as to citizenship and residence do not apply to officers, directors, and stockholders of corporations or membership in an LLC. The corporation or LLC shall either be organized under the laws of the State of Louisiana or qualified to do business within the State of Louisiana. MANAGERS, AGENTS, SERVANTS, EMPLOYEES AND REPRESENTATIVES: If the applicant’s business is to be conducted wholly or partly by one or more managers, agents, servants, employees, or other representatives, those persons shall also possess the qualifications required of the applicant. FINGERPRINTS: Must be submitted to the Department of Public Safety, Criminal Records Division, by all persons who are required to possess these qualifications. IMPORTANT NOTICE: If the applicant or any other person required to have the same qualifications does not possess the required qualifications, the permit may be denied. For further instructions, see attached application. For Office Use Only NOI Posters for all Retail Alcoholic Beverage Permits Permit #: American LegalNet, Inc. www.FormsWorkFlow.com Office of Alcohol and Tobacco Control 8585 Archives Ave., Suite 220 ● Baton Rouge, LA 70809 Telephone: 225.925.4041 ● Fax: 225.925-7652 www.atc.rev.state.la.us NOTICE OF INTENT POSTER REQUIRED FOR ALL RETAIL ALCOHOLIC BEVERAGE PERMITS ● VALID FOR 90 DAYS Page 1 of 2 IMPORTANT NOTICE ● If you are starting a new business, this application must be completed, signed, notarized, and submitted, along with the appropriate fees at least 15 days prior to submitting your application for an alcoholic beverage permit; ● If you are taking over an ongoing business that has held a valid, state-issued alcoholic beverage permit within the past 6 months, the alcoholic beverage permit application may be submitted, along with this application; ● As required by law, the Notice of Intent poster must be posted in plain view outside the business location for 15 days. PERMIT CLASS AND TYPE 1. Please mark the Class of permit that you desire: 2. Please mark the Type of alcoholic beverage(s) that you intend to sell: Class A – General (On-Premises Consumption) [RS 26:71.1(1) / 271.1(1) Class A – Restaurant (On-Premises Consumption) [RS 26:73(c)/273(c)] Beer Class A – Caterer Liquor (LAC 55, VII 325) Light Wine (Not needed if Liquor is checked; Must have “R” permit) Class B – (Off-Premises Consumption ONLY) [RS 26:2(13) / 241(13)] Class C – (Off-Premises Consumption ONLY) [RS 26:71.2(13 )/ 271.2] BUSINESS INFORMATION 3. Type of Ownership Individual 4. Owner Name of Business (Individual, Partnership, Corporation, LLC) Partnership Corporation LLC 5. Location Address 6. Trade Name of Business Street 7. Location Parish City State Zip 8. Has this location held a valid, state-issued beer/liquor permit within the last 6 months? ● If Yes, enter the trade name under which the business operated: Trade Name Yes No . APPLICANT INFORMATION 9. Applicant’s Name 10. Driver’s License # and State Issued 11. Mailing Address 12. Contact Information State DL# P. O. Box/Street City Cell ph. # State Zip ( ) - Home ph. # ( ) - Work ph. # ) - E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com FEES 13. Please check the type of alcoholic beverage to be served, and enclose the appropriate amount with this application: $50.00 – BEER (Low Alcohol Content) $50.00 – LIQUOR (High Alcohol Content) $50.00 – LIGHT WINE ONLY NOTE ● Not needed if Liquor is checked; “R” Permit is required. ● NO REFUNDS will be made once this application packet and fees have been reviewed by this office; ● Our office accepts: money orders, cashier’s checks and certified checks. DO NOT SEND CASH OR PERSONAL/BUSINESS checks; ● Make all payments payable to: Office of Alcohol and Tobacco Control; ● Cash is only accepted at the Baton Rouge Office. The cashier’s window is open during the hours of 8:00 a.m. through 4:00 p.m., Monday through Friday, excluding holidays; ● Mail fully-completed forms, all supporting documents, and proper fees to: Office of Alcohol and Tobacco Control 8585 Archives Ave., Suite 220 Baton Rouge, LA 70809 SWORN STATEMENT your Signature: Print your Name: Title: ______________________________________________________ Sworn to and subscribed before in the Parish of day of ,20 State of _________________________________ _______________________________ print name of notary public: Signature: NOTARY PUBLIC FOR OFFICE USE ONLY Poster Serial # ____________________ Date Issued ____________________ Receipt # ____________________ Issued by ____________________ Poster Serial # ____________________ Date Issued ____________________ Receipt # ____________________ Issued by ____________________ Poster Serial # ____________________ Date Issued ____________________ Receipt # ____________________ Issued by ____________________ American LegalNet, Inc. www.FormsWorkFlow.com State of Louisiana LA Alcohol and Tobacco Control Troy Hebert, Commissioner Bobby Jindal Governor To: Applicants Re: Fingerprints Instructions The Office of Alcohol and Tobacco Control will need the following to process fingerprints. 