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 - ON 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 On Premise, Class A (ABCA-192A) 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. Alcohol Beverage Control Bond (ABCA-193) and Nonintoxicating Beer Bond (ABCA-194) 5. 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 st to the West 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. BONDS – Applicants must have a $5,000.00 Alcohol Beverage Control Bond and/or a $1,000.00 Nonintoxicating Beer Bond completed on the form(s) provided by the ABCA. (Instructions continued on the back side of this page) ABCA-Lic.IA American LegalNet, Inc. www.FormsWorkFlow.com HEALTH PERMIT – Applicants must provide a copy of a valid Health Permit issued in applicant’s name. (If Association, Limited Liability Company or Corporation, the health permit must be issued in the business entity name.) 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 All applicants must apply for a “Special Occupation Tax (TTB F 5630.5d)” 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 through download at the following website: http://www.ttb.gov/forms/5630d.pdf 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) Alcohol Bond, if applicable* Nonintoxicating Beer Bond Floor Plan Waiver Zoning Form and Letter from County Commission, if applicable Copy of Valid Lease (if not owner) *Bond not required for private wine restaurant license ABCA-Lic.IA American LegalNet, Inc. www.FormsWorkFlow.com ABCA – 192A REVISED 3/11 WEST VIRGINIA ALCOHOL BEVERAGE CONTROL ADMINISTRATION APPLICATION FOR RETAIL LICENSE CONSUMPTION "ON PREMISE" CLASS A 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. LIQUOR APPLICATION B. WINE APPLICATION  Fraternal Club……….……...…$900*  Private Club (less than 1000 members)....$1,150*  Private Club (more than 1000 members)..$2,650*  Off Premises Wine Sales……………..………$100 C. BEER APPLICATION  Private Wine  Tavern, Restaurant………..……….…...$250 Restaurant, Etc…….……$150  Private Wine Spa……........…..$150  Fraternal…………….……$150  Private Wine  Brew Pub……….……...$1,000 Bed & Breakfast………….…...$150  Off Premises Wine Sales………….……....…$100 *These fees include liquor, wine, and beer. These fees do not include liquor or beer. Email: These fees do not include liquor or wine. D. APPLYING AS:       (CHECK ONE) Individual Partnership Limited Partnership Corporation Association Limited Liability Co. Only Associations, Corporations, or Limited Liability Companies may apply for a liquor license. 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 Y/N ______________________ 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 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. THE LICENSE APPLIED FOR IS NOT FOR ANY COLLEGE FRATERNITY OR SORORITY AND THE PROPOSED LOCATION OF THE PREMISES HAS NOT BEEN DETERMINED BY LAW TO BE A PUBLIC NUISANCE, EXCEPT AS FOLLOWS: ___________________________________________________________________________________________________ 12. ARE THE APPLICANT’S PREMISES LOCATED: A. WITHIN AN INCORPORATED MUNICIPALITY OR WITHIN ONE MILE OF THE CORPORATE LIMITS OF ANY MUNICIPALITY? YES  NO  B. WITHIN ONE MILE OF THE CORPORATE LIMITS OF TWO OR MORE MUNICIPALITIES: IF YES, NAME THE MUNICIPALITIES: YES  NO  (1)_____________________________________________________________ (2)_____________________________________________________________ (3)_____________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 13. LIST THE DISTANCE TO THE NEAREST: A. CHURCH _________________________________ B. SCHOOL _________________________________ C. RESIDENCE_______________________________ D. GOVERNMENT OFFICE _____________________ 14. HAS APPLICANT SUBMITTED A “SPECIAL TAX REGISTRATION AND RETURN” APPLICATION TO THE ALCOHOL AND TOBACCO TRADE BUREAU (TTB)? YES  NO  15. WILL TOBACCO PRODUCTS BE SOLD AT THIS ESTABLISHMENT? YES  NO  16. WILL THERE BE EXOTIC ENTERTAINMENT? (Only Private Clubs need to answer this question!) YES  NO  17. WILL THERE BE LIMITED VIDEO LOTTERY AT YOUR ESTABLISHMENT? YES  NO  18. IS THE APPLICANT’S LOCATION READY FOR AN INITIAL INSPECTION? YES  NO  IF NO, WHAT IS THE PROJECTED DATE FOR THE INITIAL INSPECTION?