UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 South 900 West • PO Box 30408 • Salt Lake City UT 84130-0408 • (801) 977-6800 • Fax 977-6888 website: www.abc.utah.gov PACKAGE AGENCY CONTRACT APPLICATION CHECKLIST Dear Applicant: The items below should be completed and submitted by the 10th of the month or earlier, so that your application can be processed in a timely manner. All licensing requirements must be fully satisfied in order to complete your application. You will then be notified of the next monthly Utah Alcoholic Beverage Control Commission meeting when your application will be considered for issuance of a license. We recommend that a representative attend the meeting. 1. Completed application form (enclosed). 2. Ownership entity organizational papers for business: a) if a corporation, submit a copy of the articles of incorporation; b) if a partnership, submit a copy of the written agreement; c) if a limited liability company, submit a copy of the articles of organization. 3. Criminal history background check information (see application form). 4. Copy of local business license. 5. Local consent from either city/town council or county commission, whichever is applicable. (Form enclosed) 6. Package agency bond requirement for types 2 & 3, consignment only inventory, please complete bond application (form provided separately). For types 1,4,5 non-consignment inventory, please submit $1,000 cash or corporate surety bond (form enclosed). 7. Certificate of public liability insurance. 8. Scaled floor plan (8-1/2" x 11") of package agency, highlighting areas for delivery, storage and sale of liquor. 9. $100 application fee (non-refundable). Make check payable to UDABC. 10. Evidence of proximity to schools, churches, libraries, playgrounds, and/or parks (600'). See #19 on application. Enclosed for your information are copies of statutes and rules pertaining to package agencies, as well as a list of factors considered in the evaluation of contract applications. If you have questions, contact the licensing and compliance section at (801) 977-6800. 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR PACKAGE AGENCY CONTRACT 1. Please indicate the type(s) package agency you are applying for: [ ] *Type 1 Located in a Hotel, ski lodge, summer recreational area, or other resort environment to serve the general public and guests. [ ] *Type 2 In conjunction with another business where the primary source of income to the operator is not from the sale of liquor (e.g. small grocery stores in rural communities). [ ] *Type 3 Not in conjunction with another business, but is for the sole purpose of selling liquor. [ ] *Type 4 Located in a facility for the purpose of selling and delivering liquor to tenants or occupants of specific rooms which have been leased, rented, or licensed within the same facility, and is not open to the general public (e.g. hotel room service or private suites at sports arenas. [ ] *Type 5 Located within a winery, brewery, or distillery licensed by the commission. 2. Name of Business: _________________________________________________________________ 3. Applicant/Owner of business: ________________________________________________________ 4. Agency location: __________________________________________________________________ Street City State Zip 5. Mailing Address: __________________________________________________________________ Street City State Zip 6. Agency Phone:_________________________ Other Phone: _______________________________ 7. Name/Title of package agent: _______________________________________________________ 8. Owner of real property & building. ___________________________________________________ 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com 9. Ownership: Check appropriate box and provide the requested information in the space below. (add additional sheets if necessary) [] Applicant is an individual: List below information for: (a) Individual (b) All Managers [] Applicant is a partnership: List below information for: (a) All Partners (b) All Managers [] Applicant is a corporation: List below information for: (a) Any Stockholder owning at least 20% of the corporation (b) All Corporate officers and Directors (c) All Managers [] Applicant is a limited liability company (LLC): List below information for: (a) Any members owning at least 20% of the company (b) All Managers TITLE____________NAME___________________HOME ADDRESS_______________________________________ HOME PHONE#______________DR LIC#_______________SS#______________DOB__________%OWNED______ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME___________________HOME ADDRESS_______________________________________ HOME PHONE#_______________DR LIC#_______________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME___________________HOME ADDRESS_______________________________________ HOME PHONE#_______________DR LIC#_______________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. 10. Criminal History. The law prohibits persons who have been convicted of certain crimes from being in the alcoholic beverage business. This applies to any applicant, proprietor, partner, managing agent, director, of officer of the business. This also applies to any stockholder owning at least 20% of the corporation stock, or if a limited liability company, any member owning at least 20% of the company. Please list all criminal offenses other than minor traffic offenses of which you or any of these persons (including persons listed in paragraph 9) have ever been convicted. NAME CRIMINAL OFFENSE DATE OF CONVICTION In addition, a criminal history background check must be furnished on each person listed above and in paragraph 9. This may be done as follows: 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com a. Utah residents: If any person listed has been a resident of Utah for at least two years, he/she shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Utah Bureau of Criminal Identification. b. Non Residents: Out of state residents or persons who have resided in Utah for less than two years shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Federal Bureau of Investigation (F.B.I). An informed consent and release of liability form is included with this application. Fingerprint cards are available at law enforcement agencies. You may download the fingerprint card at this web address: http://www.fbi.gov/hq/cjisd/pdf/fpcardb.pdf Submit the form(s) to the DABC with a processing fee of: • $15.00 per card for BCI background checks, or • $34.25 per card for FBI background checks. In the case of an undue delay in the processing of an F.B.I. criminal background check, here are the rules and procedures for obtaining a third-party national background check: An application that requires F.B.I. criminal