1. Authorization Form 2. Disclosure Form Authorization and Disclosure forms are utilized to request and obtain criminal history information. Please ensure that each form is filled out correctly and completely. Forms must be typed or printed, excluding signatures. 3. Fees The fee is $45.25 per request for state criminal history checks. Fees must be in the form of a money order, cashier’s check, or business checks made payable to: Louisiana Department of Public Safety or Louisiana State Police NO PERSONAL CHECKS WILL BE ACCEPTED. If an applicant decides to get electronic fingerprints completed at State Police in Baton Rouge an additional and separate $10.00 fee is required. Each applicant must provide a valid picture form of identification at the time of fingerprinting. Please include all of this information with your New Business Application. For any further assistance please call (225) 925-1886. • Title 28 Code of Federal Regulations (CFR) 50.12(b) and the rules promulgated by the Bureau of Criminal Identification and Information require that records obtained be used solely for the purpose requested and cannot be disseminated outside the receiving departments, related agencies or other authorized entities. • 5 U.S.C. 552a and the rules promulgated by the Bureau of Criminal Identification and Information require that agencies maintain a system of records which establishes appropriate administrative, technical and physical safeguards to ensure the security and confidentiality of records. • The Compact Council best business practices guidelines and the rules promulgated by the Bureau of Criminal Identification and Information are meant to ensure that an individual requesting fingerprint submission is the actual subject of the record search. American LegalNet, Inc. www.FormsWorkFlow.com SUBMIT TO: Louisiana State Police Bureau of Criminal Identification and Information PO Box 66614 (Mail Slip A-6) Baton Rouge, LA 70896 THE FEE FOR PROCESSING A STATE BACKGROUND CHECK IS $26. FOR FBI PROCESSING, WHERE AUTHORIZED, OR REQUIRED, THERE IS AN ADDITIONAL $19.25 FEE **FORMS MUST BE FILLED OUT IN INK AND BE REVIEWED BY SUBMITTING AGENCY/INDIVIDUAL FOR ACCURACY** ****FINGERPRINTS ARE NECESSARY FOR A POSITIVE IDENTIFICATION**** ****PLEASE PRINT**** OFFICE OF ALCOHOL AND TOBACCO CONTROL ATC CERTIFICATION DIVISION FACILITY OR AGENCY FACILITY OR AGENCY AUTHORIZED REPRESENTATIVE PO BOX 66404 NA MAILING ADDRESS SIGNATURE OF AUTHORIZED REPRESENTATIVE BATON ROUGE LA 70896 (225) 925 4041 CITY STATE ZIP CODE FACILITY OR AGENCY PHONE NUMBER NA FACILITY EMAIL ADDRESS Request For: (pick one only) ALCOHOL AND BEVERAGE COMMISSION ALCOHOL BEVERAGE OUTLET CASA CONCEALED HANDGUNS CRIMINAL JUSTICE EMPLOYEE DAYCARE DENISTRY BOARD DEPARTMENT OF LABOR DEPARTMENT OF PUBLIC SAFETY EMPLOYERS FIREFIGHTERS GAMING HEALTH CARE PROVIDER JUVENILE DETENTION CENTER DEPARTMENT OF INSURANCE MANUFACTURED HOUSING MEDICAL EXAMINERS OCS ABUSE/NEGLECT INVESTIGATION OCS CARETAKER OCS FOSTER/ADOPTIVE OCS PERSONNEL OFFICE OF FINANCIAL INSTITUTIONS OFFICE OF PUBLIC HEALTH PHARMACY BOARD POST SECONDARY EDUCATION PRACTICAL NURSING PRIVATE ADOPTION PRIVATE INVESTIGATORS PRIVATE SECURITY PUBLIC HOUSING PUBLIC TAG AGENT REGISTERED NURSING RELIGIOUS ACTIVISTS RIVERBOAT PILOTS SCHOOL SENATE AND GOVERNMENTAL AFFAIRS TAXI DRIVERS USED MOTOR VEHICLE COMMISSION VENDOR VOLUNTEERS WITH YOU SERVING ORG WORKING WITH CHILDREN AUTHORIZED AGENCY APPLICANTS FULL NAME: (Last, First, Middle) *PRINT USE INK INCLUDE MAIDEN NAME & PREVIOUS MARRIED NAMES IF APPLICABLE* APPLICANT’S SIGNATURE: APPLICANT’S SOCIAL SECURITY NUMBER: DATE OF BIRTH: DRIVERS LICENSE NUMBER & STATE: RACE: SEX: POSITION OR LICENSE APPLIED FOR: AUTHORIZATION TO DISCLOSE CRIMINAL HISTORY RECORDS INFORMATION By my signature