______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 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 ABCA-193 REV 8/94 Surety Bond No._____________________________________________ ALCOHOL BEVERAGE CONTROL BOND THIS BOND MAY BE USED BY AN ASSOCIATION OR CORPORATION KNOW ALL MEN BY THESE PRESENTS: That WE, of County, West Virginia, ASSOCIATION doing business under the firm name CORPORATION of as principal, and , a corporation authorized to do business in the State of West Virginia, as surety, are held and firmly bound unto the STATE OF WEST VIRGINIA in the full and just sum of Five Thousand Dollars ($5,000.00), to the payment whereof well and truly to be made, we bind ourselves, our successors and assigns, jointly and severally, firmly by these presents. THE CONDITION of the above obligation is such that whereas the above bound principal is about to obtain a license in pursuance of the provisions of Article 7, Chapter 60 of the Code of West Virginia, of 1931, as amended and regulations promulgated thereunder by the Commissioner , a LICENSE TO OPERATE A PRIVATE CLUB on the premises described in the application for such license. NOW, THEREFORE, if the said principal shall faithfully observe the laws of the State of West Virginia, and regulations promulgated thereunder by the Commissioner with respect to the distribution, sale and dispensing of alcoholic liquors, and the operation of a private club, then this obligation to be void; otherwise to remain in full force and effect, and if the license of said principal shall be revoked, then the full amount of this bond shall be forfeited to the State of West Virginia, and said amount when received by the State shall be credited to the state fund, general revenue. This bond is executed in pursuance of the provisions of said Article 7, Chapter 60 of the Code of West Virginia, of 1931, as amended, and regulations promulgated thereunder by the Commissioner, and the pertinent provisions of said article and regulations are hereby made a part of this bond. ASSOCIATION APPLICANTS EXECUTE BELOW IN WITNESS WHEREOF, each owner/member of the principal has hereunto set his hand and affixed his seal, and the said surety has caused its corporate name to be signed hereto and its corporate seal to be hereunto affixed by its official or agent thereunto duly authorized, and this bond is to be effective from the day of , ______ , to the 30th day of June, _____ , unless sooner released by the State of West Virginia or cancelled by the surety after due notice to all parties concerned. Signed and dated this day of , ALL OWNERS MUST SIGN AS PRINCIPALS (SEAL) PRINCIPAL (SEAL) (SEAL) (SEAL) (SEAL) SURETY SURETY CORPORATE SEAL (SEAL) BY ITS (TITLE) COUNTERSIGNED BY: WEST VIRGINIA RESIDENT AGENT OF SURETY American LegalNet, Inc. www.FormsWorkFlow.com CORPORATION APPLICANTS EXECUTE BELOW IN WITNESS WHEREOF, the said principal and the said surety have caused their respective corporate names to be signed hereto and their respective corporate seals to be hereunto affixed by their respective officials or agent thereunto duly authorized, and this bond is to be effective from the day of , ______ , to the 30th day of June,______ , unless sooner released by the State of West Virginia or cancelled by the surety after due notice to all parties concerned. Signed and dated this day of PRINCIPAL CORPORATE SEAL , PRINCIPAL BY (Seal) SURETY SURETY CORPORATE SEAL (Seal) (Seal) BY ITS (Title) ASSOCIATION ACKNOWLEDGMENT STATE OF WEST VIRGINIA, COUNTY OF , To-wit: I, , a Notary Public in and for the county and state aforesaid, do hereby certify , who signed the writing above, or hereto annexed, for , an association, on the day of , (has) (have) this day in my said county, before me, acknowledged the said writing that , to be the act and deed of said association. day of Given under my hand this , . NOTARY PUBLIC My commission expires on the day of , . CORPORATIONS - CORPORATION ACKNOWLEDGMENT STATE OF WEST VIRGINIA, COUNTY OF , To-wit: I, , a Notary Public in and for the county and state aforesaid, do hereby certify that , who signed the writing above, or hereto annexed, for , a corporation, on the day of , (has) (have) this day in my said county, before me, acknowledged the said writing , to be the act and deed of said corporation. Given under my hand this day of , . NOTARY PUBLIC My commission expires on the day of , . BONDING COMPANY - CORPORATE ACKNOWLEDGMENT STATE OF WEST VIRGINIA, COUNTY OF , To-wit: I, , a Notary Public in and for the county and state aforesaid, do hereby certify that , who signed the writing above, or hereto annexed, for , a corporation, on the day of , (has) (have) this day in my said county, before me, acknowledged the said writing , to be the act and deed of said corporation. Given under my hand this day of , . NOTARY PUBLIC My commission expires on the day of , . American LegalNet, Inc. www.FormsWorkFlow.com ABCA - 194 For Fiscal Year _________ to ___________ Surety Bond #:_________________ NONINTOXICATING BEER BOND THIS BOND MAY BE USED BY AN INDIVIDUAL, PARTNERSHIP, ASSOCIATION OR CORPORATION KNOW ALL MEN BY THESE PRESENTS: That (I) (we), If individual or partnership insert name of people Corporation or association insert name of corporation or association being Insert one above An