20 FIRST/SECOND CLASS LIQUOR LICENSE APPLICATION License Year: May 1st through April 30th of following year Please file application in duplicate Print Full Name of Person, Partnership, Corporation, Club or LLC Doing Business As – Trade Name Street and street number of premises covered by this application Town or City & Zip Code Telephone Number Mailing Address (if different from above) FIRST CLASS SECOND CLASS $100.00 RESTAURANT HOTEL CABARET CLUB Fee for ANY FIRST class license paid to town/city $100.00 /Fee to DLC Fee for ANY SECOND class license paid to town/city $50.00 /Fee to DLC $50.00 TO THE CONTROL COMMISSIONERS OF THE TOWN/CITY OF , VERMONT Application is hereby made for a license to sell malt and vinous beverages under and in accordance with Title 7, Vermont Statutes Annotated, as amended, and certify that all statements, information and answers to questions herein contained are true; and in consideration of such license being granted do promise and agree to comply with all local and state laws; and to comply with all regulations made and promulgated by the Liquor Control Board. Upon hearing, the Liquor Control Board may, in its discretion, suspend or revoke such license whenever it may determine that the law or any regulations of the Liquor Control Board have been violated, or that any statement, information or answers herein contained are false. MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING. If this premise was previously licensed, please indicate name I/we are applying as: INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY Please fill in name, address, social security number, date and place of birth of individual, partners, directors or members. LEGAL NAME STREET/CITY/STATE PLACE OF BIRTH Are all of the above citizens of the UNITED STATES and residents of VERMONT? (Note: Resident Alien is not considered a U.S. Citizen) Yes ____ No If naturalized citizen, please complete the following: American LegalNet, Inc. www.FormsWorkflow.com __________________________________________________________________________________________ Name Court where naturalized (City/State/Zip) Date CORPORATE INFORMATION: If you have checked the box marked CORPORATION, please fill out this information for stockholders (attach sheet if necessary). LEGAL NAME STREET/CITY/STATE PLACE OF BIRTH Date of incorporation Is corporate charter now valid? Corporate Federal Identification Number Have you registered your corporation and/or trade name with the Town/City Clerk? _______ and/or Secretary of State? ________ (as required by VSA Title 11 § 1621, 1623 & 1625). ALL APPLICANTS HAVE ANY OF THE APPLICANTS EVER BEEN CONVICTED OR PLED GUILTY TO ANY CRIMINAL OR MOTOR VEHICLE OFFENSE IN ANY COURT OF LAW (INCLUDING TRAFFIC TICKETS BY MAIL) YES NO If yes, please complete the following information: (attached sheet if necessary) Name Court/Traffic Bureau Offense Date Do any of the applicants hold any elective or appointive state, county, city, village/town office in Vermont? (See VSA, T.7, Ch. 9, §223) Name YES NO If yes, please complete the following information: Office Jurisdiction Please give name, title and date attended of manager, director, partner or individual who has attended a Liquor Control Licensee Education Seminar, as required by Education Regulation No. 3: NAME: TITLE: DATE: (If you have not attended an Education Seminar prior to making application, please contact the Liquor Control Investigator in your area regarding this mandatory training.) FOR ALL APPLICANTS: DESCRIPTION /LOCATION OF PREMISES (Section 4) Description of the premises to be licensed: Does applicant own the premises described? If not owned, does applicant lease the premises? If leased, name and address of lessor who holds title to property: American LegalNet, Inc. www.FormsWorkflow.com Are you making this application for the benefit of any other party? FIRST CLASS APPLICANTS ONLY: No first class license may be issued without the following information. HEALTH LICENSE #: Food Lodging (if licensed as a Hotel) VERMONT TAX DEPARTMENT: Meals & Rooms Certificate/Business Account # Business is devoted primarily to: (Circle one) FOOD (restaurant) ENTERTAINMENT (cabaret) HOTEL CLUB If you are considering Outside Consumption service on decks, porches, cabanas, etc. you must complete an Outside Consumption Permit. Please request this form from your Town/City or from the Department of Liquor Control. Will applicant apply for a third class (spirituous liquor) license? ____Yes ____ No CABARET APPLICANTS ONLY: Applicant hereby certifies that the sale of food shall be less in amount or volume than the sales of alcoholic beverages and the receipts from entertainment and dancing; if at any time this should not be the case, the applicant/licensee shall immediately notify the Department of Liquor Control of this fact. Signature of Individual, Partner, authorized agent of Corporation or LLC member ==================================================================================================================================== ALL APPLICANTS MUST COMPLETE AND SIGN BELOW The applicant(s) understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal repositories prior to acting on this application. I/We hereby certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, §3113). In accordance with 21 VSA, §1378 (b) I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. If applicant is applying as an individual: I hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or am in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, §795). in the County of Dated at this day of and State of , , 20 Corporations/Clubs: Signature of Authorized Agent Individuals/Partners: (All partners must sign) American LegalNet, Inc. www.FormsWorkflow.com (Title) Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. , Vermont, Town/City APPROVED Date DISAPPROVED Approved/Disapproved by Board of Control Commissioners of the City or Town (circle one) of Total Membership members present Attest, City or Town Clerk TOWN OR CITY CLERK SHALL MAIL BOTH COPIES OF APPLICATION DIRECTLY TO THE DEPARTMENT OF LIQUOR CONTROL, GREEN MOUNTAIN DRIVE, DRAWER 20, MONTPELIER, VERMONT 05620-4501. If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class application shall be considered binding except as taken or made at an open public meeting. VSA Title 1 §312. NOTICE: After local action, all new applications are investigated by the Enforcement and Licensing Division prior to approval/disapproval of the license by the Liquor Control Board. SECTION 5111 AND 5121 OF THE INTERNAL REVENUE CODE OF 1954 REQUIRE EVERY RETAIL DEALER IN ALCOHOLIC BEVERAGES TO FILE A FORM ANNUALLY AND PAY A SPECIAL TAX IN CONNECTION WITH SUCH SALES ACTIVITY. FOR FURTHER INFORMATION, CONTACT: THE BUREAU OF ALCOHOL, TOBACCO & FIREARMS DEPARTMENT OF THE TREASURY 550 MAIN STREET, CINCINNATI, OH 45202 (513) 684-2979 American LegalNet, Inc. www.FormsWorkflow.com