Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio For Questions call (614) 644-2411 Office hours 8:00 a.m. to 5:00 p.m. http://www.com.ohio.gov/liqr APPLICATION FOR CLASS "A-1-A" MANUFACTURERS PERMIT CAUTION: ALLOW 6 TO 8 WEEKS FOR PROCESSING A. B. C. D. E. F. THE FOLLOWING ITEMS MUST BE SUBMITTED ALONG WITH THIS APPLICATION FOR PROCESSING Application Processing Fee of $100.00 Application completed in its entirety, notarized and signed. If Individual, list Social Security Number on line provided. ______________________________________. If Partnership, you must submit a completed DLC form 4031, along with a copy of the Partnership Agreement. If Corporation, you must submit a completed DLC form 4030. If Limited Liability Company, you must submit a completed DLC form 4032. Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. FAILURE TO RESPOND TO ALL QUESTIONS WILL RESULT IN THE RETURN OF YOUR APPLICATION. SECTION A Check the appropriate class(es) and submit the corresponding fee(s): A-1-A $3,906.00 (Issued with A1 or A2) D-6 $ 500.00 - Sunday sales of wine, mixed beverages and spirituous liquor Check which class the A1A is to be issued in conjunction with: A1 - Brewery A2 - Winery SECTION B Applicant (Individual, Corporation, Limited Liability Company or Partnership) DBA (doing business as) Business Address Township (if outside city or village limits) Telephone: City Zip Code County Mailing Address (if different from above) Residence ( ) ____________________________ Business ) ____________________________ ( Applicants Email Address: Attorney's Name Address Telephone Number ( ) FOR DIVISION USE ONLY Coder: CLASS RCPT# REMARKS: Proc. Fee Pd: Taxing District: YES REVIEWER ACTION: NO BCI Fee Amount Paid: $ __________ Permit Number Trans. Code Bus. Type DLC 4175 EOE/ADA SERVICE PROVIDER PAGE 1 FOR TTY USERS DIAL ORS 1-800-750-0750 REV. 9-11-07 American LegalNet, Inc. www.FormsWorkflow.com SECTION B 1. Do you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit hold or have any interest in another permit business? If YES, Give permit number & address on the line provided ______________________________________ _______________________________________________________________________________________ YES NO YES NO YES NO YES NO 4. Do you own the real estate on which the proposed business will be located? If NO, return a completed a signed and dated copy of your LEASE OR RENTAL CONTRACT, OR SUMMARY OF TENANCY RIGHTS form (DLC form 4085). YES NO 5. Will the applicant be the sole owner of the business and equipment? If NO, and the fixtures or equipment are rented, submit signed and dated copy of rental agreement. YES NO 6. Will any person, partnership, LLC, or corporation, excluding banks or building and loan associations, have ANY financial interest (such as money, loans, installment contracts, property or other interest) or share in the profits in your business or your property, real or personal? If YES, attach an affidavit with details. NOTE: Ohio Revised Code Section 4303.293 provides a criminal penalty for YES NO YES NO YES NO YES NO 2a. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? If YES, attach a written explanation. 2b. If applicant is a sole proprietor or partnership, will spouse work on the permit premises? If YES, indicate spouse's full name__________________________________________________ 3. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been refused a permit, denied a renewal, or had a permit revoked from another state, by this Division, or the Liquor Commission? If YES, attach a written explanation. failure to answer this question completely and correctly. 7. Is there an existing building? If NO, on what date will construction begin? ____________________________________ If YES, give the approximate date the business will begin operation. ___________________________________ 8. Do you or any partner, office holder, managing member, stockholder, member, employee, spouse, or other person involved in this permit own any stock or have any interest in the business of another manufacturer, any wholesale distributor of alcoholic beverages, or any retail permit holder? If YES, attach a written explanation. 