R-40004 (4/03) State of Louisiana Office of Alcohol and Tobacco Control 8549 United Plaza Blvd, Suite 220 P.O. Box 66404 Baton Rouge, LA 70896-6404 Telephone (225) 925-4041 · Fax (225) 925-3975 For Office Use Only Permit Number: Seq. Number: Telephone Numbers Application for Class “R” (Restaurant) Permit Work: ( ) - Home: ( ) - The class “R” permit shall expire on the same date as the retail permit 1. Applicant’s name (individual, partnership, corporation, LLC): 2. Trade Name of Business: 3. Location address (street/city/state/ZIP) 4. Parish 5. Official mailing address (P.O. Box/street/city/state/ZIP) 6. Do you have a Class “A” restaurant beer/liquor/light wine permit issued by the State of Louisiana, Office of Alcohol and Tobacco Control? Yes No If yes, enter permit number: 7. Have you operated this business as a restaurant for the past 60 days? Yes No If yes, respond to “a” and “b” below: (a) What are your average monthly gross sales of food, food items, and nonalcoholic beverages? (b) What are your average monthly gross sales for alcoholic beverages? $ Beer $ Liquor $ Warning: Your business records are subject to audit to substantiate the sales figures provided above. You are required to maintain separate sales figures for sales of alcoholic beverages. 8. Is the primary purpose and function of this business to take orders for and serve food and food items? 9. If food served on all days of operation? Yes Yes No No 10. Are alcoholic beverages served in conjunction with meals? Yes 11. Have you applied for a local “R” permit? If yes, enter permit number or date applied. Yes No No 12. Does this place of business operate a fully-equipped kitchen used for the preparation of uncooked foods for service and consumption of such foods on Yes No the premises? 13. Have you applied for the local health department certificate showing compliance with all health and sanitary requirements? Yes No If yes, indicate date applied for A complete diagram of the restaurant premises indicating the entrances, exits, bar, kitchen, and dining areas must be attached to this application. This affidavit must be signed by a person authorized to sign the Class "A" beer and/or liquor/light wine application and must be notarized by a notary public. Affidavit I swear that I have read each of the questions in this application and that the answers that I have given are true and correct to the best of my knowledge; and that this business meets the minimum qualifications contained in R.S. 73 and 272 for a class "R" permit. Applicant’s signature: Title: Print/Type your name: Sworn to and subscribed to me this day of , 20 in the parish/county of Notary Public’s Signature: State of Print Name of Notary Public: Fee $25.00 American LegalNet, Inc. www.FormsWorkflow.com