R-40005 (12/04) 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 #: Seq. #: Application for Retail Alcoholic Beverage Permit Page 1 of 2 Please mark the space adjacent to the class of permit you desire and the type of alcoholic beverage you intend to sell. Class of permit Type of alcoholic beverage Class A – General (No one under the age of 18 admitted) Beer Class A – Restaurant (Bona fide restaurant with “R” permit) (Must complete “R” application) Liquor Class B – Package only Light wine (Not needed if liquor checked) (Must have “R” permit) 1. Type of ownership: Individual Partnership (Requires written agreement) Corporation (Requires certificate) 2. Owner name of business (individual, partnership, corporation, LLC): 3. Trade Name of Business: 4. Location address (street/city/state/ZIP) LLC (Requires certificate) 5. Telephone Work: ( ) - Home: 6. Official mailing address (P.O. Box/street/city/state/ZIP) 8. Is this applicant the owner of the premises to be occupied? ( ) - 7. Location parish Yes No If no, applicant must provide a copy of the written lease to ATC Agent. Lessor’s name and address: 9. What portion of building will business occupy? 10. If applicant is a partnership, corporation, or LLC, list the name, address, title, and percentage of ownership of each partner or stockholder. (Notice: A Schedule “A” must be completed and attached to this application for the manger, owner, each partner, officer, director, financial backer, and any stockholder owning more than 5 percent of the stock, if applicable.) (Attach additional sheet, if necessary, to list all parties.) Name Title (Stockholder/director/officer) % of stock owned 11. Is this business to be conducted wholly or partly by one or more managers other than those listed in Number 10? Yes No If yes, list names and furnish Schedule A for each person. 11a. 11b. 12. Has applicant applied for a local permit? Yes No If yes, date applied. 11c. 13. Does applicant hold any interest in any establishment that hold an ATC Yes No If yes, enter permit number. permit? 14. Has this location had a beer/liquor permit in the last 6 months? Owner name: Yes No If yes, provide the previous owner’s name. Trade name: . 15. I have read Number 20 on the back of this page and have determined that my permit will expire in the month of Beer 16. Date sale of beer will start at this address Liquor/Light Wine 17. Date sale of liquor will start at this address 18. Is business located inside limits of an incorporated city? 19. Is business located inside limits of an incorporated city? Yes No Yes No Please complete reminder of form on reverse (page 2) American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2 20. Circle and initial parish and corresponding permit expiration date. Write month of expiration on Number 15. January expiration Ascension East Baton Rouge February expiration Jefferson March expiration Allen Beauregard Calcasieu Cameron Jefferson Davis Vermilion Vernon April expiration Plaquemines St. Bernard St. Charles St. James St. John May expiration Orleans June expiration None July expiration Avoyelles Evangeline Iberville Pointe Coupee Rapides St. Landry West Baton Rouge August expiration East Feliciana Livingston St. Helena St. Tammany Tangipahoa Washington West Feliciana September expiration Bienville Bossier Caddo Claiborne DeSoto Lincoln Red River Sabine Webster October expiration Acadia Iberia Lafayette St. Martin November expiration Assumption Lafourche St. Mary Terrebonne December expiration Caldwell Catahoula Concordia East Carroll Franklin On premises consumption Class A General (no one under 18 admitted) Class A Restaurant Grant Jackson LaSalle Madison Morehouse Natchitoches Ouachita Richland Tensas Union West Carroll Winn Package only Beer fee Beer fee $70 $70 Class B $70 (bona fide restaurant with “R” permit) (Must complete “R” application.) Class A General (inside city limits) Class A General (outside city limits) Class A Restaurant Light wine (Must have “R” permit) Liquor fee $200 $100 $200 Light wine fee $30 Class B (inside city limits) Class B (outside city limits) (not required if obtaining a liquor permit) Temporary (“R” permit) Regular (“R” permit) Beer fee $ Liquor fee $100 $50 Responsible vendor fee ($50) is required for all permits. Restaurant $10 $25 Responsible vendor fee $ Liquor or light wine fee $ Notice: Once this form and fees have been accepted by this office, no refunds will be made. Payment of fees must be made in the form of a money order, cashier’s check, or certified check. Mail forms and proper fees to this office at the address listed on the top of front page (page 1). Make payment to Office of Alcohol and Tobacco Control. Do not send cash. This affidavit must be signed by the owner, if individual ownership; partner, if partnership; or authorized official, if corporation or LLC. 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. Affidavit I swear that I have read each of the questions in this application and that the answers I have given are true and correct to the best of my knowledge; that I meet the qualifications and conditions of R.S. 26:80 and 280; that I have complied with the notice requirements contained in R.S. 26:77 and 277; and that I have no interest in any business that holds a wholesaler's license issued by the Office of Alcohol and Tobacco Control. Signature: Title: Print/Type your name: Sworn to and subscribed before me this in the parish of Notary Public’s Signature: day of , 20 State of Print Name of Notary Public: American LegalNet, Inc. www.FormsWorkflow.com