On Premise Application Rev. 3 /2019 Replace 12/2018 Page 1 of 9 NOTICE To avoid any delay in the processing of your application and is suance of your liquor license, please make sure that: You completed the application in full. It is suggested to have submitted 30 days prior to the expiration date of your liquor license. Application and Corporate Questionnaire forms are signed by the owner(s) or corporate officer(s). The applicat ion is signed by the Town or City Municipal Officers or County Commissioners. The license fee submitted is for the correct Class you are applying for and includes the $10.00 filing Treasurer, State of Maine and both fees can be submitted on one check. If the business is located in an unorganized township, the application must be approved by the County Commissioners and the $10.00 filing fee must be paid to them. Please be sure to include a copy of the receip t of payment with your application. Your room (if applicable), food and liquor gross income for the year is filled in A diagram of the facility to be licensed needs to accompany ALL New and Renewal application s . Corporations, limited liab ility companies, partnerships must complete and submit the Corporate Information Required for Business Entities who are Licensees. If not a publicly traded entity, ownership must add up to 100%. Submit Completed Forms to : Bureau of Alcoholic Beverages Division of Liquor Licensing and Enforcement 8 State House Station, Augusta, Me 04333 - 0008 (Regular address) 10 Water Street, Hallowell, ME 04347 (Overnight address) S TATE OF M AINE D EPARTMENT OF A DMINISTRATIVE AND F INANCIAL S ERVICES B UREAU OF A LCOHOLIC B EVERAGES AND L OTTERY O PERATIONS D IVISION OF L IQUOR L ICENSING AND E NFORCEMENT 8 S TATE H OUSE S TATION A UGUSTA , M AINE 04333 - 0008 T ELEPHONE : (207) 624 - 7220 F AX : (207) 287 - 3434 E MAIL INQUIRIES : MAINELIQUOR @ MAINE . GOV American LegalNet, Inc. www.FormsWorkFlow.com On Premise Application Rev. 3 /2019 Replace 12/2018 Page 2 of 9 BUREAU OF ALCOHOL BEVERAGES AND LOTTERY OPERATIONS DIVISION OF LIQUOR LICENSING AND ENFORCEMENT 8 STATE HOUSE STATION, AUGUSTA, ME 04333 - 0008 (Regular Mail) 10 WATER STREET, HALLOWELL, ME 04347 (Overnight Mail) TEL: (207) 624 - 7220 FAX: (207) 287 - 3434 EMAIL INQUIRIES: MAINELIQUOR@MAINE.GOV PRESENT LICENSE EXPIRES : NEW application: Yes No If business is NEW or under new ownership, indicate starting date: Requested inspection ( New Licensees/ Ownership Changes Only ) Date : Business h ours: INDICATE TYPE OF PRIVILEGE : MALT VINOUS SPIRITUOUS INDICATE TYPE OF LICENSE : RESTAUR ANT (Class I,II,III,IV) RESTAURANT/LOUNGE (Class XI) CLASS A LOUNGE (Class X) HOTEL (Class I,II,III,IV) HOTEL, FOOD OPTIONAL (Class I - A) BED & BREAKFAST (Class V) GOLF COURSE (Class I,II,III,IV) TAVERN (Class IV) QUALIFIED CATERING OTHER: SELF - SPONSORED EVENTS (QUALIFIED CATERERS ONLY) REFER TO PAGE 3 FOR FEE SCHEDULE ALL QUESTIONS MUST BE ANSWERED IN FULL Corporation Name: Business Name (D/B/A) APPLICANT(S) (Sole Proprietor) DOB: Physical Location: DOB: City/Town State Zip Code Address Mailing Address Same As Above? City/Town State Zip Code City/Town State Zip Code Telephone Number Fax Number Business Telephone Number Fax Number Federal I.D. # Seller Certificate #: or Sales Tax #: Email Address : Website : 1 . If premise is a Hotel or Bed & Breakfast, indicat e number of rooms available for t ransient guests: 2 . State amount of gross income from period of last license: ROOMS $ FOOD $ LIQUOR $ 3 . Is applicant a corporation, limited liability company or limited partnership? YES NO If Yes, please complete the Corporate Information required for Business Entities who are licensees. 