F-4 Permit Application Form. This is a Ohio form and can be use in Department Of Commerce Statewide.
Tags: F-4 Permit Application, DLC 4200, Ohio Statewide, Department Of Commerce
Ohio Department of Commerce - Division of Liquor Control 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 Telephone No. (614) 644-2360 - http://www.com.ohio.gov/liqr F-4 PERMIT APPLICATION An F-4 permit may be issued to an association or corporation organized not-for-profit in this state to conduct an event that includes the introduction, showcasing, or promotion of Ohio wines. An F-4 permit allows the association or corporation to furnish at no charge, 2 oz. samples and to sell by the glass, for on premises consumption, wine provided by the participating A2 permit holder. The participating A2 permit holder may sell wine that they have manufactured, in sealed containers for consumption off the premises, until 1 AM for a period not to exceed three days. APPLICATION MUST BE FILED 30 DAYS PRIOR TO EVENT THE FEE FOR AN F-4 PERMIT IS $60.00 PER DAY SECTION (A) PROPOSED F-4 PERMIT PREMISES INFORMATION Name of Association or Corporation Name of Event Event Street Address Township (Only if Unincorporated Area) Mail Permit and Correspondence to (Name): City State Zip Code Address: County Phone: Contact Person/ Attorney: Title: Date and Time Function Will Begin: Date and Time Function Will End: SECTION (B) Phone: APPLICANT/ORGANIZATION'S INFORMATION 1. List the Organization's non-profit Charter/Registration number from the Ohio Secretary of State's office____________________ 2. Please provide the following information on the TOP FOUR OFFICERS: Name Title Residence Address: Name Residence Address: Name Phone Title Title Residence Address: Name Phone Phone Title Residence Address: Phone FOR OFFICE USE ONLY Taxing District Reviewer Action: Remarks: Permit Number Receipt # DLC4200 Page 1 Rev. 7-07 American LegalNet, Inc. www.FormsWorkflow.com SECTION (C) ORGANIZATION INFORMATION 1. Is the event coordinated by your association or corporation? ______ YES ______ NO 2. Will your association or corporation be responsible for the activities at the event? ______ YES ______ NO 3. Is your intent to introduce, showcase, or promote Ohio wines to persons who attend the event? ______ YES ______ NO 4. Provide the name, address and permit number of all A2 permit holders participating in the event (use additional sheet if necessary) 1) ________________________ ___________________________________________ (NAME) 2) 3) (PERMIT #) ________________________ ___________________________________________ (NAME) ____________________ (ADDRESS) (PERMIT #) ________________________ ___________________________________________ (NAME) ____________________ (ADDRESS) ____________________ (ADDRESS) (PERMIT #) State of Ohio, ____________________________________________County, ss I/We ___________________________________________________, being first duly sworn, according to law, depose (Print Name and Title) and say that I/We are at least twenty-one (21) years of age and the statements and answers made in the foregoing application are true. __________________________________________ (Signature of Officer of Organization) ______________________________ (Title of Officer of Organization) Sworn to before me and subscribed in my presence this ________ day of ________________________________, 20_______. _________________________________________________________ Notary Public Expiration Date TO ENSURE THAT THIS APPLICATION IS PROCESSED AS QUICKLY AS POSSIBLE, PLEASE SUBMIT THE FOLLOWING, ALONG WITH THIS COMPLETED, SIGNED, AND NOTARIZED APPLICATION ♦ $60.00 Permit Fee per each day of the event ♦ Completed & signed Consent Form ♦ Completed and signed "Diagram of Permit Premises for F-4 Liquor Permit" form and any attachments. ♦ Explanation of any officer's conviction for any felony or misdemeanor, if applicable. ♦ Current Certificate of Good Standing from the Ohio Secretary of State's Office indicating the organization's Not-for-Profit status. EOE/ADA SERVICE PROVIDER Page 2 FOR TTY USERS DIAL ORS 1-800-750-0750 American LegalNet, Inc. www.FormsWorkflow.com SECTION (E) CONSENT TO / NOTIFICATION OF F-4 LIQUOR PERMIT CONSENT OF REAL PROPERTY OWNER This portion must be completed by the owner of the location where the event is to be held If applicant is owner of real property mark box , and sign form. I/We, being the owner of the realty located at ______________________________________________________________________________, (Location of Function or Street address where function will be held) hereby grant tenancy to __________________________________________________________________________________ to have an event (Full Name of Association or Corporation) where alcoholic beverages will be sold, on _______________________________________________________________ between the hours of (Date) ________________________________________________ a.m./p.m., and _______________________________________________ a.m./p.m., (Time) (Time) ____________________________________________________________________________________________________________________ (Signed - Real Property Owner) (Print Name and Address of Real Property Owner) ____________________________________________________________________________________________________________________ (Telephone Number) (Date) NOTIFICATION OF CHIEF PEACE OFFICER: This portion must be completed by the Chief Peace Officer in the municipality or the township where this function will be held indicating that he/she has been notified of the date, time, place and duration of the event. (If the township does not have a Chief Peace Officer the County Sheriff's Department must be notified accordingly.) I, __________________________________________________the Chief Peace Officer of _____________________________________________ (Name) (City, Township or County) do hereby acknowledge notification that __________________________________________________ will hold a special function at which (Full Name of Association or Corporation) alcoholic beverages will be sold on _______________________________________________________________between the hours of (Date) __________ a.m./p.m. an_________ at _____________________________________________________________________________________. (Time) (Time) (Street Address Where Function Will Be Held) ______________________________________________________________________________________________________________________ (Chief Peace Officer Signature) (Title) (Date) In signing this form, the Chief Peace Officer is merely acknowledging receipt of notification of the event and not giving their approval or consent of the event on behalf of the political subdivision. (PLEASE COMPLETE SKETCH ON REVERSE SIDE) Page 3 Rev. 9-03 American LegalNet, Inc. www.FormsWorkflow.com SECTION (D) DIAGRAM OF PROPOSED PERMIT PREMISES FOR "F-4" LIQUOR PERMIT THIS DOCUMENT MUST BE COMPLETED IN ORDER TO OBTAIN YOUR TEMPORARY PERMIT Every applicant for an F-4 liquor permit must submit with the application a diagram of the premises where alcoholic beverages will be consumed. If the diagram is not included, the application will be returned to the applicant. The diagram can be submitted in the space provided below or on a separate sheet, and signed by the person who prepared the diagram or the applicant. The diagram must identify the room(s) in which alcoholic beverages will be consumed. DIAGRAM MUSTAPPEAR IN THE SPACE BELOW, OR INDICATEATTACHED SHEET _________________________________________________________ Signature of person who prepared diagram _________________________________________________________ Print Name Title Phone # Page 4 American LegalNet, Inc. www.FormsWorkflow.com