APPLICATION, NEW ALCOHOLIC BEVERAGE RETAILER'S PERMIT return to Alcoholic Beverage Control Division Permit Department P.O. Box 540 Madison, Mississippi 39130-0540 1 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION INSTRUCTIONS This application may be typed or neatly printed in ink. Please read these instructions prior to completing this application Each applicant, regardless of the type of ABC permit sought, must meet the statutory qualifications set by the Local Option Alcoholic Beverage Control Laws, codified at Title 67 of the Mississippi Code. The Department, under authority of these laws, has established policies requiring applicants to file certain documents concerning the applicant's place of business. This application asks for particular information concerning each applicant to allow the Department to determine the eligibility of the applicant for licensing as well as the suitability of the business premises to offer alcoholic beverages for sale. The application immediately follows these instructions. Indicate with an (x) the type of license sought under this application and include the appropriate license fee. It is important that you complete the appropriate SUPPLEMENTAL INFORMATION portion of the application that corresponds to the type of license that you are seeking. (I.e. package store, on-premises, or on-premises private club) (NOTE: An on-premises private club is a chartered organization formed for purposes other than profiting from the sale of alcoholic beverages. Some examples of private clubs are veteran's groups, lodges, and golf clubs). Be thorough in your completion of the STATEMENT OF OWNERSHIP section. Locate on this form the ownership classification of the applicant, whether a sole owner, partnership, corporation, limited liability company, trust or other. This form contains instructions on who must file qualifying documents (PERSONAL RECORD, Form 1001, SUMMARY FINANCIAL STATEMENT, Form 2007; and fingerprint cards) with this application. Note that partnerships, limited liability companies and corporations and trusts must also file a separate SUMMARY FINANCIAL STATEMENT disclosing the financial status of the business. Financial Statements must be within sixty (60) days. Standard Bank Confirmation Forms are also enclosed and must be completed if you have a banking institution outside of the State of Mississippi. Some in-state banks might also require this form to be completed, therefore please check with your bank. ABC collects a pass-a-long $32.00 fee for fingerprint card processing by the Federal Bureau of Investigation. This fee is due and payable with the application submission. This fee is in the form of a Cashier's Check or Personal Money Order, payable to "ABC-FF". Each applicant must submit two (2) fingerprint cards. Fingerprints must be completed by a law enforcement agency on ABC "Applicant" fingerprint cards. The cards must be complete, legible, and capable of being classified by the Federal Bureau of Investigation. Some law enforcement agencies have ABC fingerprint cards on hand. If you need fingerprint cards, contact the Permit Dept. or visit your local MS Department of Revenue office. You will notice that there are two separate waivers that must be submitted. These waivers serve different purposes. The first waiver accompanies your personal record form and authorizes ABC to conduct a thorough background investigation to determine your qualifications for an ABC license. The second waiver accompanies the SUMMARY FINANCIAL STATEMENT. The purpose of this waiver is to verify the financial solvency that you disclose on the form with banking institutions. It is required that you have your signature witnessed by two people on both waivers and authorizations to release information. Signatures on each PERSONAL RECORD form must be notarized. 2 American LegalNet, Inc. www.FormsWorkFlow.com You must submit with this application a copy of your lease, if leasing the business premises, or your deed, if you own the business premises. If a lease, the lessee must be the applicant for the alcoholic beverage permit (sole owner, partnership, Limited Liability Company, trust or corporation) and the lease may not expire for at least twelve (12) months. You must also include a FLOOR PLAN of the business premises that details your proposed areas of customer service, storage, kitchen facilities, restrooms, etc. The floor plan that you submit must receive approval from ABC prior to the issuance of an ABC license. Sales and consumption of alcoholic beverages are limited to the approved floor plan. Additionally, you must submit a menu if you are applying for a license as an on-premise retailer or caterer. New applicants are required to give public notice of their intent to make application by publication for two (2) consecutive issues in a newspaper of general circulation published in the city or town in which applicant's place of business is located. However, in such instances where no newspaper is published in the city or town, then the same shall be published in a newspaper of general circulation published in the county where the applicant's business is located. If no newspaper is published in the county, the notice shall be published in a qualified newspaper which is published in the closest neighboring county and circulated in the county of applicant's residence. Such notice shall be printed in ten-point black face type and shall set forth the type of permit to be applied for, the exact location of the place of business, the name of the owner or owners thereof, and if operating under an assumed name, the trade name together with the names of all owners, and if a corporation, the names and titles of all officers. The cost of such notice shall be borne by the applicant. An acceptable legal notice format is included in this packet. Submit with this application a PUBLISHER'S AFFIDAVIT (obtained from the newspaper) as proof of publication. You must apply to the Dept. of The Treasury and furnish with this application a completed copy of TTB Form 5630.5d (7/2008). To obtain a form, go to www.ttb.gov. If you have questions or need assistance, you may call the Alcohol and Tobacco Tax and Trade Bureau at 1-800-937-8864. You must register with the Department of Revenue and obtain a sales tax number. You can download a registration form at the MSTC website at www.dor.ms.gov. You may return this form with your application or provide a copy of the registration you file