State of West Virginia Department of Revenue Alcohol Beverage Control Administration th 322 70 Street, SE Charleston, WV 25304-2900 INSTRUCTIONS FOR COMPLETING APPLICATION FOR RETAIL LICENSE - OFF PREMISE PLEASE READ ALL INSTRUCTIONS CAREFULLY. ALL QUESTIONS ARE TO BE ANSWERED IN FULL. APPLICANT’S ACCURACY AND THOROUGHNESS IN COMPLETING THE APPLICATION FORM WILL ASSIST THIS OFFICE IN PROCESSING THE APPLICATION AND PREVENT UNNECESSARY DELAYS. APPLICANTS MUST TYPE OR PRINT (IN INK) ALL ANSWERS ON ALL FORMS Please find enclosed: 1. Application For Retail License, Consumption Off Premise, Class B (ABCA-192B) 2. Floor Plan (ABCA-Lic.FP3), give dimensions of licensed premises 3. Release of Information & Waiver of Confidentiality of Records (ABCA-Lic.RIWCR.2) 4. Zoning Form (ABCA-Lic.Z.2) INSTRUCTIONS All questions and/or descriptions must be answered. The application must be signed and notarized. If any question/description cannot be completed in the available space on the application, please submit additional pages as needed. Be sure to indicate on the additional pages which question applicant is answering (print Entity and DBA Name on the additional pages). Applications must be completed correctly and all necessary paperwork included when mailed to the ABCA. Failure to do so will result in the application being delayed and/or returned to the applicant for the necessary corrections. LICENSE FEES - License fees must be paid by Certified Check, Cashier’s Check, or Money Order. Personal checks, business checks, or cash will not be accepted. Make checks payable to the West st Virginia ABCA. If applying for a license after December 31 , the license fee is semi-annually pro-rated to half the initial fee. A processing fee of twenty-four ($24.00) dollars must be included for each individual listed for Live Scan Fingerprinting. WV SECRETARY OF STATE – All Associations, Corporations, Limited Liability Corporations, Non-Profit Clubs, and Fraternal Organizations must be duly certified and registered with the WV Secretary of State. Fraternal Organizations must contact the ABCA Licensing Department for additional requirements. INSTRUCTIONS FOR SIGNING: a. If an individual, by the owner b. If a partnership, by each member of the partnership c. If an association, by each member of the governing board d. If a corporation, by all officers, or by other persons specifically authorized by corporate resolution (copy of resolution must be enclosed) e. If a limited liability company, by all members f. Manager(s) must sign (Instructions continued on the back side of this page) ABCA-Lic.IB American LegalNet, Inc. www.FormsWorkFlow.com All applicants must apply for a “Special Occupation Tax (TTB F 5630.5a)” with the Alcohol and Tobacco Tax and Trade Bureau. Form and instructions are available by calling the toll-free number at 800-937-8864 or available through download at the following website: http://www.ttb.gov/forms/5630d.pdf WINE APPLICATIONS – Each type of specialty wine application license is described below: Wine Retail ($150.00) - “Wine Retailer” means a person licensed to sell wine at retail to the public at his or her established place of business for off premise consumption. Wine Specialty Shop ($250.00) - “Wine Specialty Shop” means a retailer who shall deal principally in the sale of table wine, non-fortified dessert wines, wine accessories and food or foodstuffs normally associated with wine and: (a) Who shall maintain a representative number of such wines for sale in his/her inventory which are designated by label as varietal wine, vintage, generic and/or according to region of production and the inventory shall contain not less than fifteen percent vintage or vintage-dated wine by actual bottle count: (b) who, any other provisions of this code to the contrary notwithstanding, may maintain an inventory of Port, Sherry, Madeira wines having an alcoholic content of not more than twenty-two percent alcohol by volume and which have been matured in wooden barrels or casks. Wine Specialty Shop Tasting ($400.00) - This license is a combination of the Wine Specialty Tasting ($150.00) and the Wine Specialty Shop ($250.00) licenses. This license allows a wine specialty shop to serve complimentary samples of wine in moderate quantities for tastings. Such wine specialty shop shall organize a wine taster’s club, which has at least fifty duly elected members or approved dues-paying members in good standing. Such club shall meet on the wine specialty shop’s premises not more than one time per week and shall either meet