above, I hereby authorize the Louisiana State Police to release all pertinent criminal record information maintained in their files, other states files, or the FBI files (if applicable) which may confirm or deny my eligibility with the facility or agency named above. American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT PROCESSING – DISCLOSURE BUREAU OF CRIMINAL IDENTIFICATION AND INFORMATION PO BOX 66614 (MAIL SLIP A-6) BATON ROUGE, LA 70896 LSPAPP5/R10.03 OFFICE OF ALCOHOL AND TOBACCO NOTICE: PLEASE PRINT OR TYPE CONTROL AGENCY INFORMATION, EXCLUDING ADMINISTRATORS OR AUTHORIZED PO BOX 66404 PERSONS SIGNATURE. INCOMPLETE MAILING ADDRESS FORMS WILL NOT BE PROCESSED. BATON ROUGE LA 70896 CITY STATE ZIPCODE NAME: (Last, First, Middle) Date of Birth: Race: Sex: SOCIAL SECURITY NUMBER: ALL INFORMATION RELEASED MUST REMAIN STRICTLY CONFIDENTIAL AND ONLY THOSE AUTHORIZED BY LAW TO RECEIVE THIS INFORMATION MAY SUBMIT A REQUEST ****DO NOT WRITE BELOW THIS LINE**** (For Bureau of Criminal Identification and Information Use Only) NOTICE: The response to your request for a criminal history check is based on a review of the State of Louisiana’s criminal history records database as is available at the time of request. This does not preclude the possible existence of conviction information not available in our database. CRIMINAL HISTORY DETERMINATION RAPSHEET ATTACHED RESPONSE BELOW American LegalNet, Inc. www.FormsWorkFlow.com For Office Use Only Permit #: Office of Alcohol and Tobacco Control 8585 Archives Ave., Suite 220 ● Baton Rouge, LA 70809 Telephone: 225.925.4041 ● Fax: 225.925-7652 www.atc.rev.state.la.us CLASS B package house ● off-premises consumption only ● factory-sealed containers only Page 1 of 3 LOCATION INFORMATION Owner Name of Business (Individual, Partnership, Corporation, LLC) 2. Trade Name of Business 4. Telephone Number 3. Location Address Street Cell ( City State Zip ) Work ( ) - Home ( ) - - 6. E-mail Address 5. Official Mailing Address P.O. Box/Street 7. Location Parish City State Zip 8. How would you prefer to be notified about permit status? Cell phone Home phone Work phone 9. Does the applicant listed in Question 1 own the premises to be permitted? Yes No ● If No, provide landlord’s contact information. ● You MUST submit a copy of the signed, written lease or management agreement with this application. Email IF YOU ANSWERED NO TO QUESTION 9, you must complete this section Landlord’s Name P.O. Box/Street City Telephone Number ( State ) Zip - OWNER INFORMATION 10. Type of Ownership: Individual Partnership Corporation LLC 11. If the applicant is not an individual, list the name, title, and percentage of ownership for each partner, stockholder, officer or member. A Schedule A must be completed and attached to this application for all managers, owners, partners, officers, directors, and financial backers. Members and stockholders who own more than five percent (5%) of stock must also submit a Schedule A. If any percentage of ownership is held by a Corporation, LLC, or Limited Partnership, those entities should be entered here. (Use additional sheet, if needed). ● If applying as a Corporation or LLC, Articles of Incorporation and a copy of the Secretary of State certificate must be submitted with application. ● If applying as a Partnership, a notarized partnership agreement must be submitted with application. Name Title (Stockholder/Director/Officer/Member) % of Stock Owned 12. Are there any managers or authorized representatives for this business (Power of Attorney, General Manager, etc.)? Yes No ● If Yes, you must list names and furnish Schedule A for each person. Name Title American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 QUALIFICATIONS NOTICE: Misstatement or suppression of material facts in this application is GROUNDS FOR DENIAL OF THIS PERMIT. Conviction of filing false public records, a violation of Louisiana Revised Statute 14:133, may result in imprisonment for not more than five years, with or without hard labor, and fines of not more than $5,000 (five thousand dollars), or both. *Law definitions for this permit type can be found on-line @ www.atc.rev.state.la.us, and in the application packet (Informational Section). 13. Has a local (city, town, parish, etc.) alcoholic beverage permit been issued? Yes No ● If No, list the date you applied for your local permit. _______________ ● If Yes, submit a copy of your local permit with this application. 