4 . Do you permit dancing or entertainment o n the licensed premises? YES NO DIVISION USE ONLY License No: Class: By: Deposit Date: Amt. Deposited: Cash Ck Mo : Good SOS & DBA: YES NO American LegalNet, Inc. www.FormsWorkFlow.com On Premise Application Rev. 3 /2019 Replace 12/2018 Page 3 of 9 5 . Do you own or have any interest in any another Maine Liquor License? Yes No (Use an additional sheet(s) if necessary.) If yes, please list License Number, Name, and physical location of any other Maine Liquor Licenses. License # Name of Business Physical Location City / Town 6 . If manager is to be employed, give name: 7 . Business records are located at: 8 . Is/are applicants(s) citizens of the United States? YES NO 9 . Is/are applicant(s) residents of the State of Maine? YES NO 1 0 . List name, date of birth, and pl ace of birth for all applicants, managers, and bar managers. Full Name (Please Print) DOB Place of Birth 1 1 . Residence address on all of the above for previous 5 years (Limit answer to city & state) Name: City: State: Name: City: State: Name: City: State: 1 2 . Has/have applicant(s) or manager ever been convicted of any violation of the law, other then minor traffic violations, of any State of the United States? YES NO Name: Date of Conviction: Offense: .. Location: Disposition: (use additional sheet(s) if necessary) 1 3 . Will any law enforcement official benefit directly in your license, if issued? Yes No If Yes , give name: 1 4 . Has/have applicant(s) formerly held a Maine liquor license? YES NO 1 5 . Does/do applicant(s) own the premises? Yes No If No give name and a ddress of owner: 1 6 . Describe in detail the premises to be licens ed: ( On Premise Diagram Required ) 1 7 . Does/do applicant(s) have all the necessary permits required by the State Department of Human Services? YES NO Applied for: 1 8 . What is the distance from the premises to the NEAREST school, school dormitory, church, chapel or parish house, measured from the main entrance of the premises to the main entrance of the school, school dormitory, church, chapel or parish house by the ordinary course of travel? Which of the above is nearest? j jkj American LegalNet, Inc. www.FormsWorkFlow.com On Premise Application Rev. 3 /2019 Replace 12/2018 Page 4 of 9 19 . Have you received any assistance financially or otherwise (including any mortgages) from any source other than your - self in the establishment of your business? YES NO If YES, give details: The Division of Liquor Licensing & Enforcement is hereby authorized to obtain and examine all books, records and tax returns pertaining to the business, for which this liqu or license is requested, and also such books, records and returns during the year in which any liquor license is in effect. NOTE: information on this f orm is a Class D offense under the Criminal Code, punishable by confinement of up to one year or by Dated at: on , 20 Town/City, State Date PLEASE SIGN IN BLUE I NK Signature of Applicant or Corporate Officer(s) Signature of Applicant or Corporate Officer(s) Print Name Print Name FEE SCHEDULE FILING FEE : (must be included on all applications) ................................ ................................ .......................... $ 10.00 Class I Spirituous, Vinous and Malt ................................ ................................ ................................ ................ $ 900.00 CLASS I: Airlines; Civic Auditoriums; Class A Rest aurants: Clubs with catering privileges; Dining Cars; Golf Clubs; Hotels; Indoor Ice Skating Clubs; Indoor Tennis Clubs; Vessels; Qualified Caterers; OTB Class I - A Spirituous, Vinous and Malt, Optional Food (Hotels Only) ................................ ................................ $1,100.00 CLASS I - A: Hotels only that do not serve three meals a day. Class II Spirituous Only ................................ ................................ ................................ ................................ .... $ 550.00 CLASS II: Airlines; Civic Auditoriums; Class A Restaurants; Clubs with catering privileges; Dining Cars; Golf Clubs; Hotels; Indoor Ice Skating Clubs; In door Tennis Clubs; and Vessels. Class III Vinous Only ................................ ................................ ................................ ................................ ........ $ 220.00 CLASS III: Airlines; Civic Auditoriums; Class A Restaurants; Clubs with catering privileges; Dining Cars; Golf Clubs; Hotels; Indoor Ice Skating Clubs; Indoor