at a time when the premises are closed to the general public, or shall meet in a separate segregated facility on the premises to which the general public is not admitted. Must have a Wine Specialty Shop license to obtain a Wine Specialty Shop Tasting license. Wine Specialty Shop Sampling ($150.00) - This license allows a wine specialty shop to conduct special wine sampling events at a licensed wine specialty shop location during regular hours of business. The wine specialty shop may serve up to three complementary samples of wine, consisting of no more than one ounce each, to any one consumer in one day. Must have Wine Specialty Shop license to obtain a Wine Specialty Shop Sampling license. Note: A wine Specialty Shop ($250.00) may add Wine Specialty Shop Tasting ($150.00) = $400.00, or add the Wine Specialty Shop Sampling ($150.00) = $400.00 or add both for a combined total of $550.00. Wine Tasting “Farm Winery” ($150.00) - This license allows a farm winery to attend fairs and festivals they have listed on Wine Tasting at a Festival, Fair or Special event (ABC-Lic.w.1) form, that has been submitted to and approved by the WVABCA Commissioner. The license allows the approved farm winery to provide samples served in moderate quantities, which serving size will not exceed two ounces and bottles of wine sold for off-premise consumption. All wines Port, Sherry, or Madeira offered or sold at the fair or festival must be offered or sold by the farm winery which produced the product. BUSINESS CLOSURE – Upon sale or closure of the applicant’s business, the license must be returned to the ABCA Licensing Department. The license will not be abandoned, rented, leased, given, loaned, or sold to another. MAIL COMPLETED APPLICATION, FEES, AND REQUIRED ACCOMPANYING FORMS TO: West Virginia Alcohol Beverage Control Administration ATTN: Licensing Department th 322 70 Street SE Charleston, WV 25304-2900 IF YOU HAVE ANY QUESTIONS OR NEED ASSISTANCE PLEASE CALL THE ADMINISTRATION AT 1-800-642-8208 OR (304) 558-2481 AND ASK FOR THE LICENSING DEPARTMENT. CHECKLIST OF FORMS/PAPERS TO RETURN TO THE WVABCA, LICENSING DEPARTMENT:       Application Form License fee(s) and Live Scan Processing Fee(s) Floor Plan Waiver Zoning Form and Letter from County Commission, if applicable Copy of Valid Lease (if not owner) ABCA-Lic.IB American LegalNet, Inc. www.FormsWorkFlow.com ABCA - 192B REVISED 3/11 WEST VIRGINIA ALCOHOL BEVERAGE CONTROL ADMINISTRATION APPLICATION FOR RETAIL LICENSE CONSUMPTION "OFF PREMISE" CLASS B FOR FISCAL YEAR _______ TO _______ COUNTY: ___________________ PLEASE CHECK ALL APPROPRIATE BOXES BELOW. BE SURE TO CHECK THE BOX(ES) BESIDE EACH (ALL) OF THE LICENSES FOR WHICH YOU ARE APPLYING. A. WINE APPLICATION      B. BEER APPLICATION Wine Retail…..………………………$150 Wine Specialty………..……..……...$250 Wine Specialty/Tasting………..…..$400 Wine Sampling*..……………………$150 Wine Tasting “Farm Winery”…..…$150  Carry-out ...................... $150 C. Applying as: (CHECK ONE)       Individual Partnership Limited Partnership Corporation Association Limited Liability Company *Wine Sampling only available to Wine Specialty license holders Email: Fax Number: _______________ WV TAX I.D./FEIN: ____________________ 1. Licensee/Entity Name: 2. Doing Business As (DBA) Name: 3. Business Address: (STREET) (CITY) (STATE) (ZIP CODE) (TELEPHONE) (ZIP CODE) (TELEPHONE) 4. Mailing Address (if different): (STREET) (CITY) (STATE) 5. SUPPLY THE FOLLOWING INFORMATION ABOUT OWNER(S) AND/OR OFFICER(S) AND MANAGER(S). US Citizen ** _____________ TITLE ____________________________________________________________ ___________ NAME _____/______/______ DATE OF BIRTH _____________ TITLE _____________ _____________ Y/N ______________________ YRS RESIDENT OF WV RESIDENCE ADDRESS ___________-___________-____________ SOCIAL SECURITY NUMBER % OWNERSHIP ( ______ )__________________________________ TELEPHONE NUMBER Y/N ______________________ YRS RESIDENT OF WV RESIDENCE ADDRESS ___________-___________-____________ SOCIAL SECURITY NUMBER % OWNERSHIP ( ______ )__________________________________ TELEPHONE NUMBER Y/N ______________________ YRS RESIDENT OF WV ____________________________________________________________ ___________ NAME _____/______/______ DATE OF BIRTH _____________ TITLE % OWNERSHIP ( ______ )__________________________________ TELEPHONE NUMBER ____________________________________________________________ ___________ NAME _____/______/______ DATE OF BIRTH TITLE ___________-___________-____________ SOCIAL SECURITY NUMBER ____________________________________________________________ ___________ NAME _____/______/______ DATE OF BIRTH TITLE RESIDENCE ADDRESS RESIDENCE ADDRESS ___________-___________-____________ SOCIAL SECURITY NUMBER % OWNERSHIP ( ______ )__________________________________ TELEPHONE NUMBER Y/N ______________________ YRS RESIDENT OF WV ____________________________________________________________ ___________ NAME _____/______/______ DATE OF BIRTH RESIDENCE ADDRESS ___________-___________-____________ SOCIAL SECURITY NUMBER % OWNERSHIP ( ______ )__________________________________ TELEPHONE NUMBER ______________________ YRS RESIDENT OF WV **IF A NATURALIZED US CITIZEN, PLEASE ATTACH A WRITTEN EXPLANATION OF WHEN AND WHERE NATURALIZED. American LegalNet, Inc. www.FormsWorkFlow.com Y/N 6. CRIMINAL HISTORY-THE FOLLOWING IS A RECORD OF ALL CONVICTED ARRESTS OF THE OWNERS, PARTNERS, OFFICERS, DIRECTORS, MEMBERS AND/OR MANAGERS. ALL APPLICANTS WILL BE CHECKED THROUGH THE SECURITY DIVISION AT THE WV LOTTERY. ATTACH ADDITIONAL PAGES IF NECESSARY. IF THERE HAVE BEEN NO ARRESTS INSERT THE WORD ” NONE” . _______________________________________________________________________________________________________ NAME DATE OF CHARGE DISPOSITION LOCATION OF COURT ARREST OF ARREST (COUNTY & STATE) _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 7. STATE NAME AND ADDRESS OF ALL PERSONS HAVING TWENTY PERCENT (20%), OR MORE INTEREST IN THE APPLICANTS’ CORPORATION, ASSOCIATION, PARTNERSHIP, LIMITED PARTNERSHIP, AND/OR LIMITED LIABILITY COMPANY. STATE THE EXACT PERCENTAGE OF OWNERSHIP INTEREST FOR EACH PERSON LISTED. NAME ADDRESS SOC. SEC.# %OWNERSHIP _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 8. HAS ANY OFFICER, MANAGER, OR 20% STOCKHOLDER EVER HELD OR CURRENTLY HOLD A WVABCA LICENSE? YES  NO  IF YES, WHO?_______________________________________________________________________ DBA NAME?_________________________________________________________________________ WAS THE LICENSE: REVOKED _______________ DATE_________________________________ SUSPENDED_____________ DATE_________________________________ SANCTIONED_____________ DATE_________________________________ 9. OWNER OF PREMISES TO BE LICENSED (PROPERTY OWNER’S NAME)______________________________________ IF NOT PROPERTY OWNER, APPLICANT MUST HOLD A VALID LEASE (ATTACH A COPY OF THE LEASE) 10. DOES THIS LOCATION CURRENTLY HAVE AN ABCA LICENSE? YES  NO  IF YES, NAME OF LICENSED ESTABLISHMENT:_________________________________ LICENSE #_________________________________ 11. IS THE APPLICANT’S LOCATION WITHIN AN INCORPORATED MUNICIPALITY OR WITHIN ONE MILE OF THE CORPORATE LIMITS OF ANY MUNICIPALITY? YES  NO  12. WILL TOBACCO PRODUCTS BE SOLD AT THIS ESTABLISHMENT? YES  NO  13. HAS APPLICANT SUBMITTED A “SPECIAL TAX REGISTRATION AND RETURN” APPLICATION TO THE ALCOHOL AND TOBACCO TRADE BUREAU (TTB)? YES  NO  14. IS THE APPLICANT’S LOCATION READY FOR AN INITIAL INSPECTION? YES  NO  IF NO, WHAT IS THE PROJECTED DATE FOR THE INITIAL INSPECTION?______________________________________ RETAIL NON-INTOXICATING BEER: 14. ESTIMATED RETAIL SALES PER MONTH OF FOOD AND FOOD PRODUCTS (FOR THE TABLE): ___________________________________________________________________________________ ESTIMATE BASED ON:________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com WINE SPECIALTY SHOP REQUIREMENTS: IF A WINE SPECIALTY SHOP, THE ESTABLISHMENT MUST STOCK ACCESSORIES AND FOOD OR FOOD ITEMS ASSOCIATED WITH WINE. IF A WINE SPECIALTY SHOP, THE ESTABLISHMENT MUST STOCK WINE INVENTORY WHICH INCLUDES FIFTEEN PERCENT (15%) VINTAGE OR DATED WINES. The undersigned agree, if a license is issued as herein applied for, to comply at all times and observe all the provisions of West Virginia Code §§ Chapter 11, Article 16 et seq., and Chapter 60, Articles 1 through 8 et seq., and all Federal and State Statutes and all other laws of this State and the rules and regulations promulgated by the Alcohol Beverage Control Administration. I or we certify under penalty of law and disqualification of licensure that all statements are true and complete. I or we release the State of West Virginia and any agent acting on its behalf from any and all liability by reason of the request for such information. The undersigned hereby verify that we are all officers and all members of the board of directors on the application and that the statements and answers made in the foregoing application are true and the said writing is the act and deed of said Corporation, Limited Liability Company, Association, Individual, Partnership, Limited