14. Have you submitted your Notice of Intent (NOI) Poster Application, received and posted your NOI Poster in plain view outside the premises for the mandatory 15 days? Yes No [LA RS 26:77(E) & 26:277(E)] * ● If the location has not been permitted within the last 6 months, and your NOI Posters have not been posted for 15 days, your application packet will be rejected and will not be processed. 15. Does this location have at least two restrooms designated only for this business? Yes No ● If No, you must contact the Louisiana Department of Health and Hospitals (DHH) to obtain a health certificate. 16. Will this business sell alcoholic beverages in factory-sealed containers for consumption off-premises only? Yes No [LA RS 26:2(12)] * Notice: A Class B permit prohibits the following: 1) Disruption or tampering of factory seals; 2) Mixing of drinks; and 3) On-premises consumption. 17. Is this location at least 300 feet from any public playground, public library, correctional facility, church, school, synagogue or day care center? Yes No Don’t Know [LA RS 26:81C & 26:281C] * 18. Does this location maintain at least 500 square feet of permanent enclosed space within the structure that is accessible to patrons? (excluding restricted spaces such as employee areas, restrooms, closets, storage/utility rooms, porches, patios, etc.) Yes No [LA RS 26:2(12)] * ● If No, please provide explanation. . DETAILED DIAGRAM REQUIRED ● A DETAILED AND EXACT DIAGRAM OF THE PREMISES MUST BE SUBMITTED WITH YOUR APPLICATION (include all entrances, exits, restrooms, bar, tables, kitchen, storage, office, etc.). ● YOUR DIAGRAM WILL ONLY BE ACCEPTED IN FORMATS OF 8-1/2” x 11” (letter-size) OR 8-1/2” x 14” (legal-size). American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 ADDITIONAL INFORMATION 19. Does applicant hold interest in any other establishment(s) that hold(s) a Louisiana ATC permit? Yes No 20. Has this location held a valid, state-issued beer/liquor permit Yes No within the last 6 months? ● If Yes, in the space below, enter the trade name under which the business operated: Trade Name: ● If Yes, enter the alcoholic beverage permit # of the establishment(s) below. (Use additional sheet, if necessary). Permit #: 21. On what date do you want to start selling alcoholic beverages at this location? / / 20 ______________________ Month FEES 22. Day Year ● NO REFUNDS will be made once this application packet and fees have been reviewed by this office. Please check the appropriate amount enclosed with this application: ● All totals shown include the required $50 Responsible Vendor fee. ● Totals do not include the Notice of Intent (NOI) Poster fee. ● Our office accepts: money orders, cashier’s checks and certified checks. DO NOT SEND CASH OR PERSONAL/BUSINESS checks. ● Make all payments payable to: Office of Alcohol and Tobacco Control $120 – Beer Only $170 – Beer & Liquor - OUTSIDE incorporated CITY limits * ● Cash is only accepted at the Baton Rouge Office. The cashier’s window is open during the hours of 8:00 a.m. through 4:00 p.m., Monday through Friday, excluding holidays. $220 – Beer & Liquor - INSIDE incorporated CITY limits * If amount submitted is not listed above, please indicate the amount submitted and the permit applied for: ___________ * An Incorporated City List is included with this application packet (Informational Section), and on our website at www.atc.rev.state.la.us. ● Mail fully-completed forms, all supporting documents, and proper fees to: Office of Alcohol and Tobacco Control 8585 Archives Ave., Suite 220 Baton Rouge, LA 70809 If Applicant Is ● Individual ● Partnership ● Corporation ● LLC SWORN STATEMENT Who Must Sign Individual Owner Partner Officer/Director Officer/Member/Director By signing below, you are swearing, under oath, that you have read each of the questions in this application packet, and that all answers are true and correct to the best of your knowledge; that you meet the qualifications and conditions of R.S. 26:80 and 280; that you have complied with the notice requirements contained in R.S. 26:77 and 277; and that you have no interest in any business that holds a wholesaler's or manufacturer’s license issued by the Louisiana Office of Alcohol and Tobacco Control. You are also swearing, under oath that pursuant to La. R.S. 26:934, you have read and understand the responsible vendor