Application For Off-Premises Caterer Liquor Permit

For Official Use Only DCPLC ­ Off-Premises Caterer App Rev 10/14 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 OFF-PREMISES CATERER LIQUOR PERMIT Please print clearly or type the information entered on this application. An application and permit fee of $540.00 is required. 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 ADDRESS AT WHICH BUSINESS WILL BE CONDUCTED 1. Trade Name (DBA Name) 2. Business Address 3. Business Telephone Number 4. Business Fax Number City 5. Business Email Address If yes, current permit number NO State Zip Code 6. Is there currently a liquor permit at the proposed premises? YES 7. Will you be regularly engaged in the business of providing food and beverages to others for service at private gatherings or at special events to sell and serve alcoholic liquor for on-premises consumption at any activity, event or function for which such person has been hired? YES NO Section B: PERMITTEE APPLICANT INFORMATION 8. Permittee Name (First, Middle, Last) 9. Permittee Residence Street Address City State Zip Code 10. Permittee Telephone Number 11. Permittee Fax Number 12. Permittee Email Address Section C: PREFERRED MAILING ADDRESS Check () one box below and enter address if different than Business or Permittee Address BUSINESS ADDRESS 13. Name 14. Address City State Zip Code PERMITTEE ADDRESS ADDRESS BELOW American LegalNet, Inc. www.FormsWorkFlow.com DCPLC ­ Off-Premises Caterer App Rev 10/14 2 Section D: BACKER INFORMATION * Each backer must also complete the "Authorization for Release of Financial Information & Statement of Personal History" form that accompanies this application 15. 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 16. Name of Corporation, LLC, Partnership, Sole Proprietorship, etc. 17. Street Address City State Zip Code 18. Backer Telephone Number 19. Backer Fax Number 20. Backer Email Address 21. 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 E: 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. 22a. Does any Permittee or Backer currently hold a liquor permit? 22b. Has any Permittee or Backer held a liquor permit in the past? 23a. Type of liquor permit (e.g., cafe) Liquor permit # YES YES NO NO Name of business If yes, please complete the permit information for each past or present permit below State in which issued Name of backer or permittee for the permit Were/Are you a backer or permittee of the permit? Backer Permittee Dates held 23b. 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 American LegalNet, Inc. www.FormsWorkFlow.com DCPLC ­ Off-Premises Caterer App Rev 10/14 3 Liquor permit # State in which issued Name of business 23c. 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 24. 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 F: CERTIFICATION OF PERMITTEE APPLICANT AND BACKER OR AUTHORIZED REPRESENTATIVE OF BACKER 25. 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. 26. Backer Certification (To be signed Date by backer or the authorized representative Signed by Backer or Authorized Representative of Backer of the backer) Date I certify that the information provided in X__________________________________________________ this application is true to the best of my knowledge and that the permittee Title of Backer or applicant identified in "Section A" of this Print name of Backer or Representative Representative application is designated as my principal representative on the premises for which this application is being submitted. American LegalNet, Inc. www.FormsWorkFlow.com