UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 South 900 West • PO Box 30408 • Salt Lake City, UT 84130-0408 • (801) 977-6800 • Fax (801) 977-6889 www.abc.utah.gov “PRIVATE CLUB LIQUOR LICENSE” APPLICATION CHECKLIST The items below must be completed and submitted by the 10th of the month or earlier, so that your application can be processed in a timely manner. Because there are a limited number of private club licenses available, you will be notified of the next monthly Utah Alcoholic Beverage Control Commission meeting when your application will be considered. We request that a representative attend the meeting to make a brief presentation. 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.____Copy of club’s bylaws and/or house rules. 4.____Criminal history background check information (see application form). 5.____Evidence of proximity to schools, churches, libraries, playgrounds and/or parks. See #19 on application. 6.____Written consent from either city/town council or county commission, whichever is applicable. (form enclosed) 7.____Copy of current local business license. 8.____$10,000 cash or corporate surety bond. (form enclosed) 9.____Certificate of insurance for public liability and liquor liability “dram shop” coverage (minimum coverage is $500,000 per occurrence/$1,000,000 in the aggregate). 10.____Scaled floor plan (8-1/2" x 11") highlighting area(s) for sale, storage and consumption of alcohol. 11.____$250 application fee (non-refundable). 12.____$2,500 initial license fee (make checks payable to UDABC). 13.____Club Classification (check only one): A. [ ] Country Club C. [ ] Dining Club (at least 50% gross sales in food) B. [ ] Fraternal Club D. [ ] Social Club 14.____Evidence that the private club meets the requirements for the above classification. 15.____Profit & loss statement for previous year (or projected profit and loss statement). 16.____Copy of any food menu and posted price list for alcoholic beverages. Enclosed are copies of Utah law and commission rules pertaining to private clubs, and a list of factors considered in the evaluation of license applications. If you have questions concerning these forms or the application process, please contact our Licensing and Compliance Division at (801)-977-6800. American LegalNet, Inc. 5.23.08 www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR PRIVATE CLUB LIQUOR LICENSE 1. Entity applying for licensing: 2. Club name (if different): 3. Location: __________________________________________________________________________ 4. Mailing address: ____________________________________________________________________ Street City Street P.O. Box State City Zip State Zip 5. Business phone: _________________ Other phone: ______________ Fax: _____________________ 6. Manager: _______________ DOB ______________ SS# ______________ DL# ________________ 7. Contact person: _____________________ 8. Owner of real property and building: ____________________________________________________ 9. List other alcoholic beverage licenses previously and/or currently held by applicant/principals: 10. Date club opened for business: ________________(or projection): ___________________________ 11. Days and hours of operation: _________________________________________________________ 12. Total seating capacity: _____________ Number of parking stalls: ___________________________ 13. Square footage of facility: ___________________________________________________________ 14. Anticipated membership: ____________________________________________________________ 15a. Projected monthly revenue: Food Sales $ _______________ Alcohol Sales $ _________________ 15b. Projected yearly (12 month) cost of liquor, wine, and heavy beer: $ __________________________ 16. Do you plan to issue visitor cards? Yes________ No_________ 17. Describe type of entertainment, if any: ________________________________________________ E-mail _______________________________________ Will the club have sexually oriented adult entertainment (operate as a sexually oriented business)? ______ Will the club operate a dance or concert hall that admits minors (either on the premises of the club, or an adjoining premises operated by the club)? ______ 18. 5.23.08 List name of previous business at location: _______________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 19. 20. List any private or public schools, churches, public libraries, public playgrounds or parks located within 600' of your premises. See Utah Code Sections 32A-5-101(7)&(8) as to how proximity is determined and measured and for an explanation on variances. Property Address Measured Distance ____________________________________________________________________________________ ____________________________________________________________________________________ Ownership: Check appropriate box and provide the requested information in the spaces 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: [] Applicant is a limited liability company (LLC): (a) Any Stockholders owning at least 20% of the corporation (b) All Corporate Officers and Directors (c) All Managers 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 #___________DOB___________SS#____________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE__________NAME___________________________HOME ADDRESS__________________________________ HOME PHONE #___________________DR LIC #___________DOB___________SS#____________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE__________NAME___________________________HOME ADDRESS__________________________________ HOME PHONE #___________________DR LIC #___________DOB___________SS#____________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE__________NAME___________________________HOME ADDRESS__________________________________ HOME PHONE #___________________DR LIC #___________DOB___________SS#____________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. 21. 5.23.08 Criminal History. The Commission may not grant a private club license to any person who has been convicted of a felony under any federal or state law or any violation of any federal or state law or local ordinance concerning the sale, manufacture, distribution, warehousing, adulteration, or transportation of alcoholic beverages. The Commission may not grant a private club license to any person who has been convicted of any crime involving moral turpitude or, on two or more occasions within the last five years, has been convicted of driving under the influence of alcohol, any drug, or the combination of alcohol and any drug. American LegalNet, Inc. www.FormsWorkflow.com This proscription also applies to any officers, partners, managers, managing agents, directors, stockholders who hold at least 20% of the total issued and outstanding stock of an applicant corporation, members who own at least 20% of an applicant limited liability company and to any person employed to act in a supervisory or managerial capacity. Please list all criminal offenses other than minor traffic offenses of which you or any of the above persons have ever been convicted: NAME CRIMINAL OFFENSE DATE OF CONVICTION_________ _____________________________________________________________________________ A criminal history background check must be furnished on each person listed in #6 and #20 above. This may be done as follows: 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. 