handbook and any amendments thereto, that you understand your obligations as an alcoholic beverage permit holder under the responsible vendor program, and that you have enrolled in the program. The responsible vendor handbook and amendments are available for download at www.atc.rev.state.la.us. Title: Signature: Print your name:: _____________________________________________________________________________________________________ Sworn to and subscribed before me day this of in the Parish of ___________________________ ,20 State of __________________________ print name of notary public: Signature: NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com ON PREMISE CONSUMPTION PERMITS SCHEDULE OF PERMIT FEES ON-PREMISE CONSUMPTION PERMITS CLASS/ TYPE OF PERMIT BEER FEE LIQUOR / LIGHT WINE FEE RESPONSIBLE VENDOR FEE RESTAURANT FEE $50 $25 (IF REQUIRED) TOTAL DUE CLASS A-RESTAURANT Beer Only $70 Beer & Light Wine $70 $30 $50 $25 Beer & Liquor $70 $200 $50 $25 CLASS A-GENERAL $145 $175 $345 ● No one under 18 years of age admitted Beer Only $70 Beer & Liquor ● OUTSIDE Incorporated City Limits ● INSIDE Incorporated City Limits $70 $70 $50 $120 $100 $50 $200 $50 $220 $320 OFF-PREMISE CONSUMPTION PERMITS CLASS/ TYPE OF PERMIT BEER FEE LIQUOR FEE RESPONSIBLE VENDOR FEE TOTAL DUE $50 $120 $170 $220 CLASS B-PACKAGE Beer Only $70 Beer & Liquor ● OUTSIDE Incorporated City Limits $70 $50 $50 Beer & Liquor ● INSIDE Incorporated City Limits $70 $100 $50 CLASS C-PACKAGE ● No one under 18 years of age admitted Beer Only $70 Beer & Liquor ● OUTSIDE Incorporated City Limits $70 $50 $50 Beer & Liquor $70 $100 $50 NOTE: ● INSIDE Incorporated City Limits $50 $120 $170 $220 A $50 Responsible Vendor fee is required for each licensed establishment. This fee has already been calculated into the totals listed above. American LegalNet, Inc. www.FormsWorkFlow.com INCORPORATED CITIES LIST Use this list to: ● Determine whether the city in which your business is located is “Incorporated” (inside the city limits) or outside the city limits of an incorporated city; ● Accurately calculate your necessary fees; ● Answer #18 on the Application for Retail Alcoholic Beverage Permit. ** If the city in which your business is located is NOT listed below, your business location is considered to be outside the city limits of an incorporated city ** ABBEVILLE JEANERETTE RUSTON ALEXANDRIA JENNINGS SCOTT BAKER KAPLAN SHREVEPORT BASTROP KENNER SLIDELL BATON ROUGE LAFAYETTE SPRINGHILL BOGALUSA LAKE CHARLES ST. GABRIEL BOSSIER CITY LEESVILLE ST. MARTINVILLE BREAUX BRIDGE MANDEVILLE SULPHUR BROUSSARD MANSFIELD TALLULAH BUNKIE MARKSVILLE THIBODAUX CARENCRO MINDEN VILLE PLATTE CENTRAL MONROE WEST MONROE COVINGTON MORGAN CITY WESTLAKE CROWLEY NATCHITOCHES WESTWEGO DERIDDER NEW IBERIA WINNFIELD DENHAM SPRINGS NEW ORLEANS WINNSBORO DEQUINCY NEW ROADS YOUNGSVILLE DONALDSONVILLE OAKDALE ZACHARY EUNICE OPELOUSAS FRANKLIN PATTERSON GONZALES PINEVILLE GRETNA PLAQUEMINE HAMMOND PONCHATOULA HARAHAN PORT ALLEN HOUMA RAYNE American LegalNet, Inc. www.FormsWorkFlow.com 21411 PERMIT EXPIRATION MONTHS Parishes listed in alphabetical order Permits expire on the last day of the month Acadia (October) Iberville (July) St. James (April) Allen (March) Jackson (December) St. John (April) Ascension (January) Jefferson (February) St. Landry (July) Assumption (November) Jeff Davis (March) St. Martin (October) Avoyelles (July) Lafayette (October) St. Mary (November) Beauregard (March) Lafourche (November) St. Tammany (August) Bienville (September) LaSalle (December) Tangipahoa (August) Bossier (September) Lincoln (September) Tensas (December) Caddo (September) Livingston (August) Terrebonne (November) Calcasieu (March) Madison (December) Union (December) Caldwell (December) Morehouse (December) Vermilion (March) Cameron (March) Natchitoches (December) Vernon (March) Catahoula (December) Orleans (May) Washington (August) Claiborne (September) Ouachita (December) Webster (September) Concordia (December) Plaquemines (April) W. Baton Rouge (July) DeSoto (September) Pointe Coupee (July) West Carroll (December) E. Baton Rouge (January) Rapides (July) West Feliciana (August) East Carroll (December) Red River (September) Winn (December) East Feliciana (August) Richland (December) Evangeline (July) Sabine (September) Franklin (December) St. Bernard (April) Grant (December) St. Charles (April) Iberia (October) St. Helena (August) American LegalNet, Inc. www.FormsWorkFlow.com 082110 State of Louisiana Office of Alcohol and Tobacco Control 8585 Archives Ave., Suite 220 P.O. Box 66404 Baton Rouge, LA 70896-6404 Telephone (225) 925-4041 · Fax (225) 925-3975 Bobby Jindal Governor Schedule A A Schedule “A” must be executed by the manager, owner, each partner, each officer, director, and every stockholder owning more than 5 percent of the capital stock. 