Partnership. PRESIDENT, INDIVIDUAL, OR CONTROLLING MEMBER(S) SIGNATURES MUST BE NOTARIZED! MUST MATCH OFFICERS LISTED WITH THE SECRETARY OF STATE. MANAGERS MUST ALSO SIGN. PRINT CLEARLY/WRITTEN SIGNATURES REQUIRED NAME: ______________________________________________________________________ TITLE: ________________________________ SIGNATURE:______________________________________________________________ DATE OF SIGNATURE:__________________ NAME: ______________________________________________________________________TITLE:________________________________ SIGNATURE:______________________________________________________________ DATE OF SIGNATURE:__________________ NAME: ______________________________________________________________________ TITLE:________________________________ SIGNATURE:______________________________________________________________ DATE OF SIGNATURE:__________________ NAME: ______________________________________________________________________ TITLE:________________________________ SIGNATURE:______________________________________________________________ DATE OF SIGNATURE:__________________ NAME: ______________________________________________________________________ TITLE:________________________________ SIGNATURE:______________________________________________________________ DATE OF SIGNATURE:__________________ State of West Virginia, __________________________________________________________ County, To-Wit: ____________________________________________________________________________________, Being first duly sworn according to law, deposes and says that he/she is______________________________________________________________ of the President, Individual, or controlling Member(s) _______________________________________________, authorized by law to do business in the State of West Virginia, and that the Business Entity statements and answers made in the foregoing application are true and acknowledged the said writing to be the act and deed of said corporation. (Applicant Signature)___________________________________________ STATE OF WEST VIRGINIA, COUNTY OF__________________________________, to wit: Sworn to before me and subscribed in my presence this_________ day of_________________________ , _______________. ___________________________________________________ NOTARY PUBLIC My Commission Expires________________________________ SEAL OF NOTARY American LegalNet, Inc. www.FormsWorkFlow.com Applicant/Entity Name:________________________________________________________ Doing Business As (DBA) Name:______________________________________ WEST VIRGINIA ALCOHOL BEVERAGE CONTROL ADMINISTRATION RELEASE OF INFORMATION AND WAIVER OF CONFIDENTIALITY OF RECORDS I or we, having made application with the West Virginia Alcohol Beverage Control Administration for issuance of a license to sell alcoholic beverages within the State of West Virginia, hereby waive the benefit of any municipal, county, state, or federal statute, rule, ordinance, regulation or other law prescribing the confidentiality of any records or documents, whether formal or informal, pending or closed, maintained by any public or private agency or organization as those records or documents pertain to residency, business location, business activities, education and/or training, employment, criminal history, civil litigation, or law enforcement investigation. I or we, hereby authorize and request every public or private agency, organization, or person maintaining such records to furnish to the West Virginia Alcohol Beverage Control Administration, or their agents or representatives, any information contained therein and to permit them to inspect and make copies of such records and documents. I or we, hereby authorize the West Virginia Alcohol Beverage Control Administration to disclose any information pertaining to the licensure to any municipal, county, state, federal or private agency or organization that has any interest in the licensing of said applicant. I or we, hereby release the West Virginia Alcohol Beverage Control Administration, their agents and representatives, and any agency, organization, or person furnishing information from all liability arising out of any investigation concerning the applicant. I or we further agree that a copy of this Release and Waiver shall function as an original. I or we acknowledge that by affixing a signature(s) below gives this document full force, and upon this date all aforementioned information may be received and shared as prescribed. Name: Must include owner’s, officer’s, member’s and