Application For New D-5B Permit Form. This is a Ohio form and can be use in Department Of Commerce Statewide.
Tags: Application For New D-5B Permit, DLC 4137, Ohio Statewide, Department Of Commerce
For Questions call (614) 644-3155 Office Hours 8:00 - 5:00 OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD, P.O. BOX 4005 REYNOLDSBURG, OHIO 43068-9005 http://www.com.ohio.gov/liqr APPLICATION FOR NEW D-5B PERMIT - Fee $2,344.00 CAUTION: ALLOW 10 TO 12 WEEKS FOR PROCESSING THE FOLLOWING ITEMS MUST BE SUBMITTED FOR YOUR APPLICATION TO BE ACCEPTED FOR PROCESSING A. B. C. D. E. F. G. 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. If filing for a D-6, you are not required to submit any documentation listed on page 4, complete A & C only on pages 1 & 2. 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. If you would like a Class D6 with your D-5B, please check the box: D-6 - with D class $500.00 (WHEN APPLYING FOR D-6 CLASS ALONE, YOU ARE ONLY REQUIRED TO COMPLETE SECTIONS A, B, & D). SECTION A NAME OF ENCLOSED SHOPPING CENTER OR MALL: City: Address: Zip Code: State: 1. Is enclosed shopping center or mall under construction? YES NO If YES, give estimated date of completion on the line provided, SECTION B Applicant (Individual, Corporation, Limited Liability Company or Partnership) Permit Premises Address: DBA (doing business as): Township (if outside city limits): City: County: Zip Code: Residence Phone #: Business Phone #: Address: Phone # Attorney's Name: City, State, & Zip: Pending or Issued State Liquor Agency Number, (if applicable): Coder: CLASS FOR DIVISION USE ONLY REMARKS: RCPT# Proc. Fee Pd: Taxing District: YES REVIEWER ACTION: NO BCI Fee Amount Paid: $ __________ Permit Number Trans. Code DLC 4137 Bus. Type EOE/ADA SERVICE PROVIDER PAGE 1 FOR TTY USERS DIAL ORS 1-800-750-0750 REV. 10/2010 American LegalNet, Inc. www.FormsWorkFlow.com SECTION C 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 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, or pled guilty, accepted a plea bargain or reduced charge in any criminal proceeding, including any alcohol-related offenses, or criminal traffic offense? 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 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 YES NO 7. If filing as an individual or partnership, is individual or all partners a U.S. citizen? YES NO 8. Do you or any partner, office holder, managing member, 5% stockholder or member, employee, spouse, or other person involved in this permit own any stock or have any interest in the business of a manufacturer or wholesale distributor of alcoholic beverages? If YES, attach a written explanation. YES NO 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. 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 failure to answer this question completely and correctly. SECTION D - SHOULD BE ANSWERED ONLY IF APPLYING FOR A D-6 9. What percentage of your total gross receipts is currently, or do you estimate will be, attributed to the sale of food and other goods (excluding alcoholic beverages)? 10. If you hold "D" class permit(s) and your D-6 request can be approved for carryout only, do you still desire this permit? YES NO 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: State of Ohio, County, ss I, being first duly sworn, according to law, depose and say that the statements (Please Print) and answers made in the foregoing application are true. ___________________________________________________________________________ _____________________ (Title) (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) (Residence Address) (City) (State) (Zip Code) _______________ (Date) (Area Code & Telephone Number) (To be completed by Notary Public) 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 (“Division”) 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. The Division logs your application into a computerized system for processing. 2. The Division will send an Official Notice to the legislative authority of the municipality, city council, or township trustees and county commissioners of your application. Note: Any of these entities has the right to object to your application, provided that they do so within 30 days of that notification. The Division also sends a separate notice to the local law enforcement agency however they do not have a right to formally object to the issuance of your permit. 3. The Division works with the Ohio Bureau of Identification and Investigation (“BCI&I”) to have conducted a required background check on all persons involved in your business. In order for the Division and BCI&I to conduct this background check, you are required to provide the Division with the proper documentation/information so that a background check can be performed. Please see the enclosed Form DLC 4191 to determine whether you or persons involved in your business should submit a completed paper fingerprint card or be fingerprinted electronically via a “Web Check” system. 4. The Division will send the Personal History Background Form(s) you provided to the law enforcement agency in the municipality or township of your permit premises in order to have a background check conducted with them. 5. A Division Compliance Officer will contact you to set up an appointment to conduct an initial physical inspection of your premises. At the time your inspection is completed our compliance officer will survey the area surrounding the proposed permit premises to determine if there are any institutions such as schools, churches, libraries, public playgrounds, or township parks within 500 feet. By law, any of these institutions 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 at the initial inspection, 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. The Division will work with your County Board of Elections to determine the wet/dry status of your proposed permit premises. Note: This information is not needed on applications for transfer of ownership. 7. Where required, the Food Service Operation or Food Establishment License must be in the exact name as the liquor permit applicant. 8. Your permit certificate is issued for a permit period that expires on either February 1, June 1 or October 1, depending on the county where your permit is located, and is renewed annually on that date. If your permit is issued within six months of the expiration date, you will receive a 50% refund of the class fees paid, not including the $100.00 application fee. Renewal dates by county may be found by visiting our web site at http://www.com.ohio.gov/liqr/docs/LIQR_RenewalDistricts.pdf. It is our goal to process your application in a timely and efficient manner. Many factors determine the length of time it takes 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 D5B 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. $100.00 - Check made payable to Division of Liquor Control. Application Processing Fee: Background Check: PLEASE READ "BACKGROUND CHECK INFORMATION" DLC 4191 Personal History Background Form: Section A. ONLY must be completed in full for each stockholder or officer for whom a background check will be performed by the Ohio Bureau of Identification and Investigation (BCI&I). (DLC 4121) Submit copy of signed and dated lease, tenancy agreement, or may submit DLC Form 4085 "Summary of Tenancy Rights" completed in full. Lease or Tenancy Agreement: Financial Verification: This form (DLC 4096) is to be completed in full, attaching supporting documentation if necessary. Copy of Food Service Operator OR Food Establishment License: Rental Agreement: Only if applying for Class A1A, D1, D2, D3, D5, D5A, D5C, D5D, D5F, D5I, D5J, D5K, D5L, D5M or D7 permit(s). If fixtures and equipment are rented. REQUIRED DOCUMENT TO BE FILED WITH NON PROFIT ENTITIES 4029: To be filed with Governmental or Educational entities, or other non-profit businesses. Form must be completed in full. List the top five officers, 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 stockholders 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. Ohio Secretary of State: (614) 466-3910 or 1-877-767-3453 - www.sos.state.oh.us REQUIRED DOCUMENTS TO BE FILED WITH PARTNERSHIPS 4031 Form (Partnership): Partnership Agreement (If General Partnership): Form must be completed in full. Indicate all partners or corporations within a partnership including social security number or tax identification number. Limited Partnerships need only indicate general partners. Must be notarized. 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. Certificate of Fictitious Name from the Secretary of State: Ohio Secretary of State: (614) 466-3910 or 1-877-767-3453 www.sos.state.oh.us 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 Ohio Secretary of State: (614) 466-3910 or 1-877-767-3453 www.sos.state.oh.us American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL DOCUMENTATION THAT MAY BE REQUESTED DURING THE PROCESSING OF YOUR D5B 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, 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