5.23.08 American LegalNet, Inc. www.FormsWorkflow.com 22. Have you as an applicant, or any proprietor, partner, managing agent, director, officer, 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: _________________________________________________________________________________________________ 23. Applicant agrees to immediately notify the department of any change in the ownership entity, and understands that failure to do so may result in immediate suspension of the license. 24. By signing below, the applicant attests that: a) it operates a club where a variety of food is prepared and complete meals are served on the premises, and at all times when alcohol is sold, served and consumed. b) the club has a governing body consisting of three or more members of the club that holds regular meetings to review membership applications and conduct any other business required by the club’s bylaws or house rules. The current members of the governing body are: _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ c) no member of the club or any of its officers, directors, or trustees is under 21 years of age. d) the club will not be used for permitting gambling or any other violation of law or ordinance. e) 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 licensee. f) authorization is granted to the department to access to federal, state and local sales, payroll, income, and real and personal property tax information. g) 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 of a licensee may result in suspension or revocation of the liquor license and forfeiture of compliance bond. h) the applicant does not and will not discriminate against persons on the basis of race, color, sex, religion, ancestry, or national origin. i) 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 #: 5.23.08 _____________________ _____________________ American LegalNet, Inc. www.FormsWorkflow.com 25. The undersigned acknowledges that he/she has read and understands the statements made herein and that execution thereof is done voluntarily and by authorization of the club; and that any false statement made on this application or any other related document is a second degree felony. 26. The undersigned hereby makes application to the Utah Alcoholic Beverage Control Commission for a private club license and certifies that the information contained herein and attached hereto is true and correct. Date_____________________ STATE OF: ________________ COUNTY OF: ___________________ ______________________________ Applicant/Owner of Business Subscribed & sworn to before me this _______ day of _________________________, ___________ ______________________________ Authorized Signature __________________________________________________ Notary Public _____________________________ Print Name/Title 5.23.08 SEAL: American LegalNet, Inc. www.FormsWorkflow.com “PRIVATE CLUB LIQUOR LICENSE” LOCAL CONSENT Date: __________________________ Attn: DABC Licensing & Compliance Section __________________________________________________, [ ] City [ ] Town [ ] County hereby grants its consent to the issuance of a private club liquor license to: Business Name: ________________________________________________________________ Applicant / Business Owner: ______________________________________________________ Location Address: ______________________________________________________________ Pursuant to the provisions of Utah Code 32A-5, this license allows for the storage, sale and consumption of liquor on the premises. Furthermore, the applicant has met all ordinances and requirements relating to issuance of local business license(s). [ ] Check if applicable LOCAL CONSENT FOR PROXIMITY VARIANCE In accordance with Utah Code 32A-5-101(7),(8)&(9), 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. 5.23.08 _____________________________________ Authorized Signature _____________________________________ Print Name / Title American LegalNet, Inc. www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL PRIVATE CLUB LIQUOR LICENSE APPLICATION EVALUATION FACTORS The Alcoholic Beverage Control Department and Commission utilize factors for evaluating a private club liquor license application, including, but not limited to: 1. Location factors such as: - proximity to and density of other liquor outlets in the area, - traffic flow, - demographics, - population to be served, - proximity to any educational, religious and recreational facility such as public schools, nursery schools, infant day care centers, trade and technical schools, churches, public libraries, public playgrounds, and parks. 2. Physical characteristics such as: - condition of the premises, - square footage, - seating capacity, - parking availability. 3. Management experience: - familiarity with food and alcoholic beverage operations, - familiarity with financial record keeping, - management scheme employed by the club, - length of time in operation, - past compliance with alcoholic beverage laws and rules. 4. Nature or type of private club operation: - type of menu items offered and emphasized, - whether emphasis is on an adult clientele rather than minors, - days and hours of operation, - gross sales of food items, - responsibleness of the club's articles, bylaws, house rules, and conformity with the Act. 5. Public input. 6. If a Class C (dining club): - percentage of food sales - portion of square footage and seating capacity used for the dining area vs. bar area. - whether full meals are served including appetizers, main dishes and desserts. - Adequacy of on-premise culinary facilities. - Type of entertainment (if any). Note: Keep this sheet and refer to it for presentation before the DABC Commission. 5.23.08 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) _______________________________ Signature 5.23.08 _________________________________ Applicant/ doing business as _________________________________ Date 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 5.23.08 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 “PRIVATE CLUB BOND” BOND # _______________________ KNOW ALL PERSONS BY THESE PRESENTS: That Principal, _________________________________________, a private club liquor licensee, 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 Utah Department of Alcoholic Beverage Control in the sum of $10,000, 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 private club liquor license pursuant to the provisions of 32A-5, 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 Utah Alcoholic Beverage Control Commission and the Utah 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 commission or department may issue, then this bond shall be in full force and effect and payable to the Utah Department of Alcoholic Beverage Control. This bond shall run for a continuing term effective ________________________ unless canceled by service of written notice upon the Utah 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 licensee / principal. ___________________________________ Surety ___________________________________ Principal / Licensee ___________________________________ Attorney in fact ___________________________________ Authorized signature { Corporate Seal } 5.23.08 __________________________________ Name / Title 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 Signature & Seal Note: Corporate surety's own affidavit also acceptable 5.23.08 American LegalNet, Inc. www.FormsWorkflow.com