STATE OF WEST VIRGINIA DEPARTMENT OF REVENUE ALCOHOL BEVERAGE CONTROL ADMINISTRATION 900 Pennsylvania Avenue, 4th floor Charleston, WV 25302 INSTRUCTIONS FOR COMPLETING APPLICATION FOR RETAIL CLASS A LICENSE-ON PREMISES PLEASE READ ALL THE INSTRUCTIONS CAREFULLY. ALL QUESTIONS ARE TO BE ANSWERED IN FULL. APPLICANT222S 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 ANSWERES ON FORMS Please find enclosed: 1.) Application for Retail License, Consumption on Premises, Class A (ABCA 226 192A) 2.) Release of Information & Waiver of Confidentiality of Records (ABCA-Lic. RIWCR.2) 3.) Alcohol Beverage Control Bond (ABCA-193) and Nonintoxicating Beer Bond (ABCA-194) 4.) Floor Plan (ABCA-Lic.FP3), give dimensions of licensed premises 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 questions/description cannot be completed in the available space on the application, please submit additional pages as needed. Each additional page submitted must include entity name, DBA name, and indicate which question applicant is answering. Applications must be completed correctly and all necessary paperwork included when mailed to the WVABCA. Failure to do so will result in the application being delayed and/or returned to the applicant for the necessary corrections. LEASE 226 Applicants must provide a copy of a valid lease if not the property owner. LICENSE FEES 226 License fees must be paid by Certified Check, Cashier222s Check, or money order. Personal checks, business checks, or cash will not be accepted. Make checks payable to the WVABCA. All retail licenses are valid from issue date to June 30th of the current licensing period. If applying for a license to be issued after December 31st, most license fees are semi-annually prorated to half the initial fee. American LegalNet, Inc. www.FormsWorkFlow.com LIVE SCAN FINGERPRINTING 226 All applicants must complete a Live Scan Fingerprint in order to obtain a valid license. IdentoGO by MorphoTrust will provide fingerprinting services for all WVABCA license applicants. Contact IdentoGo at 855-766-7746 or online at https://uenroll.identogo.com for information on fingerprinting, locations, scheduling appointments, and fee requirements. Fingerprint result reports MUST be sent to WVABCA directly from Morpho Trust. NO REPORTS WILL BE ACCEPTED DIRECTLY FROM LICENSE APPLICANTS. BONDS 226 Applicants must have a $1,000.00 Nonintoxicating Beer Bond and/or a $5,000.00 Alcohol Beverage Control Bond completed on the form(s) provided by the WVABCA. (If applying for a Brew Pub only no bond is required.) HEALTH PERMIT 226 Applicants must provide a copy of a valid Health Permit issued in applicant222s name. (If Association, Limited Liability Company, or Corporation, the Health Permit must be issued in the business entity name and list the DBA name.) WV SECRETARY OF STATE 226 All Associations, Corporations, Limited Liability Companies, Non-Profit Clubs, and Fraternal Organizations must be duly certified and registered with the WV Secretary of State. INSTRUCTIONS FOR SIGNING: a.) If an individual, by the owner b.) If a partnership, by each member of the partnership (Copy of Partnership Agreement to be submitted to WVABCA) 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 223Special Occupation Tax (TTB F 5630.5d)224 with the Alcohol and Tobacco Tax and Trade Bureau. Form and instructions are available through download at the following website: http://www.ttb.gov/forms/f56305d.pdf or by calling the toll-free number at 1-800-937-8864. A copy of the TTB form must be submitted with application to the WVABCA. BUSINESS CLOSURE If Issued the license may not be abandoned, rented, leased, given, loaned, or sold to another. Upon sale or closure of the applicant222s business, the license must be returned to the WVABCA Licensing Division. Please include reason for closure, date business closed, and signature on back of license. MAIL COMPLETED APPLICATION, FEES, AND REQUIRED ACCOMPANYING FORMS TO: West Virginia Alcohol Beverage Control Administration ATTN: Licensing Division 900 Pennsylvania Avenue, 4th Floor Charleston, WV 25302 IF YOU HAVE ANY QUESTIONS OR NEED ASSISTANCE PLEASE CALL THE ADMINISTRATION AT 1-800-642-8208 OR (304) 356- 5500 AND ASK FOR THE LICENSING DIVISION. American LegalNet, Inc. www.FormsWorkFlow.com CHECKLIST OF FORMS/PAPERS TO RETURN TO THE WVABCA, LICENSING DIVISION: Application Form Release of Information & Waiver of Confidentiality of Records Copy of Valid Lease (if not owner) License Fee(s) Floor Plan Copy of Valid Health Permit Zoning Form completed by applicant & municipality if within city limits or, Zoning Form completed by applicant & letter from County Commission if outside city limits Copy of TTB form Bonds Copy of menu for Private Club and Private Wine Restaurant Naturalization papers (if applicable) FRATERNAL REQUIREMENTS: 1.) A copy of the by-laws. 2.) A list verifying the names, addresses and phone numbers of the officers of the national and/or state organization with which your organization is affiliated. 3.) A list verifying the names, addresses and phone numbers of all dues-paying members. 4.) A copy of all documents verifying membership in a national and/or state charter. 5.) A copy of all documents verifying that the national and/or state charter with which your organization is affiliated permits lodges to seek a WVABCA license. 6.) A copy of all motions and/or minutes where the president and/or officers of your organization were permitted or authorized by the membership to seek a WVABCA license. American LegalNet, Inc. www.FormsWorkFlow.com WEST VIRGINIA ALCOHOL BEVERAGE CONTROL ADMINISTRATION APPLICATION FOR RETAIL LICENSE CONSUMPTION 223ON PREMISES224 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 Fraternal Club 205205205205..205..$900* Private Club (less than 1,000 members) 205205205205205205205205$1,150* Private Club (more than 1,000 members) 205205205205205205205...$2,650* Off Premises Wine Sales205.$100 *These fees include liquor, wine, and beer. B. WINE APPLICATION Private Wine Restaurant205..$250 Private Wine Spa205205205205205...$150 Private Wine Bed & Breakfast205205205.205205205205.........$150 Off Premises Wine Sales205205$100 C. BEER APPLICATION Fraternal205205205205205205205205205205..$150 Tavern, Restaurant, Etc.205205205205205205205205205205205.....205.$150 Brew Pub205205205.205205205..........$500 (Resident Brewers Only) *Must hold Resident Brewer License prior to applying for Brew Pub License D. APPLYING AS: (CHECK ONE) Individual Partnership Limited Partnership Corporation Association Limited Liability Corporation Only Associations, Corporations, or Limited Liability companies may apply for liquor license. Email (Required): Fax Number: WV TAX I.D./FEIN: 1.) Applicant/Entity Name: 2.) Doing Business As (DBA) Name: 3.) Business Address: (STREET) (CITY) (STATE) (ZIP CODE) (TELEPHONE) 4.) Mailing Address (required): (STREET) (CITY) (STATE) (ZIP CODE) (TELEPHONE) 5.) SUPPLY THE FOLLOWING INFORMATION ABOUT OWNER(S) AND/OR OFFICER(S) AND MANAGER(S). US Citizen** Title Name Residence Address, City, State and Zip Code % Ownership Y/N / / - - Date of Birth Social Security Number Telephone Number YRS Resident of WV Title Name Residence Address, City, State, and Zip Code % Ownership Y/N / / - - Date of Birth Social Security Number Telephone Number YRS Resident of WV Title Name Residence Address, City, State and Zip Code % Ownership Y/N / / - - Date of Birth Social Security Number Telephone Number YRS Resident of WV Title Name Residence Address, City, State, and Zi