ALL RETAILERS & PRIVATE CLUBS TRADE NAME: ALL RETAILERS & PRIVATE CLUBS 1. 2. 3. ON-PREMISE LICENSES/PERMITS YES NO YES NO YES NO 1. 2. 3. YES NO 4A. 4A. Do you share the premises with another business entity? B. If “YES,” indicate the trade name(s) of business(es) and sales and use tax number(s) for other business(es): ↓Trade Name 5. ↓Sales & Use Tax Number ↓Trade Name ↓Sales & Use Tax Number If operating under a lease, indicate: A. Expiration date(s)/Options: B. Monthly rental amount: $ C. Other fees and payments to landlord: 6A. Are you operating under any concession, service or management agreement(s) that contain terms for services or management beyond property rental? If “YES,” indicate the following and attach copy of agreement(s): 6A. YES NO 1. Expiration date(s)/Options: 2. Monthly fee: $ 3. Other fee(s) made to concession, service or management companies: $ 4. If management company differs from lessor or sublessor, enter name below and complete Form L-101-SL, giving name, address and officers of concession, service or management companies. 7. FOR APPLICANTS IN MUNICIPALITIES WITH A POPULATION OF 1,500,000 OR MORE FORM L-101-RET (12/2007) Is the proposed location in a hotel or motel? Does the applicant own or operate a hotel at the location for which this application is filed? Do you or anyone else at the location operate under a franchise agreement? If “YES,” attach a copy. 8. 9. 10. 11. Name: Are there any agreements, excluding 5 and 6 above, which require payment by the applicant in a dollar figure or percentage of gross or net income of the business? If “YES,” attach a copy. Does the proposed licensed premises have running water, if available? Does the proposed premises have separate, free, properly identified toilets for males and females? If “NO,” please answer the following: 7. YES NO 8. YES NO 9. YES NO A. Is location in a multitenant business complex that has free public restrooms for males and females available during your hours of operation? YES NO A. -ORB. Is location a restaurant that has 2,500 sq. ft. or less, less than 50% gross revenue from alcoholic beverages, an occupancy rating of 50 persons or less, and at least one properly B. YES NO marked restroom? YES NO 10. Does the proposed licensed premises have adequate seating for customers? Provide the sales data for the last year of operation or projected yearly sales at the proposed licensed premises: Alcoholic Beverage Sales: $ Other Sales: $ Food Sales: $ Total Sales: $ 12A. Is any property line of your premises within 300 feet of a residential address or established neighborhood association? 12A. B. If “YES,” and if Food and Beverage Certificate is not applied for, notify each residential address or established neighborhood association. Attach a list of all addresses notified with a copy of the completed notice. (Refer to Instruction Booklet for sample of notice and instructions.) YES NO FOR APPLICANTS IN MUNICIPALITIES WITH A POPULATION OF 1,500,000 OR MORE 13A. Will your business be located within 300 feet of residence, church, school, day care or social service facility when measuring in a straight line from the nearest point of the property line of the proposed location to the nearest point of the property line of any of these facilities? 13A. B. If “YES,” is 75% or more of the applicant’s actual or anticipated gross revenue from the sale of alcoholic beverages? B. C. If answers to 13A and 13B are “YES,” have you notified all tenants or property owners described in 13A within five days of filing the original application that an application has been filed? C. YES NO YES NO YES NO American LegalNet, Inc. www.FormsWorkflow.com