Individual, Partnership, Corporation, or Association doing business under the name of / / (County) (Mailing Address) (City) West Virginia, as principal, and a corporation authorized (Name of corporate surety) to do business in the State of West Virginia, as surety, are held and firmly bound unto the STATE OF WEST VIRGINIA in the full and just sum of One Thousand Dollars ($1,000.00), to the payment whereof well and truly to be made, we bind ourselves, our successors and assigns, jointly and severally, firmly by these presents. THE CONDITION of the above obligation is such that whereas the above bound principal is about to obtain a license in pursuance of the provisions of: Article 16, Chapter 11 of the Code of West Virginia, of 1931, as amended, and regulations promulgated thereunder by the Commissioner, a CLASS A RETAIL DEALER'S LICENSE to sell nonintoxicating beer on the premises described in the application for such license. NOW, THEREFORE, if the said principal shall faithfully observe the laws of the State of West Virginia, and regulations promulgated thereunder by the Commissioner, with respect to the distribution, sale and dispensing of nonintoxicating beer, then this obligation to be void; otherwise to remain in full force and effect, and if the license of said principal shall be revoked, then the full amount of this bond shall be forfeited to the State of West Virginia, and said amount when received by the State shall be credited to the state fund, general revenue. This bond is executed in pursuance of the provisions of said Article 16, Chapter 11 of the Code of West Virginia, of 1931, as amended, and regulations promulgated thereunder by the Commissioner, and the pertinent provisions of said articles and regulations are hereby made a part of this bond. INDIVIDUAL OR PARTNERSHIP APPLICANTS EXECUTE BELOW IN WITNESS WHEREOF, the said principal(s) (has) (have) hereunto set (his) (their) hand and seal(s), and the said surety has caused its corporate name to be signed hereto and its corporate seal to be hereunto affixed by its official or agent there unto duly authorized, and this bond is to be effective from the ________ day of , , to the 30th day of June, _________, unless sooner released by the State of West Virginia or cancelled by the surety after due notice to all parties concerned. day of Signed and dated this , (All Partners Must Sign As Principal) Principal: Surety: (Seal) Address: (Seal) (Seal) By: Title (SURETY CORPORATE SEAL) (Seal) CORPORATE OR ASSOCIATION APPLICANTS EXECUTE BELOW IN WITNESS WHEREOF, the (said corporate principal) (said association principal) and the said surety have caused their respective names to be signed hereto and their respective seals to be hereunto affixed by their respective officials or agents thereunto authorized, and this bond is to be effective from the day of , , to the 30th day of June _______,unless sooner released by the State of West Virginia or cancelled by the surety after due notice to all parties concerned. Signed and dated this day of , Surety: INSTRUCTIONS FOR SIGNING If Association or Fraternal Club has two owners, all must sign bond as Association principals. If ownership involves more than two persons, one officer or (owner) can be Address: (Seal) By: Its: (SURETY CORPORATE SEAL) empowered to sign on behalf of Association. Corporation must be signed by President (Title) or Vice-President. If any other officer signs, attach corporate resolution or Power of Attorney permitting him to bind corporation. Association (Seal) Resident Agent:__________________________________ Address:________________________________________ ________________________________________ Phone No:______________________________________ (Seal) (Seal) Principals: (Seal) Corporate Name: By: American LegalNet, Inc. www.FormsWorkFlow.com (Seal) Its: Title Note: No. 1 -To be completed by Notary Public for an Individual or Partnership. No. 2 -To be completed by Notary Public for a Corporation or an Association. No. 3 -To be completed by Notary Public for Bonding Company Signature. Power of Attorney should be attached and dated, notarized same day as issuance of bond. NO. 1 - INDIVIDUAL OR PARTNERSHIP ACKNOWLEDGMENT STATE OF WEST VIRGINIA, COUNTY OF _______________________________, To-wit: I,_________________________ , a Notary Public in and for the county and state aforesaid, do hereby certify that ________________________________,whose name(s) (is) (are) signed to the writing above or hereto annexed, bearing date on the ______ day of __________ , ______, (has) (have) this day acknowledged the same before me in my said county. Given under my hand this _______ day of _________________ , ______. _____________________________________________________________ Notary Public My