1. Owner name of business (individual, partnership, corporation, LLC): 2. Trade Name of Business: 3. Name of person to be certified (Enter Full Legal Name): 4. Daytime Telephone #: ( ) - 5. Race: 6. Sex: 7. Residence Address (street/city/state/zip): 8. Date of Birth: 12. Social Security Number: 9. Present Age: 10. Place of Birth: 11. Naturalization Number (if applicable): 13. Your Driver’s License Number & State: 14. Are you a citizen of the United States? Yes No 16. Name, Social Security Number, and Date of Birth of spouse: 15. Are you a citizen of Louisiana? Yes No 17. Have you continuously resided in Louisiana for the past two years? Yes No 18. Do you or your spouse own or hold interest in any other business holding a state retail beer and/or liquor permit? Yes No If yes, enter permit number: 18a. Trade Name of Business: 18b. Location Address (street/city/state/zip): Note: If this person is an Officer, Member, or Partner in another entity that maintains a state alcohol permit, answer 19. Do you or your spouse own or hold interest in any business holding a wholesale permit or solicitors permit? Yes No If yes, enter the name of business: 20. Have you or your spouse ever been convicted of a felony? This includes any offense adjudicated under Article 893. Yes No If yes, complete Schedule “F” as provided by this office. 21. Have you or your spouse ever been convicted of violating any liquor or beer regulatory statute or rule? Yes No 22. Have you or your spouse ever been convicted of solicitation for prostitution, pandering, letting premises for prostitution, contributing to the delinquency of a juvenile, keeping a disorderly place, or dealing in narcotics? Yes No 23. Have you of your spouse had a license or permit to sell or deal in alcoholic beverages revoked within the last two years prior to the filing of this schedule? Yes No 24. Have you or your spouse ever been denied an alcoholic beverage permit? Yes No 25. If the response to Questions 20 and 22 is “yes,” state the offense, date, location, and provide certified copied of the disposition to include documents relative to felony pardons. If the response to Questions 21, 23, and 24 is “yes,” state the offense, date, and location. Apply attachment(s) to this document if necessary. 26. Have you or your spouse ever had or used any name(s) other than the one stated above? (Official name change, maiden name, alias, nickname, etc.) Yes No If yes, please list. 27. Are you employed by the State of Louisiana? Yes No If yes, enter the name of the department. 28. Is this application being made by you to permit any person other than yourself to secure a beer/liquor permit in your Yes No name for his/her benefit? Affidavit I swear that I have read each of the above questions and the answers that I have given are true and correct to the best of my knowledge; and that I meet the qualifications and conditions set out in R.S. 26:80 and 26:280. Signature: Title: Print/Type your name: Sworn to and subscribed to me this in the parish/county of Notary Public’s Signature: day of , 20 State of Print Name of Notary Public: American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE F ADDENDUM Schedule F – This form must be completed by any applicant who has been convicted of a felony, and seeks lawful issuance of an alcohol beverage permit under the provisions of R.S. 26:80f and/or 26:280f. Applicant attests that the felony was not a crime of violence as defined in R.S. 14:2(13), and that ten (10) or more years have elapsed between the date of application and the successful completion of any sentence, deferred adjudication or period of probation, parole and the final discharge of the defendant. Applicant is required to submit official documentation of such at the time of application. IMPORTANT NOTICE A “CRIME OF VIOLENCE” is defined as any of the below-listed crimes. [R.S. 14.2(13)] If you have been convicted of ANY of the below-listed crimes, you will NOT qualify for an alcoholic beverage