Utah Department of Alcoholic Beverage Control 1625 South 900 West P.O. Box 30408 Salt Lake City, UT 84130 RESTAURANT ON-PREMISE RETAIL APPLICATION CHECKLIST Website: www.abc.utah.gov Phone 801-977-6800 Fax 801-977-6889 Restaurant (Beer Only) The items below must be completed and submitted no later than the 10th of the month. Incomplete applications may be returned for additional information in order to process the application. Applicants with completed applications will be notified of the next monthly Utah Alcoholic Beverage Control Commission meeting when the application will be considered. All licenses issued under a statewide population quota require a brief presentation to the Commission. 1. ____ Completed Application Form 2. ____ $825 Initial licensing fee $330 non-refundable application fee 3. ____ Ownership entity / organizational documents filed with Utah Department of Commerce Individual / Sole Proprietor Partnership – written partnership agreement Corporation – articles of incorporation Limited Liability Company – articles of organization 4. ____ Criminal history background documents Fingerprint card [FBI Form FD 258 or similar] Informed Consent and Release of Liability Third-party Attestation/Stipulation Third-party background check Fees 5. ____ Local consent to the issuance of the license from city, town or county where the restaurant is located 6. ____ Current local business license 7. ____ $5,000 Cash or corporate surety bond (template attached) Licensed entity listed as the Principal Restaurant name listed as ‘doing business as’ 8. ____ Certificate of insurance for public liability and dramshop (liquor liability) coverage (template attached) (minimum dramshop coverage of $1,000,000 per occurrence/$2,000,000 in the aggregate). 9. ____ Projected profit and loss statement [Pro forma income statement] (template attached) 10.____ Food Menu 11.____ Alcoholic product List or menu identifying individual brand or price level Business / Property Information 12. ____ Lease agreement 13. ____ Floor plan of retail license premise including areas of consumption, storage, sale or furnishing an alcoholic product 14. ____ Business tax, withholding, workforce services identification documentation Utah Sales Tax & Payroll withholding Utah Workforce Services Federal Taxpayer Identification 15. ____ TC-721 Utah State Tax Commission – Exemption Certificate 16. ____ Evidence of proximity to schools, churches, libraries, playgrounds and/or parks Copies of Utah laws and commission rules pertaining to restaurants, and a list of factors considered in the evaluation of license applications are available at www.abc.utah.gov. If you have any questions concerning these forms or the application process, please contact our DABC Licensing and Compliance Division at (801) 977-6800. DABC (RB) Checklist (07/2012) Authority: UCA 32B American LegalNet, Inc. www.FormsWorkFlow.com Utah Department of Alcoholic Beverage Control 1625 South 900 West P.O. Box 30408 Salt Lake City, UT 84130 RESTAURANT ON-PREMISE RETAIL LICENSE APPLICATION Restaurant (full) Licensing and Compliance Division Application Number ___________ Restaurant (limited) Initial license fee $2,200 Application fee (non-refundable) $330 Restaurant (Beer Only) Initial license fee $825 Application fee (non-refundable) $330 Initial license fee $825 Application fee (non-refundable) $330 Ownership Information 1. Ownership Entity: __________________________________________________________________________________ Entity Type: Individual Partnership Corporation Limited Liability Company 2. DBA:(assumed name of business) _________________________________________________________________________ 3. Business address: _________________________________________________________________________________________________ STREET CITY STATE ZIP 4. Mailing address: _________________________________________________________________________________________________ (IF DIFFERENT) STREET CITY STATE ZIP 5. Business Phone: ________________________ Fax:_______________________ Other/office: _____________________ 6. Contact person: ___________________________ Phone number: ________________ Email _____________________ 7. Manager: ________________________________ Phone number: ________________ Email: _____________________ 8. Other alcoholic beverage licenses currently or previously held by applicant/entity/principals: _________________________________________________________________________________________________ Business / Property Information 9. Date opened for business (projected): ______________ Days / hours of operation: ______________________________ 10a.Monthly gross food sales (projected): _____________ 10b. Monthly gross alcohol sales (projected):________________ 11. Projected annual cost of alcohol (liquor, wine, heavy beer) _____________________ (applicable to full service restaurant) 12. Square footage: _________________ Seating/dining capacity: _________________ # of Parking stalls: ____________ 13. Business tax, withholding, workforce services identification numbers Utah Sales Tax __________________________ Utah Payroll Withholding ________________________ Utah Workforce Services ___________________ Federal Taxpayer Identification ____________________ 14. Owner of real property & building (lease holder) Name: _____________________________________ Address: ________________________________________ Phone: _____________________________________ City,State,zip ______________________________________ 15. Proximity: List any private or public schools, churches, public libraries, public playgrounds, parks, or educational facilities (nursery school, infant day care center or trade / technical school) located within 600 feet pedestrian travel or 200 feet straight line. ______________________________________________________________________________________________ ______________________________________________________________________________________________ DABC R101 (07/2012) Authority: UCA 32B American LegalNet, Inc. www.FormsWorkFlow.com 16. Ownership / Management List individuals; managers; partners; corporate officers; any stockholder owning 20% of the corporation; employees appointed to manage or direct operations A criminal history background check must be submitted on each person listed. See Instructions for list of documents required. US Citizen – if “no”, provide residency status in section 17. Use additional sheets if necessary. Date of US Position Percent Complete home address Name Birth Citizen Owned (include city, state, zip code) Social Security Number (DDMMYY) Y/N 17. Residency status (list and attach proof of residency status for all individuals in section 16 who are not US citizens): ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 18. Criminal Offenses: List all criminal offenses other than minor traffic offenses of which you or any person listed in section 16 have been convicted or pending criminal charges (name, criminal offense, date of conviction – use additional sheets if necessary) 19. Are you an industry member; or do you own or have interest in a brewery, winery or distillery? Yes __ No __ if Yes explain below (use additional sheets as necessary) Applicant agrees as a condition of licensing that he/she has read and will abide by the provisions of Title 32B, Utah Code, and all rules of the commission and directives of the Department of Alcoholic Beverage Control; and understands that failure to adhere or to no longer possesses the qualifications of a licensee may result in the suspension or revocation of the alcohol license and forfeiture of the compliance bond. Applicant agrees to immediately notify the department of any change in ownership entity and understands that failure to do so may result in immediate suspension of the license The undersigned verifies that the premises will not be used for permitting gambling or any other violation of law or ordinance. The undersigned hereby authorizes the department access to federal, state and local sales, payroll, income, and real and personal property tax information. The undersigned verifies that the applicant is in compliance with all federal and state laws pertaining to payment of taxes and contributions to unemployment and insurance funds. The undersigned applicant does not and will not discriminate against persons on the basis of race, color, sex, religion, ancestry, or national origin. The undersigned hereby voluntarily consents that representatives of the Alcoholic Beverage Control Department, Commission, State Bureau of Investigation (Bureau of Alcoholic Beverage Law Enforcement), and any other law enforcement agencies shall be admitted immediately and permitted without hindrance or delay to inspect the entire premises and all records of the licensee. The undersigned acknowledges that he/she has read and understands the statements herein and that the execution thereof is done voluntarily and by authorization of the applicant entity; and that any false statement made on this application or any other related document is a second degree felony. The undersigned hereby makes application to the Utah Alcoholic Beverage Control Commission and certifies that the information contained herein and attached hereto is true and correct. ________________________ Date _____________________________________ Title / Position _____________________________________________________ Applicant/Owner of business _____________________________________________________ Authorized Signature State of ________________________________ County of _______________________________ Subscribed and sworn before me this day ________ of ____________________, 20___ _____________________________________________________________ Notary Public UDABC R101 (07/2012) American LegalNet, Inc. www.FormsWorkFlow.com Application Instructions: Please review these instructions prior to completing the application 6. Contact person: Person responsible for the completion and submission of the application. License Types / Definitions 7. Manager: a person chosen or appointed to manage, direct, or administer the operations at a licensed business; also enter the individuals information in section 16 (Ownership / Management) Restaurant full service - Restaurant means any business establishment where a variety of foods is prepared and complete meals are served to the general public; located on a premises having adequate culinary fixtures for food preparation and dining accommodations; and that is engaged primarily in serving meals to the general public. A full service license allows the storage, sale, service, and consumption of liquor, wine, heavy beer, and beer. Restaurant limited service - Restaurant means any business establishment where a variety of foods is prepared and complete meals are served to the general public; located on a premises having adequate culinary