12072006 LOUISIANA DEPARTMENT OF REVENUE OFFICE OF ALCOHOL AND TOBACCO CONTROL P.O. BOX 66404 BATON ROUGE, LOUISIANA 70896-6404 TELEPHONE (225) 925-4041 – FAX (225) 925-3975 OFFICE USE ONLY “R” Permit Number: _______________ Application for Temporary Class “R” Restaurant Telephone Number INSTRUCTIONS: Application Fee - $10.00 – This application must be completed with proper fees attached in the form of Cash, Money Order or Certified Cashiers Check - made payable to the Office of Alcohol and Tobacco Control. APPLICANTS FULL NAME: (must be same as shown on Class A Beer and/or Liquor/Light Wine Permit) TRADE NAME: (must be same as shown on Class A Beer and/or Liquor/Light Wine Permit) RESTAURANT LOCATION ADDRESS: Street City/State Zip MAILING ADDRESS: P.O. Box/street/city/state/ZIP 1. Do you hold a Class A Retail Beer and/or Liquor/Light Wine license with the State of YES NO Louisiana, Office of Alcohol and Tobacco Control? If yes, give permit number. 2. Is the primary purpose and function of this business to take orders for food and serve NO food items? YES 3. Is food served on all days of operation? 4. Are alcoholic beverages served in conjunction with meals? 5. Is an affidavit from the local health department showing compliance with all health and YES NO sanitary requirements attached to this application? YES NO YES NO TEMPORARY “R” RESTAURANT PERMIT TO BE ISSUED FOR THE SAME PERIOD AS YOUR CLASS A BEER AND/OR LIQUOR/LIGHT WINE PERMIT American LegalNet, Inc. www.FormsWorkflow.com 6. 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 the premises? YES NO 7. Do you hold a local “R” restaurant permit? If yes, give permit number. YES NO Please submit complete diagram of the restaurant premises indicating entrances, exits, bars, kitchen and dining areas. AFFIDAVIT THIS AFFIDAVIT MUST BE SIGNED BY THE SAME PERSON AUTHORIZED TO SIGN THE CLASS A BEER AND/OR LIQUOR/LIGHT WINE APPLICATION AND MUST BE NOTARIZED BY A NOTARY PUBLIC. I swear that I have read each of the questions in this application and that the answers which I have given are true and correct to the best of my knowledge, and that I meet the qualifications and conditions set out in LA R.S. 26:73 and R.S. 26:272. Signature: ______________________________________________________________ Title: Print/Type your name: Sworn to and subscribed to me this In the parish of day of , 20 , State of Notary Public’s Signature: ________________________________________________ Print Name of Notary Public: THIS PERMIT WILL BE ISSUED FOR SIXTY (60) DAYS. PRIOR TO EXPIRATION OF THIS TEMPORARY PERMIT YOU WILL BE REQUIRED TO FURNISH US YOUR GROSS SALES AND PAY ADDITIONAL FEES OF $25.00 FOR EACH PERMIT BEFORE YOU CAN RECEIVE A DOCUMENTARY “R” RESTAURANT PERMIT. YOU WILL RECEIVE A NOTICE FROM THIS OFFICE THIRTY (30) DAYS AFTER RECEIVING YOUR TEMPORARY PERMIT INSTRUCTING YOU ON THE PROCEDURES FOR ACQUIRING A DOCUMENTARY RESTAURANT PERMIT. THIS PERMIT WILL EXPIRE AT THE SAME TIME AS YOUR CLASS A BEER AND/OR LIQUOR/LIGHT WINE PERMIT. ONCE APPLICATION AND FEES HAVE BEEN ACCEPTED BY THIS OFFICE, NO REFUNDS WILL BE MADE. American LegalNet, Inc. www.FormsWorkflow.com