permit. CRIMES OF VIOLENCE 1. Solicitation for Murder 2. First Degree Murder 3. Second Degree Murder 4. Manslaughter 5. Aggravated Battery 6. Second Degree Battery 7. Aggravated Assault 8. Mingling Harmful Substances 9. Aggravated Rape 10. Forcible Rape 11. Simple Rape 12. Sexual Battery 13. Second Degree Sexual Battery 14. Intentional Exposure to AIDS Virus 15. Aggravated Kidnapping 16. Second Degree Kidnapping 17. Simple Kidnapping 18. Aggravated Arson 19. Aggravated Criminal Damage To Property 20. Aggravated Burglary 21. Armed Robbery 22. First Degree Robbery 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. Simple Robbery Purse Snatching Extortion Assault By Drive-by Shooting Aggravated Crime Against Nature Carjacking Illegal Use of Weapons or Dangerous Instrumentalities Terrorism Aggravated Second Degree battery Aggravated assault upon a peace officer with a firearm Aggravated assault with a firearm Armed Robbery; use of firearm; additional penalty Second Degree Robbery Disarming of a peace officer Stalking Second Degree Cruelty to Juveniles Aggravated Flight from an Officer Aggravated Incest Battery of a Police Officer Trafficking of Children for Sexual Purposes Human Trafficking Home Invasion American LegalNet, Inc. www.FormsWorkFlow.com 082110 State of Louisiana Office of Alcohol and Tobacco Control 8585 Archives Ave., Suite 220 P.O. Box 66404 Baton Rouge, LA 70896-6404 Telephone (225) 925-4041 · Fax (225) 925-3975 Bobby Jindal Governor Schedule F Application Date (paperwork initially submitted to this office, Agent etc.): Owner name of business (individual, partnership, corporation, LLC): Trade Name of Business: Type of Applicant: Individual Corporation LLC Partnership Limited Partnership (LP) Individual Information: Name (print/type full legal name) ID #, State (Driver’s License, State ID, etc) Phone Number (Primary Contact #) ( Date of Birth (month, day, & year) Age Sex Social Security Number ) - Race Charge/Conviction Information: Enter Type of Felony Conviction and Statute Number: Date of Conviction: Date of Final Discharge: I affirm that I have been convicted of felony, which is not considered a crime of violence as defined in R.S. 14:2(13), and that ten of more years have elapsed since the completion of sentence and final discharge. A copy of official documentation attesting this fact is attached hereto. Signature: Title: Print/Type your name: Sworn to and subscribed to me this in the parish/county of Notary Public’s Signature: day of , 20 State of Print Name of Notary Public: This form is to be completed by applicants that have been convicted of a felony, and seek lawful issuance of an alcohol beverage permit under the provisions of R.S. 26:80F and R.S. 26:280F. Applicant attests that the felony was not a crime of violence as defined in R.S. 14:2 (13) and that ten of more years have elapsed between the date of application and the successful completion of any sentence, deferred adjudication, or period of probation or parole and the final discharge of the defendant. Applicant is required to submit official documentation of pardon, restoration of rights, or official certification that ten years or more have elapsed since successful completion of any sentence, deferred adjudication, or period of probation or parole and the final discharge of the defendant at the time of application. American LegalNet, Inc. www.FormsWorkFlow.com STATE SALES TAX CLEARANCE LOCATIONS OFFICE OF ALCOHOL AND TOBACCO CONTROL Important Notice – DO NOT IGNORE Act 976 of the 1992 Regular Louisiana Legislative Session provides that a clearance be issued from the Department of Revenue for sales tax purposes before the Office of Alcohol and Tobacco Control can issue or renew a beer or liquor permit. This act became effective January 1, 1993. If you have not received a state sales tax clearance certificate from the Louisiana Department of Revenue within the last 30 days, contact the nearest regional office listed below. Offices open on Tuesday and Thursday by appointment only. Baton Rouge State of Louisiana-Department of Revenue 617 North Third Street Baton Rouge, LA 70802 225-219-5511 (This office is open Monday through Friday) New Orleans State of Louisiana- Department of Revenue New Orleans Regional Office 1555 Poydras Street, Suite 900 New Orleans, LA 70112 504-568-5233 Alexandria State of Louisiana- Department of Revenue Alexandria Regional Office 900 