fixtures for food preparation and dining accommodations; and that is engaged primarily in serving meals to the general public. A limited service license allows the storage, sale, service, and consumption of wine, heavy beer, and beer. Restaurant beer only - Beer only restaurant licenses are issued for the storage, sale, service, and consumption of beer on the premises of a restaurant that is engaged primarily in serving meals to the general public 1. Ownership Entity: Individual or Sole Proprietor – List the individual operating the business General Partnerships or Limited Partnerships - Limited Partnerships or General Partnerships are composed of one or more general partners and one or more limited partners. The general partners manage the business and share fully in its profits and losses. Limited Liability Company – a company formed by one or more individuals or entities through a special written agreement. The agreement details the organization of the LLC including: provisions for management, assignability of interests, and distribution of profits or losses. Corporation - a legal entity organized and chartered under the laws of a state and is considered domestic by the chartering state 2. DBA: Assumed name of the operating business (trade or operating name) 3. Business address: Legal physical address of the business street, city and zip code to include suite or section number if applicable. 4. Mailing address (if different from business address) for official correspondence, licensing renewal, etc. 8. Other Utah Alcoholic Beverage Control licenses held; list any DABC licenses currently or previously held by the applicant i.e. any individual, Limited Liability Company member or manager, Corporation or Partnership 9. Date open for business (projected): Days and hours of operations: i.e Tuesday – Sunday 10a – 10p; 7days 11a-12a, etc 10a. Monthly gross food sales (projected): food and nonalcoholic beverages. 10b. Monthly gross alcohol sales (projected): wholesale beer, heavy beer, wine and/ liquor. 11. Projected annual costs of alcohol (liquor, wine heavy). This is applicable to full service restaurant applicants only. List the annual costs projected for the business. This figure is utilized in determining subsequent renewal fees. 12. Square footage/seating capacity/parking stalls: Square footage of the operating business, total seating capacity, total number of dedicated parking stalls 13. Business, tax, withholding, workforce service numbers Sales Tax and Payroll Withholding Tax Utah State Tax Commission 210 North 1950 West Salt Lake City, UT 84134 (801) 297-2200 1-800-662-4335 www.tax.utah.gov Department of Workforce Services 140 East 300 South Salt Lake City, UT 84111 (801) 526-9675 http://jobs.utah.gov Federal Taxpayer Identification (EIN) Internal Revenue Service 50 South 200 East Salt Lake City, UT 84111 Information: 1-800-829-1040 Forms: 1-800-829-3676 14. Owner of real property or building (lessor). List the names, address and telephone number of the lease holder. Provide a copy of the lease substantiating owner or control of the property. 5. Business phone: XXX-XXX-XXXX Fax: XXX-XXXXXXX Other phone (cell, home, alternate business phone) UDABC R101 (07/2012) American LegalNet, Inc. www.FormsWorkFlow.com 15. Proximity Restrictions: List any private schools, churches, public libraries, public playgrounds and parks located within 600 feet as measured from the nearest entrance of the outlet by following the shortest route of ordinary pedestrian travel to the property boundary of the public or private school, church, public library, public playground, or park; or within 200 feet as measured straight line from the nearest entrance of the outlet to the property boundary of the public or private school, church, public library, public playground, or park. 16. Ownership / Management: List the full name, complete home address, position held in the company, social security (SSN) or tax identification number (TIN), date of birth, percentage held in the entity and U.S. citizenship status (Yes or No). Individual – sole proprietor List individual owner and all managers responsible to manage, direct, or administer the operations at a licensed business. Partnership List all individuals from the partnership agreement, managing agent and all managers responsible to manage, direct, or administer the operations at a licensed business. an informed consent and release of liability form and a processing fee of $20.00 Non Residents: If the person listed is an out of state resident or has resided in Utah for less than two years, he/she shall submit a completed fingerprint card [FBI Form FD258 or similar] accompanied by an informed consent and release of liability form and a processing fee of $36.50 Third Party Background Check Stipulation UCA 32B-1-307 / Commission Rule 81-1-26 An application that requires a B.C.I or 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 B.C.I or 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; Corporation List all corporate officers and directors; any stockholder owning 20% of the corporation, managing agent and all managers responsible to manage, direct, or administer the operations at a licensed business. 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 B.C.I. or F.B.I. Limited Liability Company List all managers or members of the limited liability company who owned at least 20% of the limited liability company, managing agent and all managers responsible to manage, direct, or administer the operations at a licensed business. 