manager’s printed and written signature(s). Title Date ABCA-Lic.RIWCR.2 American LegalNet, Inc. www.FormsWorkFlow.com West Virginia Alcohol Beverage Control Administration Floor Plan License period: _____-_____ Applicant Entity Name: Doing Business As (DBA) Name: ______ County: Floor plan must include all areas under the control or lease of the applicant where alcohol is to be stored, sold or consumed. All areas under control or lease of the licensee must be licensed. Submit (1) copy to ABCA. (Give Dimensions) Keep (1) copy at licensed premises. *If there are attached drawings please check: ______ (additional drawings must be signed). *Complete information on reverse side of form. ABCA-Lic.FP.3 American LegalNet, Inc. www.FormsWorkFlow.com Room or Outside Structure (Width, Length)(example: 24' X 36') Seating Capacity Located on What Floor Location (serving, kitchen, storage, etc...) I or we hereby certify that the floor plan above and/or attached is the only area where alcoholic beverages will be sold, dispensed, consumed, and/or stored. And, I or we further understand that any violation of this provision will mean immediate revocation or suspension of my license. Signature:________________________________________ Title: Date: Signature:________________________________________ Title: Date: Signature:________________________________________ Title: Date: Signature:________________________________________ Title: Date: Signature:________________________________________ Title: Date: American LegalNet, Inc. www.FormsWorkFlow.com Zoning Form (Original copy must be submitted to the WVABCA Licensing Department) Note: If an establishment’s location is not situated within a municipality, this office will need a letter from the County Commission stating that the establishment location is zoned properly. All applicants must complete the front portion of the form. To: Municipal Clerk or Recorder Under the requirements set forth in W.Va. State Code § 11-16-8(a)(5), a person intending to apply for a license to operate an WVABCA licensed Class B establishment at any location within a municipality must file a notice of such intention with the Clerk or Recorder of such municipality at least ten (10) days prior to filing an application for such license with the WVABCA. Pursuant to this requirement, notice is herein given that the following intends to apply to the WVABCA for a license to operate a Class B licensed establishment issued pursuant to the provisions of § Chapter 11, Article 16 of the W.Va. State Code. Entity Name:__________________________________________________________ DBA (Doing Business As):_______________________________________________ Address of Establishment:________________________________________________________ (Street/Route) (City) (State) (Zip Code) Applicant’s Name(s):_____________________________________________________________ (Last) (First) (Middle) _____________________________________________________________ (Last) (First) (Middle) General Description of Premises: __________________________________________ _____________________________________________________________________ This Notice has been filed with the Clerk or Recorder of the City/Town of ___________________ on this ________ day of _____________, _______________. Applicant’s Signature(s):_________________________ Date: _________________ _________________________ Date: _________________ (Municipality to fill out reverse side of form) ABCA-Lic.Z.2 American LegalNet, Inc. www.FormsWorkFlow.com (FOR USE BY MUNICIPAL AUTHORITIES ONLY) 1. Is the proposed location for the Class B “Carry-Out” described consistent with the zoning ordinances of your Municipality as either a permitted use or a conditional use of such premises? Yes____ No____ 2. If the answer to the first question was “No” does your Municipality provide within its zoning requirements suitable alternative locations for Class B “Carry-Outs”? Yes____ No____ 3. Additional comments to the Alcohol Beverage Control Administration: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. Is the proposed location situated in a “Dry County” or in a Town/Municipality designated as a “Dry” area. Yes____ No____ Unsure____ ________________________________________________________________ Approved By: Authorized Official Signature and Title ________________________________________________________________ City/Town Date:______________________________________ Return Original To: WVABCA Licensing Division 322 70th Street, SE Charleston, WV 25304 American LegalNet, Inc. www.FormsWorkFlow.com