Murray Street, Room B-100 Alexandria, LA 71301 318-487-5333 Lafayette State of Louisiana-Department of Revenue Lafayette Regional Office 825 Kaliste Saloom Road, Brandywine III Lafayette, LA 70502 337-262-5455 Lake Charles State of Louisiana-Department of Revenue Lake Charles Regional Office One Lakeshore Drive, Suite 1550 Lake Charles, LA 70601 337-491-2504 Monroe State of Louisiana- Department of Revenue Monroe Regional Office 122 St. John Street, Room 105 Monroe, LA 71201 318-362-3151 Shreveport State of Louisiana- Department of Revenue Shreveport Regional Office 1525 Fairfield Avenue Shreveport, LA 71130 318-676-7505 ****************************************************************************** • Act 1016 of the 1995 Regular Louisiana Legislative Session states: Original and renewal applications shall also be accompanied by a signed sales tax clearance from the Secretary of Revenue and sales tax collection agencies in the parish in which the application is made, which clearance request shall be processed within seven days. • This office will not renew a permit, nor will a new permit be issued without sales tax clearance from both the State Department of Revenue and the local taxing authority. It is the taxpayer’s responsibility to contact both the state and local taxing authorities. • Act 1054 of the 1997 Regular Louisiana Legislative Session state: A Responsible Vendor Program will be established to educate vendors and their employees and customers about selling, serving, and consuming alcohol. New and renewal applicants must include the $50 Responsible Vendor Fee with their application. American LegalNet, Inc. www.FormsWorkFlow.com Retail Keg Registration April 5, 2004 The Louisiana Legislature passed Act 191 in the 2003 session, which requires all retailers of keg beer sold for consumption off premise, to maintain certain documentation of those sales for a period of six (6) months. This requirement is found in LRS 26:306. The Office of Alcohol and Tobacco Control has the responsibility for its implementation and enforcement. Wholesalers have supplied this office a list of their sales records of keg beer to determine retail locations. If you have received this letter and sell keg beer for off premise consumption you will have to maintain certain “new” requirements to be within the scope of LRS 26:306. We will provide you with the proper retail keg registration forms. You may contact ATC Headquarters directly and request the forms from Mrs. Carrie Guillot at (225) 925-4043 or cguillot@rev.state.la.us; in either case, they will be mailed to the address you provide. You may also pick up the forms at ATC Headquarters or an ATC satellite office. Updated information with regard to this and other matters will be posted on the ATC website at www.atc.rev.state.la.us, where forms will be available to download in the near future. If you do not comply with the enclosed law, you will be jeopardizing your license. Please contact us if you have any questions regarding implementation of retail keg registration forms. American LegalNet, Inc. www.FormsWorkFlow.com DIRECTIONS OFFICE OF ALCOHOL & TOBACCO CONTROL HEADQUARTERS 8585 ARCHIVES AVE., STE. 220 #12 THE BROADWING BLDG. BATON ROUGE, LA 70809 225-925-4041 From Lafayette: Take I-10 to Baton Rouge. Once in Baton Rouge, take the Essen Lane Exit and turn left onto Essen Lane. Get in the right lane and continue for 6/10 of a mile. As you approach the State Archives Building on the right, turn right onto that street. ATC is located in the second building on the left behind the State Archives Building. ATC is on the 2nd Floor, Suite 220 From Hammond via I-12: Take 1-12 to Drusilla Lane Exit, and then turn left. Turn right at the first red light signal, which will be Jefferson Hwy. As you approach Essen Lane, there will be a double turn lane. Get into the far left lane and turn left onto Essen Lane. At the second red light signal, turn left just past the State Archives Bldg. The ATC office building is the next building on the left. The ATC office is on the 2nd Floor, Suite 220. From New Orleans: Take I-10 West to Baton Rouge. Exit onto Essen Lane and turn right. Travel a little less than 6/10 of a mile until you approach the State Archives Building. Turn right there. The ATC office building is the second building on the left. ATC is on the 2nd Floor, Suite 220. American LegalNet, Inc. www.FormsWorkFlow.com