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 Manager: a person chosen or appointed to manage, direct, or administer the operations at a licensed business 5. The applicant stipulates in writing that if a B.C.I. or 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. Applicant/Manager/Supervisor Criminal History Background Check Procedures PURPOSE: To determine qualification of an owner, corporate officer or director, stockholder of 20% or more, managing agents and managers responsible for directing, or administration of alcohol operations. AUTHORITY: Utah Code 32B-1-301 Criminal history background checks are required for each person listed as an owner; corporate officer or director, any stockholder owning 20% of the corporation; member or manager of a limited liability company owning 20% or more; managing agents; and managers responsible to manage, direct, or administer the operations at a licensed business. Attestation/stipulation letter that satisfies the above requirements is enclosed. 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. Utah residents: If any person listed has been a resident of Utah for at least two years, he/she shall submit a completed fingerprint card [FBI Form FD258 or similar] accompanied by UDABC R101 (07/2012) American LegalNet, Inc. www.FormsWorkFlow.com 17. Residency status: Utah State Law (Utah Code, Title 11-101, -2, -3, & -4) allows issuance of a business license only to persons who are citizens of the United States, which includes lawfully admitted resident aliens (see Attorney General Opinion #91-21). Utah Alcoholic Beverage Control Act (Utah Code, Title 32B) requires that any person who applies for a license to sell or serve alcoholic beverages for on-premise consumption, must first obtain a local business license and precludes any person who does not qualify to hold a local business license from being: a proprietor, a partner, a managing agent, an officer, director, a stockholder holding at least 20% of the total issued and outstanding corporate stock, a member or manager of a limited liability company owning at least 20% of the company, or an employee. 18. Criminal offenses: List all criminal offenses other than minor traffic offenses of which you or any of the persons listed in sections 16 who have been convicted or have pending criminal charges (name, criminal offense, date of conviction). The commission may not grant a restaurant alcohol license to any person who has been convicted of: a felony under any federal or state law; any violation of any federal or state law or local ordinance concerning the sale, manufacture, distribution, warehousing, adulteration, or transportation of alcoholic beverages; any crime involving moral turpitude; or on two or more occasions within the five years before the day on which the license is granted, driving under the influence of alcohol, any drug, or the combined influence of alcohol and any drug. In the case of a partnership, corporation, or limited liability company the proscription applies if any of the following has been convicted of any offense described above to a partner; a managing agent; a manager; an officer; a director; a stockholder who holds at least 20% of the total issued and outstanding stock of the applicant corporation; or a member or manager who owns at least 20% of the applicant limited liability company. The proscription applies if any person employed to act in a supervisory or managerial capacity for a restaurant has been convicted of any offense described above. 19. Are you an industry member; own or have an interest in a brewery, winery or distillery: An industry member is considered under federal law CFR 27 Part 6 or UCA 32B as an alcoholic product manufacturer; a producer; a supplier; an importer; a wholesaler; a bottler; a warehouser and bottler; or industry representative. Signature of person authorized to submit the application on behalf of the sole proprietor, partnership, corporation or limited liability company. The signature affirms the applicant agrees as a condition of licensing that he/she has read and will abide by UDABC R101 (07/2012) the provisions of Title 32B, Utah Code, and all rules of the commission and directives of the Department of Alcoholic Beverage Control; and understands that failure to adhere or to no longer possesses the qualifications of a licensee may result in the suspension or revocation of the alcohol license and forfeiture of the compliance bond; agrees to immediately notify the department of any change in ownership entity and understands that failure to do so may result in immediate suspension of the license; verifies that the premises will not be used for permitting gambling or any other violation of law or ordinance; authorizes the department access to federal, state and local sales, payroll, income, and real and personal property tax information; verifies that the applicant is in compliance with all federal and state laws pertaining to payment of taxes and contributions to unemployment and insurance funds; applicant does not and will not discriminate against persons on the basis of race, color, sex, religion, ancestry, or national origin; voluntarily consents that representatives of the Alcoholic Beverage Control Department, Commission, State Bureau of Investigation (Bureau of Alcoholic Beverage