history background report(s) may be included on a commission meeting agenda, and may be considered by the commission for issuance of a license, permit, or package agency if: 1). the applicant has completed all requirements to apply for the license, permit, or package agency other than the department receiving the F.B.I. criminal history background report(s); 2). the applicant attests in writing that he or she is not aware of any criminal conviction of any person identified in the application that would disqualify the applicant from applying for and holding the license, permit, or package agency; 3). the applicant has submitted to the DABC the necessary fingerprint card(s) required for the application and consented to the fingerprint criminal background check(s) by the F.B.I. 4). the applicant at the time of application supplies the department with a current criminal history background report conducted by a third-party background check reporting service on any person for which an F.B.I. background check is required; and 5). the applicant stipulates in writing that if an F.B.I. report shows a criminal conviction that would disqualify the applicant from holding the license, permit, or package agency, the applicant shall immediately surrender the license, permit, or package agency to the department. A suggested attestation/stipulation letter that satisfies the above requirements is enclosed. A third-party national criminal background check can be obtained by; • searching the yellow pages under Background Screening • searching the internet under Background Screening or Background Checks Because the DABC is State Agency, we cannot recommend any one background screening service over another. It is your responsibility however, to obtain the most complete, nationwide, criminal history available for the application process. 11. Have you as an applicant, or any proprietor, partner, managing agent, director, officer or stockholder owning at least 20% corporation stock, or if a limited liability company, any member owning at least 20% of the company had a state alcoholic beverage license, permit or agency revoked within the last three years? ____________ If so, please explain. _______________________________ __________________________________________________________________________________ 12. Type of business agency to be associated with: ______________________________________ 13. List other alcoholic beverage licenses held by applicant/principals: _______________________ ____________________________________________________________________________ 14. 6.04.08 Date applicant opened for business (or projection): ______________________ American LegalNet, Inc. www.FormsWorkflow.com 15. Proposed days and hours of agency operation: ______________________________________ 16. Square footage of retail space, including storage: ____________ 17. Number of parking stalls: _________ 18. Number of guest rooms, if hotel:______ Occupancy rate: ____________ 19. List any private or public schools, churches, public libraries, public playgrounds or parks located within 600' of the package agency premises: Property Address Measured Distance ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 20. Applicant agrees to immediately notify the department of any change in ownership, and if a corporation, any change in the officers/directors, and understands that failure to do so may result in immediate suspension of the package agency contract. 21. By signing below, the applicant attests that: a) the applicant is in compliance with all federal and state laws pertaining to the payment of taxes and contributions to unemployment and insurance funds. The following are tax identification numbers of the business. i. State Sales Tax #: ______________________ ii. State Payroll Withholding Tax #: ______________________ iii. State Dept. of Workforce Services #: ______________________ iv. Federal Taxpayer Identification #: ______________________ b) the proprietor/applicant is at least 21 years of age. c) consent is granted to representatives of the Alcoholic Beverage Control Department, Commission, State Bureau of Investigation (Bureau of Alcoholic Beverage Law Enforcement), and other law enforcement agencies to be admitted immediately and permitted without hindrance or delay to inspect the entire premises and all records of the package agency. d) he/she has read and will abide by the provisions of Title 32A, Utah Code, and all rules of the commission and directives of the Department of Alcoholic Beverage Control; and understands that failure to adhere thereto or to no longer possess the qualifications for the granting of a package agency contract may result in suspension or revocation of the package agency contract and forfeiture of compliance bond. e) the applicant does not and will not discriminate against persons on the basis of race, color, sex, religion, ancestry, or national origin. 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com 22. Applicant agrees as a condition of licensing that he/she has read and will abide by the provisions of the Alcoholic Beverage Control Act (Title 32A, Utah Code) and all Rules of the Commission and directives of the Department and understands that failure to adhere to them shall constitute grounds for suspension or revocation of the package agency contract and forfeiture of compliance bond. 23. The undersigned acknowledges that he/she has read & understands the statements made herein, that execution thereof is done voluntarily and by authorization of said organization; and certifies that the information provided in this application and attached hereto is true and correct. Date: ___________________________ __________________________________ Applicant/Owner of Business STATE OF ________________________ COUNTY OF_______________________ Subscribed & sworn to before me ___________________________________ Authorized Signature this _______ day of _________________, ________. ___________________________________ Name/Title _______________________________ Notary Public SEAL: 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 S 900 W • PO Box 30408 • Salt Lake City, UT 84130-0408 • Phone (801) 977-6800 • Fax (801) 977-6889 “PACKAGE AGENCY CONTRACT ” LOCAL CONSENT Date: __________________________ Attn: DABC Licensing & Compliance Section ____________________________________ (City)(Town)(County) hereby grants its consent to the establishment of a package liquor agency for ______________________________________ operated by _______________________________________________________________ and located at _______________________________________________ pursuant to the provisions of Section 32A-3, Utah Code, for the purpose of storage and sale of liquor, wine and heavy beer in unopened containers