Application For New D-5B Permit {DLC 4137}

For Questions call (614) 644-3155 Office Hours 8:00 - 5:00 OHIO DEPARTMENT OF COMMERCE DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD, P.O. BOX 4005 REYNOLDSBURG, OHIO 43068-9005 http://www.com.ohio.gov/liqr APPLICATION FOR NEW D-5B PERMIT - Fee $2,344.00 CAUTION: ALLOW 10 TO 12 WEEKS FOR PROCESSING THE FOLLOWING ITEMS MUST BE SUBMITTED FOR YOUR APPLICATION TO BE ACCEPTED FOR PROCESSING A. B. C. D. E. F. G. Processing Fee of $100.00 Application completed in its entirety, notarized and signed. If Individual, list Social Security Number on line provided. ________________________________________. If Partnership, you must submit a completed DLC Form 4031, along with a copy of the Partnership Agreement. If Corporation, you must submit a completed DLC Form 4030. If Limited Liability Company, you must submit a completed DLC Form 4032. If filing for a D-6, you are not required to submit any documentation listed on page 4, complete A & C only on pages 1 & 2. Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. FAILURE TO RESPOND TO ALL QUESTIONS WILL RESULT IN THE RETURN OF YOUR APPLICATION. If you would like a Class D6 with your D-5B, please check the box: D-6 - with D class $500.00 (WHEN APPLYING FOR D-6 CLASS ALONE, YOU ARE ONLY REQUIRED TO COMPLETE SECTIONS A, B, & D). SECTION A NAME OF ENCLOSED SHOPPING CENTER OR MALL: Address: City: YES NO State: Zip Code: 1. Is enclosed shopping center or mall under construction? If YES, give estimated date of completion on the line provided, SECTION B Applicant (Individual, Corporation, Limited Liability Company or Partnership) DBA (doing business as): Township (if outside city limits): Residence Phone #: Email Address: Address: Attorney's Name: City, State, & Zip: Pending or Issued State Liquor Agency Number, (if applicable): City: Permit Premises Address: Zip Code: County: Business Phone #: Phone # Coder: Taxing District: Permit Number CLASS FOR DIVISION USE ONLY REMARKS: RCPT# Proc. Fee Pd: YES NO BCI Fee Amount Paid: $ __________ REVIEWER ACTION: Trans. Code DLC 4137 Bus. Type EOE/ADA SERVICE PROVIDER PAGE 1 FOR TTY USERS DIAL ORS 1-800-750-0750 REV. 02/2013 American LegalNet, Inc. www.FormsWorkFlow.com SECTION C 1. Do you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit hold or have any interest in another permit business? If YES, Give permit number & address on the line provided YES NO 2a. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been convicted of a felony or misdemeanor, or pled guilty, accepted a plea bargain or reduced charge in any criminal proceeding, including any alcohol-related offenses, or criminal traffic offense? If YES, attach a written explanation. 2b. If applicant is a sole proprietor or partnership, will spouse work on the permit premises? If YES, indicate spouse's full name 3. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been refused a permit, denied a renewal, or had a permit revoked from another state, by this Division, or the Liquor Commission? If YES, attach a written explanation. 4. Do you own the real estate on which the proposed business will be located? If NO, return a completed a signed and dated copy of your LEASE OR RENTAL CONTRACT, OR SUMMARY OF TENANCY RIGHTS form (DLC form 4085). 5. Will the applicant be the sole owner of the business and equipment? If NO, and the fixtures or equipment are rented, submit signed and dated copy of rental agreement. 6. Will any person, partnership, LLC, or corporation, excluding banks or building and loan associations, have ANY financial interest (such as money, loans, installment contracts, property or other interest) or share in the profits in your business or your property, real or personal? If YES, attach an affidavit with details. NOTE: Ohio Revised Code Section 4303.293 provides a criminal penalty for failure to answer this question completely and correctly. YES YES NO NO YES YES NO NO YES NO YES NO 7. If filing as an individual or partnership, is individual or all partners a U.S. citizen? 8. Do you or any partner, office holder, managing member, 5% stockholder or member, employee, spouse, or other person involved in this permit own any stock or have any interest in the business of a manufacturer or wholesale distributor of alcoholic beverages? If YES, attach a written explanation. YES NO YES NO SECTION D - SHOULD BE ANSWERED ONLY IF APPLYING FOR A D-6 9. What percentage of your total gross receipts is currently, or do you estimate will be, attributed to the sale of food and other goods (excluding alcoholic beverages)? 10. If you hold "D" class permit(s) and your D-6 request can be approved for carryout only, do you still desire this permit? DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THE APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION. THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT: YES NO State of Ohio, I, (Please Print) County, ss being first duly sworn, according to law, depose and say that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) _____________________ (Title) _______________ (Date) (Residence Address) (To be completed by Notary Public) (City) (State) (Zip Code) (Area Code & Telephone Number) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) NOTE: ALL DOCUMENTS BECOME PART OF THE PERMIT FILE AND WILL NOT BE RETURNED PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com _______________ (Notary Expiration) DLC 4137 REQUIRED DOCUMENTS FOR ACCEPTANCE OF A D5B PERMIT APPLICATION Please use the list below to check off all items as you complete them, to submit with the application packet