Law Enforcement), and any other law enforcement agencies shall be admitted immediately and permitted without hindrance or delay to inspect the entire premises and all records of the licensee; acknowledges that he/she has read and understands the statements herein and that the execution thereof is done voluntarily and by authorization of the applicant entity; and that any false statement made on this application or any other related document is a second degree felony; makes application to the Utah Alcoholic Beverage Control Commission and certifies that the information contained herein and attached hereto is true and correct. Related Documents TC -721 Utah State Tax Commission – Exemption Certificate (applicable for Full-service and Limited-Service applicants) The prices of liquor, wine, and heavy beer at the liquor stores and package agencies do not include sales tax. In order for a licensee to purchase alcohol that is for resale, the licensee must file Utah State Tax Commission Form TC-721 with the DABC. A copy of this form is included in this application packet. Once filed, the licensee can buy liquor, wine, and heavy beer exempt from sales tax at any DABC owned and operated state liquor store. (See Commission Rule 81-4A-5; 81-4C-5) Pro-forma income statements summarize the projected future sales and revenues, operating costs and expenses, and projected earnings before and after taxes. American LegalNet, Inc. www.FormsWorkFlow.com BEER ONLY RESTAURANT LICENSE Local Consent PURPOSE: Local business licensing authority provides written consent to the Alcoholic Beverage Control Commission (1) to issue an on-premise alcohol license for a person to store, sell, offer for sale, furnish, or allow the consumption of an alcoholic product on the premises of the applicant; and (2) to authorize a variance reducing the proximity requirements AUTHORITY: Utah Code 32B-1-202; 32B-5-201 through 203; 32B-5-205 and -206 __________________________________________________, [ ] City [ ] Town [ ] County Local business license authority hereby grants its consent to the issuance of a beer only restaurant license to: Business Name (DBA): ______________________________________________________________________ Applicant Entity/Business Owner: _____________________________________________________________ Location Address: __________________________________________________________________________ ____________________________________ Authorized Signature ____________________________________ Name/Title _______________________ Date LOCAL CONSENT FOR PROXIMITY VARIANCE In accordance with Utah Code 32B-1-202, 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. ____________________________________ Authorized Signature ____________________________________ Name/Title ________________________ Date This is a suggested format. A locally produced city, town, or county form is acceptable. Local consent may be faxed to the DABC at 801-977-6889 or mailed to: Department of Alcoholic Beverage Control, PO Box 30408, Salt Lake City, UT 84130-0408 DABC RE 1/2012 American LegalNet, Inc. www.FormsWorkFlow.com INFORMED CONSENT AND RELEASE OF LIABILITY PURPOSE: Determine an applicant’s qualifications to hold for a package agency, license, or permit AUTHORITY: Utah Code 32B-1-301 to -307; Commission Rule 81-1-16, -26 The Alcoholic Beverage Control Commission is prohibited from issuing a package agency, license or permit to persons who have been convicted of certain criminal offenses:  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 or 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 (last, first, middle initial) __________________________/_________ Driver License# or ID card# / state issued ________________________________________ Formerly used last names (please print) ___________________________________ Name of Business ________________________________________ Signature ___________________________________ Date DABC Consent and release ver 1.1.12 previous editions accepted American LegalNet, Inc. www.FormsWorkFlow.com Third Party Background Check Stipulation PURPOSE: Determine an applicant’s qualifications to hold for a package agency, license, or permit AUTHORITY: Utah Code 32B-1-301 to -307; Commission Rule 81-1-16, -26 Date __________________________ To: Department of Alcoholic Beverage Control I, ______________________________________, attest: 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). 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 a criminal background 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. ________________________________________ Printed Name ________________________________________ Signature DABC 3rd Party Stipulation ver 1.1.12 previous editions accepted 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 “BEER ONLY RESTAURANT BOND” BOND # _______________________ KNOW ALL PERSONS BY THESE PRESENTS: That Principal, ____________________________________________, a limited restaurant 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 $5,000 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 beer only restaurant license pursuant to the provisions of 32B-5-204, Utah Code. NOW, THEREFORE, if said principal, its officers, agents and employees shall faithfully comply with the provisions of Title 32B, 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 } __________________________________ 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 