for off-premise consumption. Furthermore, said organization has met all ordinances relating to issuance of local business license(s). [ ] Check if applicable LOCAL CONSENT FOR PROXIMITY VARIANCE _____________________________________ Authorized Signature In accordance with Utah Code 32A-3-101(3), the local authority also grants consent to a variance regarding the proximity of this establishment relative to a public or private school, church, public library, public playground, or park. _____________________________________ Print Name / Title 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL PACKAGE AGENCY LIQUOR BOND BOND #_______________________ KNOW ALL PERSONS BY THESE PRESENTS: That principal, _________________________________________, a liquor package agency, doing business as ____________________________________________________________, and surety, ________________________________________, a corporation organized and existing under the laws of the state of _____________ and authorized to do business in Utah, are held and bound unto the Department of Alcoholic Beverage Control in the sum of $1,000, for which payment will be made, we hereby bind ourselves and our representatives, assigns, and successors firmly by these presents. Dated this _______ day of _______________________, ______. THE CONDITION OF THIS OBLIGATION IS SUCH THAT: WHEREAS, the above principal has made application to the Utah Alcoholic Beverage Control Commission for a liquor package agency pursuant to the provisions of 32A-3, Utah Code. NOW, THEREFORE, if said principal, its officers, agents and employees shall faithfully comply with the provisions of Title 32A, Utah Code, and the rules and directives of the Department of Alcoholic Beverage Control, then this bond shall be void; but, if said principal, its officers, agents and employees fail to comply with the provisions of the laws, rules, and directives or orders as the department or commission may issue, then this bond shall be in full force and effect and payable to the Department of Alcoholic Beverage Control. This bond shall run for a continuing term effective _________________________ unless canceled by service of written notice upon the Department of Alcoholic Beverage Control, which cancellation shall be effective 30 days after receipt of such notice; provided however, that no part of this bond shall be withdrawn or canceled while violations, legal actions or proceedings are pending against said agency/principal. ______________________________ Surety ________________________________ Principal ______________________________ Attorney in fact ________________________________ Authorized Signature ______________________________ Name/Title 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com STATUTORY AFFIDAVIT FOR CORPORATE SURETY STATE OF____________________________________ COUNTY OF___________________________________ On the _________ day of ______________, _______, personally appeared before me, _________________________, who being by me duly sworn, did say that he/she is the attorney in fact of _________________________, surety, and that said instrument was signed in behalf of said surety by authority, and acknowledged to me that he/she as such attorney in fact executed the same. ________________________________________ Notary Public Note: Corporate surety's own affidavit also acceptable. 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com PACKAGE AGENCY APPLICATION EVALUATION FACTORS The Department of Alcoholic Beverage Control and Alcoholic Beverage Control Commission will utilize the following factors for package agency contract application evaluation: 1. Density of liquor availability in area. 2. Days and hours of operation. 3. Nature of business agency associated with. 4. Size of retail sales and storage space. 5. Parking and public and delivery access. 6. Length of time in operation. 7. Management experience: a. Liquor b. Financial 8. Population and traffic area. 9. Tourist traffic. 10. Compliance relative to the alcoholic beverage laws and rules. 11. Public input. 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com INFORMED CONSENT AND RELEASE OF LIABILITY PURPOSE: To determine, in accordance with Utah Code 32A-1-702 and 32A-1-703, if an applicant with the Department of Alcoholic Beverage Control has been: convicted of a felony under federal or state law; convicted of a violation of a federal law, state law, or local ordinance concerning the sale, manufacture, distribution, warehousing, or transportation of an alcoholic beverage; convicted of a crime involving moral turpitude; convicted on two or more occasions within the previous five years, driving under the influence of alcohol, a drug, or the combined influence of alcohol and a drug. RELEASE I hereby authorize the Department of Alcoholic Beverage Control (DABC) to investigate my criminal history records to ascertain any and all information which may be pertinent to my qualifications as an applicant with the DABC. The release of any and all information is authorized whether it is of record or not, and I do hereby release all persons, firms, agencies, companies, groups or installations, whomsoever, from any damages of or resulting from, furnishing such information to the DABC. I further agree that a copy of this release will remain in my application file. ______________________________________________________________________ Name (please print; last, first, middle initial) _______________________________ Formerly used last names (please print) _________________________________ Applicant/ doing business as _______________________________ Signature _________________________________ Date 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com (suggested attestation/stipulation letter to the DABC for a third-party national criminal background check) Date: ________________________ To whom it may concern: I, _____________________________, attest: 1. That I have submitted to the DABC the necessary fingerprint card(s) required for the application and consented to the fingerprint criminal background check(s) by the F.B.I. 2. That I am not aware of any criminal conviction that would disqualify me from applying for and holding a Utah Department of Alcoholic Beverage Control license or permit. I stipulate that if an F.B.I. report shows a criminal conviction that would disqualify me from holding the license, permit, or package agency, I shall immediately surrender the license, permit, or package agency to the department. I am enclosing a national criminal history background report from a third party background check reporting service. _____________________________________ Signature _____________________________________ Name/Title 6.04.08 American LegalNet, Inc. www.FormsWorkflow.com