9. If you are filing as an individual or partnership, have you or all partners resided in the State of Ohio for 1 yr.? DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THE APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION. THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT(S): State of Ohio, ______________________________________________________________County, ss I, ____________________________________________________________________ being first duly sworn, according to law, depose and say (Please Print) that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ _____________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) _____________________________________ (Residence Address) __________________ _____________ (City) (State) _______________ (Date) (Title) ___________ _______________________ (Zip Code) (Area Code & Telephone Number) (To be completed by NotaryPublic) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ _______________ (Notary Public) (Notary Expiration) NOTE: ALL DOCUMENTS BECOME PART OF THE PERMIT FILE AND WILL NOT BE RETURNED PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com IMPORTANT - PLEASE READ FIRST Dear Applicant: The Division of Liquor Control is eager to process your application. In order to process your application in a timely and efficient manner it will be necessary for you to file a complete package in accordance with the items listed on the "Application Required Documents" check off sheet. Please follow and complete this list as you gather the items necessary for your transaction. If your application is filed without all of the documents, the application will not be accepted and will be returned to you. It is our goal to provide you with the most efficient and courteous service while processing your application. Your assistance in providing us with a complete application will ensure prompt service. In order to minimize inquiries regarding the status of your application, the following is an outline of the process used in completing your application. Once your application is received, provided all required documents are submitted, the following process begins: 1. Logged in a computerized system for processing. 2. Notification will be sent to the legislative authority of the municipality, city council, or township trustees and county commissioners of your application. They may object to the issuance of your permit and have 30 days to respond. The local law enforcement agency will also be notified. 3. The Division will conduct a criminal background check on each individual for which a civilian identification card (fingerprint card) was submitted. The civilian identification card will be sent to the Ohio Bureau of Criminal Identification and Investigation. This may take up to six weeks to complete. The Division also offers an electronic background check, known as "WebCheck." For further information regarding WebCheck, please see DLC4191, "Back ground Check Information." PLEASE DO NOT SUBMIT A BACKGROUND CHECK REPLY CONDUCTED BY AN AGENCY NOT AUTHORIZED BY THE DIVISION. 4. The Personal History Background Form will be sent to the law enforcement agency in the municipality or township of your permit premises. 5. A physical inspection of your premises will be completed. At the time your inspection is completed a survey of the area is conducted for any school, churches, libraries, public playgrounds, or township parks. By law, any of these within 500 feet of your premises can object to the issuance of your permit within 30 days of notification. If the business is not in operation or the premises did not meet all requirements, a final inspection will need to be conducted at a later date. Please allow two weeks when notifying the Division for a final inspection. 6. All applications, other than a transfer of ownership, require a local option check to be conducted to determine the wet/dry status of the proposed permit premises. This check is done with the assistance of the County Board of Elections. 7. Where required, the Food Service Operation or Food Establishment License must be in the exact name as the liquor permit applicant. It is our goal to process your application in a timely and efficient manner. Many factors determine the length of time to complete the processing of your application. Your assistance in providing us with a completed application and necessary documents will help in accomplishing our goal. Bruce D. Stevenson Deputy Superintendent Page 3 American LegalNet, Inc. www.FormsWorkflow.com REQUIRED DOCUMENTS FOR ACCEPTANCE OF A A1A PERMIT APPLICATION Please use the list below to check off all items as you complete them, to submit with the application packet. CAUTION: ALLOW 10 TO 12 WEEKS FOR PROCESSING. FAILURE TO SUBMIT THE FOLLOWING DOCUMENTS MAY RESULT IN THE RETURN OF YOUR APPLICATION, UNRECEIPTED, WITH THE POSSIBLE LOSS OF PRIORITY ON THE QUOTA LIST. Application: Application must be completed in full, all questions answered, signed, and notarized. Application Processing Fee: $100.00 - Check made payable to Division of Liquor Control. Civilian Identification Card: PLEASE READ "BACKGROUND CHECK INFORMATION" DLC4191 Must be submitted for each individual, partner, general partner, managing member, officer, stockholder or member over 5%, and for spouses who will work on the premises when applicant is a sole proprietor or partnership. All fields must be completed. A $15.00 fee is required for each card. Personal History Background Form #4121: Lease or Tenancy Agreement: Financial Verification: Submit copy of signed and dated lease, tenacy agreement, or may submit DLC Form 4085 "Summary of Tenancy Rights" completed in full. This form (DLC4096) is to be completed in full, attaching supporting documentation if necessary. Copy of Food Service Operator OR Food Establishment License: Rental Agreement: Must be completed in full for each individual for whom a civilian identification card was submitted. Only if applying for Class A1A, D1, D2, D3, D5, D5A, D5C, D5D, D5F, D5I, D5J, D5K or D7 permit(s). If fixtures and equipment are rented. REQUIRED DOCUMENT TO BE FILED WITH NON PROFIT ENTITIES 4029 Form: To be filed with Governmental or Educational entities, or other non-profit businesses. Form must be completed in full. List the top five officer, including social security numbers. This form must be notarized. REQUIRED DOCUMENTS TO BE FILED WITH CORPORATIONS ONLY 4030 Form (Corporation): Form must be completed in full. List the top five officers, including social security numbers. Indicate all stock holders over 5% including social security numbers. Indicate total shares issued. Must be notarized. Certificate of Good Standing From the Secretary of State: If not incorporated in the State of Ohio, submit a copy of CERTIFICATE OF AUTHORITY TO DO BUSINESS IN OHIO, issued by the Ohio Secretary of State. If corporation is nonprofit, submit a Certificate of CONTINUED EXISTENCE from the Ohio Secretary of State. REQUIRED DOCUMENTS TO BE FILED WITH PARTNERSHIPS 4031 Form (Partnership) Form must be completed in full. Indicate all partners including social security numbers. Limited Partnerships need only indicate general partners. Must be notarized. Partnership Agreement (if general partnership) Certificate of Fictitious Name from the Secretary of State If name is different from and not including the names of all partners. Must be dated within one year of the filing of this application. REQUIRED DOCUMENTS TO BE FILED WITH LIMITED LIABILITY COMPANIES 4032 Form (LLC): Form must be completed in full, indicating all members with 5% or more membership or voting interest, all managing members, and officers, if applicable, including social security numbers. Must be notarized. Certificate of Organization from the Secretary of State Page 4 American LegalNet, Inc. www.FormsWorkflow.com ADDITIONAL DOCUMENTATION THAT MAY BE REQUESTED DURING THE PROCESSING OF YOUR "A-1-A" APPLICATION, EXCEPT CLASSES D-3A, D-6, and D-8 ADDITIONAL INFORMATION: 1. When filing as an individual, make certain you indicate the "individuals name" under Section B on page 1 of the application. The name of the actual business may then be listed under "DBA" (doing business as). 2. An individual or a majority of the partners in a partnership must have been a resident of the State of Ohio for at least one (1) year prior to filing an application. All individuals and partners must have U.S. Citizenship. (This does not apply to stockholders in a corporation, or members in an LLC). 3. ISSUANCE OF PERMITS IS SUBJECT TO THE WET OR DRY STATUS OF THE LOCATION, AND MAY BE SUBJECT TO THE EXISTENCE OF AN OPENING UNDER THE QUOTA. 4. Return the application, all fees, Civilian Identification Cards, and all required documents to: OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD, P.O. BOX 4005 REYNOLDSBURG, OHIO 43068-9005 WARNING: NO permit will be issued until the proposed business is ready for operation and meets Division regulations. ALL CONSTRUCTION OR REMODELING COSTS ARE AT THE APPLICANT'S RISK, AS THE DIVISION CANNOT GUARANTEE THE ISSUANCE OF A PERMIT. PAGE 5 American LegalNet, Inc. www.FormsWorkflow.com