Commission expires on the _______ day of _______________, _____. NO. 2- CORPORATION OR ASSOCIATION ACKNOWLEDGMENT STATE OF WEST VIRGINIA, COUNTY OF ______________________________, To-wit: I, ________________________ , a Notary Public in and for the county and state aforesaid, do hereby certify that _________________________________, who signed the writing above, or hereto annexed, for ___________________,(a corporation) (an association), bearing date on the ______ day of ______________ , ________ , (has) (have) this day in my said county, before me, acknowledged the said writing to be the act and deed of said (corporation) (association). Given under my hand this ______ day of _________________ , ________. ______________________________________________________________ Notary Public My commission expires on the ______ day of __________________ , _______. NO. 3-BONDING COMPANY - CORPORATE ACKNOWLEDGMENT (For Individual Signing For Surety) STATE OF WEST VIRGINIA, COUNTY OF ________________________________, To-wit: I, ___________________________ , a Notary Public in and for the county and state aforesaid, do hereby certify that _______________________________ , who signed to the writing above, or hereto annexed for ___________________ , a corporation, bearing date on the _______ day of ___________ , ______, (has) (have) this day in my said county, before me, acknowledged the said writing to be the act and deed of said corporation. Given under my hand this _______ day of ____________________, _______. ______________________________________________________________ Notary Public My commission expires on the _______ day of __________________, ______. 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.FP3 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 obverse (front) portion of this form. To: Municipal Clerk or Recorder Under the requirements set forth in 60-7-4a and/or 11-16-8(a)(5) of the W. Va. State Code, a person intending to apply for a license to operate an ABCA licensed Private Club, Private Wine Restaurant or Tavern 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 Alcohol Beverage Control Administration. Pursuant to this requirement, notice is herein given that the following intends to apply to the WV ABCA for a license to operate a Private Club, Private Wine Restaurant, Private Wine Bed and Breakfast, Private Wine Spa, or Tavern issued pursuant to the provisions of §§ Chapter 60, Article 7 and Article 8 and/or 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: __________________________________________________ _____________________________________________________________________________ Food Services to be Offered: ______________________________________________________ _____________________________________________________________________________ Patron Capacity: _______________________________________________________________ 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 Private Club, Private Wine Restaurant, Private Wine Bed and Breakfast, Private Wine Spa, or Tavern described consistent with the zoning ordinances or your municipality as either a permitted use or a conditional use of such premises? Yes _______ No _______ 1. (a) If the answer to the first question is “no,” does your municipality provide within its business zones suitable alternative locations for Private Club, Private Wine Restaurant, Private Wine Bed and Breakfast, Private Wine Spa, or Tavern? Yes _______ No _______ 2. Is the proposed location for the Private Club, Private Wine Restaurant, Private Wine Bed and Breakfast, Private Wine Spa, or Tavern herein described situated in an area designated for the use of community development block grant funds in the municipality? Yes _______ No ________ 2. (a) If yes, is the planned use of the premises at the location herein described consistent with any plan adopted by the governing body of the municipality for revitalization of the area wherein the premises are situated? Yes _______ No ________ 3. Does the municipality have any restrictions or regulations prohibiting Limited Video Lottery? Yes _______ No ________ 4. Does the municipality have any restrictions or regulations prohibiting Exotic Dancing establishments? Yes _______ No ________ 5. Additional comments to the Alcohol Beverage Control Administration: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. _____________________________________________________________________ Approved by (Authorized Official Signature and Title): _____________________________________________________________________ City/Town Date: ____________________________________ Return Original To: WVABCA Licensing Department 322 70th Street, SE Charleston, WV 25304-2900 American LegalNet, Inc. www.FormsWorkFlow.com