Application For Gift Basket Retailer Liquor Permit

For Official Use Only DCPLC ­ LWG App New 9/11 1 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Email: liquor.control@ct.gov Web Site: www.ct.gov/dcp APPLICATION FOR SALE OF WINE WITH GIFT BASKETS Please print clearly or type the information entered on this application. An application and permit fee is required. Please submit the required fee of $300.00. Checks and/or money orders should be made to "Treasurer, State of Connecticut" and must accompany this application. The application fee is non-refundable. Return your completed application, documentation and appropriate fee to: Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT 06106 Section A: BUSINESS INFORMATION 1. Trade Name (DBA Name) 2. Business Address 3. Is there currently a liquor permit at the proposed premises? YES NO 5. Business Telephone Number City If yes, current permit number State Zip Code 4. Are you requesting a Provisional Permit? YES NO 6. Business Fax Number 7. Business Email Address Section B: APPROVAL/CERTIFICATION OF LOCAL OFFICIALS 8. Zoning Authority Approval: I certify that I am familiar with the zoning ordinances and bylaws of the city/town identified in item #2 of this application and they do not prohibit the sale of alcoholic beverages under the type of liquor permit/establishment identified in this application and/or entertainment listed in #10. Signature of Zoning Official X _______________________________________Print Name ____________________________________ Title of Official ______________________________________________________________________ Date ______ /______ /________ 9. Certification of Town Clerk: The town in which the business identified in item # 4 of this application is to be operated, has no ordinance restricting the hours of sale of alcoholic liquors beyond those set forth in State law except as indicated in the box below. (If none, please enter "NONE") Additional Restrictions: Signature of Town Clerk X_____________________________________________________________ Date ______ /______ /________ Section C: PERMITTEE APPLICANT INFORMATION 10. Permittee Name (First, Middle, Last) 11. Permittee Residence Street Address City State Zip Code 12. Permittee Telephone Number 13. Permittee Fax Number 14. Permittee Email Address American LegalNet, Inc. www.FormsWorkFlow.com DCPLC ­ LWG App New 9/11 2 Section D: PREFERRED MAILING ADDRESS Check () one box below and enter address if different than Business or Permittee Address BUSINESS ADDRESS 15. Name 16. Address City State Zip Code PERMITTEE ADDRESS ADDRESS BELOW Section E: BACKER INFORMATION * Each backer must also complete the "Authorization for Release of Financial Information & Statement of Personal History" form that accompanies this application 17. Backer: Please select the type of Backer (individual or legal entity that owns the business) below Please check () only one Sole Proprietorship/ Owner Corporation Limited Liability Company Partnership Limited Liability Partnership Unincorporated Association 18. Name of Corporation, LLC, Partnership, Sole Proprietorship, etc. 19. Street Address City State Zip Code 20. Backer Telephone Number 21. Backer Fax Number 22. Backer Email Address 23. Backers: List individuals below (for example; sole owner, corporate officers, members, etc.) Attach additional sheet if needed. a. Name (First, Middle, Last) Title % of ownership or # of shares b. Name (First, Middle, Last) Title % of ownership or # of shares c. Name (First, Middle, Last) Title % of ownership or # of shares d. Name (First, Middle, Last) Title % of ownership or # of shares Section F: CURRENT OR PREVIOUS LIQUOR PERMITS HELD BY PERMITTEE OR BACKER This section applies to the permittee applicant, and to each backer who is a sole proprietor, partner or a member of a partnership organization, corporation, and members of a limited liability organization or unincorporated associations. Attach a separate sheet if needed. 24a. Does any Permittee or Backer currently hold a liquor permit? 24b. Has any Permittee or Backer held a liquor permit in the past? YES YES NO NO If yes, please complete the permit information for each past or present permit below American LegalNet, Inc. www.FormsWorkFlow.com DCPLC ­ LWG App New 9/11 3 Liquor permit # State in which issued Name of business 25a. Type of liquor permit (e.g., cafe) Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 25b. Type of liquor permit (e.g., cafe) Liquor permit # State in which issued Name of business Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 25c. Type of liquor permit (e.g., cafe) Liquor permit # State in which issued Name of business Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 26. Have any of the permits listed above been revoked, suspended or denied in CT or any other state? YES NO If yes, attach a statement detailing the enforcement action(s) taken including violation(s), date(s), and the circumstance(s) involved. Section G: CERTIFICATION OF PERMITTEE APPLICANT AND BACKER OR AUTHORIZED REPRESENTATIVE OF BACKER 27. Permittee Certification (To be signed by permittee applicant, identified Signed by Permittee Applicant in "Section A" of this application) I certify that the information provided in this application is true to the best of my X__________________________________________________ knowledge. 28. Backer Certification (To be signed Date by backer or the authorized representative of the backer) Signed by Backer or Authorized Representative of Backer Date I certify that the information provided in X__________________________________________________ this application is true to the best of my knowledge and that the permittee Print name of Backer or Representative Title of Backer or applicant identified in "Section A" of this Representative application is designated as my principal representative on the premises for which this application is being submitted. American LegalNet, Inc. www.FormsWorkFlow.com DCPLC - LWG INST New 9/11 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Web Site: www.ct.gov/dcp INSTRUCTIONS AND INFORMATION Sale of Wine With Gift Baskets Application PLEASE READ ALL INSTRUCTIONS AND INFORMATIO