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF LIABILITY INSURANCE PRODUCER DATE (MM/DD/YYYY) Month/Date/Year THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Insurnce Agent/Broker Name Insurnce Agent/Broker Street Address or P.O. Box Insurnce Agent/Broker City, State & Zip Code Contact & Phone Number INSURERS AFFORDING COVERAGE INSURER A: Name of Insurance Company INSURED Your Business entity (LLC, Corp, Partnership or individual) Your DBA - business name Address City, State Zip NAIC # Enter NAIC# INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD’L LTR INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS CLAIMS MADE OCCUR Liquor Liability POLICY PROJECT AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS GARAGE LIABILITY ANY AUTO AM EX GEN’L AGGREGATE LIMIT APPLIES PER: $N/A $1,000,000 $2,000,000 $1,000,000 LOC CLAIMS MADE DEDUCTIBLE WORKERS COMPENSATION AND EMPLOYERS’ LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below COMBINED SINGLE LIMIT (Each Occurrence) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ AUTO ONLY - EA ACCIDENT $ EA ACC $ AGG OTHER THAN AUTO ONLY: $ EACH OCCURRENCE $ AGGREGATE $ $ $ E RETENTION $ $ PL EXCESS/UMBRELLA LIABILITY OCCUR $100,000 PRODUCTS - COMP/OP AGG Enter Expiration Date $1,000,000 MED EXP (Any one person) Enter Effective Date DAMAGE TO RENTED PREMISES (Ea occurrence) PERSONAL & ADV INJURY Enter Policy # COMMERICAL GENERAL LIABILITY EACH OCCURENCE GENERAL AGGREGATE A GENERAL LIABILITY $ WC STATUTORY LIMITS OTHER E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Business located at: CERTIFICATE HOLDER Department of Alcoholic Beverage Control 1625 S 900 W Salt Lake CIty, UT 84104 Facsimile Number: (801) 977-6889 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) © ACORD CORPORATION 1988 American LegalNet, Inc. www.FormsWorkFlow.com _______________________________ Business Name Pro Forma Income Statement REVENUE Food ________________ Beer (3.2% ________________ Other ________________ $_______________ Total Sales Revenue COSTS OF GOODS SOLD Food ________________ Beer (3.2) ________________ Other ________________ $_______________ Total Costs of Goods Sold $_______________ GROSS PROFIT EXPENSES Variable Costs - Salaries & wages ________________ - Employee Benefits ________________ - Other Operating Expenses Janitorial ________________ Advertising ________________ Entertainment ________________ Utilities ________________ Telephone ________________ Total other operating expenses ________________ ________________ Total Variable Expenses Fixed Costs Mortgage/Rent ________________ Insurance ________________ Interest ________________ Depreciation ________________ ________________ Total Fixed Expenses Total Operating Expenses Net Profit (loss) before taxes Taxes Net Profit (loss) after taxes $_______________ $_______________ $_______________ $_______________ American LegalNet, Inc. www.FormsWorkFlow.com Name of business or institution claiming exemption (purchaser) Telephone Number City Street Address Authorized Signature State ZIP Code Name (please print) Title Date Name of Seller or Supplier: Department of Alcoholic Beverage Control The person signing this certificate MUST check the applicable box showing the basis for which the exemption is being claimed. Questions should be directed (preferably in writing) to Taxpayer Services, Utah State Tax Commission, 210 N 1950 W, Salt Lake City, UT 84134. Telephone (801) 297-2200, or toll free 1-800-662-4335. DO NOT SEND THIS CERTIFICATE TO THE TAX COMMISSION Keep it with your records in case of an audit. Sales tax account numbers with an “H” prefix are not to be used for tax-free purchases for resale or re-lease. RESALE OR RE-LEASE Sales Tax License No. ________________ I certify I am a dealer in tangible personal property or services that is for resale or re-lease. If I use or consume any tangible personal property or services I purchase tax free for resale, or if my sales are of food, beverages, dairy products and similar confections dispensed from vending machines (see Rule R865-19S-74), I will report and pay sales tax on the proper cost thereof directly to the Tax Commission on my next regular sales and use tax return. RELIGIOUS OR CHARITABLE INSTITUTION Sales Tax Exemption No. N ___ ___ ___ ___ ___ I certify the tangible personal property or services purchased will be used or consumed for essential religious or charitable purposes. This exemption can only be used on purchases totaling $1,000 or more, unless the sale is pursuant to a contract between the seller and purchaser. COMMERCIAL AIRLINES I certify the food and beverages purchased are by a commercial airline for in-flight consumption; or, any parts or equipment purchased are for use in aircraft operated by common carriers in interstate or foreign commerce. To be valid this certificate must be filled in completely, including a check mark in the proper box. A sales tax license number is required only where specifically indicated. Please sign, date and, if applicable, include your license or exemption number. NOTE TO SELLER: Keep this certificate on file since it must be available for audit review. NOTE TO PURCHASER: Keep a copy of this certificate for your records. You are responsible to notify the seller of cancellation, modification, or limitation of the exemption you have claimed. DO NOT SEND THIS CERTIFICATE TO THE TAX COMMISSION American LegalNet, Inc. www.FormsWorkFlow.com