Special Use Permit Public Service Application

UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 S 900 W PO Box 30408 Salt Lake City, Utah 84130-0408 (801) 977-6800 Fax 977-6888 website: www.abc.utah.gov "SPECIAL USE PERMIT" (PUBLIC SERVICE) APPLICATION CHECKLIST The items below should be completed and submitted by the 10th of the month or earlier, so that your application can be processed in a timely manner. All licensing requirements must be fully satisfied in order to complete your application. You will be notified of the next monthly Utah Alcoholic Beverage Control Commission meeting when your application will be considered for issuance of a license. 1.____Completed application form (enclosed). 2.____Ownership entity organizational papers for business: a) if a corporation, submit a copy of articles of incorporation; b) if a partnership, submit a copy of written agreement; c) if a limited liability company, submit a copy of articles of organization. 3.____Criminal history background check information (see application form). 4.____Written consent from either city/town council or county commission, whichever is applicable (form enclosed). 5.____$1,000 special use permit cash or corporate surety bond (form enclosed). 6.____Scaled floor plan (8 ½"x11") of hospitality room premises only, highlighting the areas where alcohol will be stored, sold and consumed and also reflecting distance between the hospitality room and the arrival and departure area used by carrier. 7.____$75 application fee (nonrefundable). 8.____$250 initial license fee (make checks payable to UDABC). Enclosed are copies of Utah laws and rules pertaining to Public Service Special Use permits. If you have questions concerning these forms or the application process, please contact our Licensing and Compliance Division at (801) 977-6800. American LegalNet, Inc. www.FormsWorkFlow.com Effective 7.1.11 v7.18 page 1 of 25 UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR SPECIAL USE PERMIT (PUBLIC SERVICE) 1. Applicant/Organization:______________________________________________________________ 2. Business Name:_____________________________________________________________________ 3. Location: __________________________________________________________________________ Street City State Zip 4. Mailing Address:____________________________________________________________________ Street P O Box City State Zip 5. Business phone: __________________ Other phone:_________________ Fax: __________________ 6. Contact person: _________________________________ E-mail: ____________________________ 7. Ownership: Check appropriate box and provide the requested information in the space below. (add additional sheets if necessary). [] Applicant is an individual: List below information for: (a) Individual [] [] Applicant is a partnership: List below information for: Applicant is a corporation: List below information for: (a) All Partners (a) Any Stockholder owning at least 20% of the corporation (b) All Corporate officers and Directors (a) Any members owning at least 20% of the company [] Applicant is a limited liability company (LLC): List below information for: TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. Effective 7.1.11 v7.18 page 2 of 25 American LegalNet, Inc. www.FormsWorkFlow.com 8. Criminal History. The law prohibits any person who has been convicted of a felony under any federal or state law or any violation of any federal or state law or local ordinance concerning the sale, manufacture, distribution, warehousing, adulteration, or transportation of alcoholic beverages from being in the alcoholic beverage business. The law also prohibits any person who has been convicted of any crime involving moral turpitude or, on two or more occasions within the last five years, has been convicted of driving under the influence of alcohol, or any drug, or the combination of alcohol and any drug from being in the alcohol business. This proscription also applies to any officers, partners, managers, managing agents, directors, stockholders who hold at least 20% of the total issued and outstanding stock of an applicant corporation, members who own at least 20% of an applicant limited liability company and to any person employed to act in a supervisory or managerial capacity. Please list all criminal offenses other than minor traffic offenses of which you or any of the above persons have ever been convicted: NAME CRIMINAL OFFENSE DATE OF CONVICTION In addition, a criminal history background check must be furnished on each person listed above and in subparagraph 7. This may be done as follows: a. Utah residents: If any person listed has been a resident of Utah for at least two years, he/she shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Utah Bureau of Criminal Identification. b. Non Residents: Out of state residents or persons who have resided in Utah for less than two years shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Federal Bureau of Investigation (F.B.I). An informed consent and release of liability form is included with this application. Fingerprint cards are available at law enforcement agencies. You may download the fingerprint card at this web address: http://www.fbi.gov/hq/cjisd/pdf/fpcardb.pdf Submit the form(s) to the DABC with a processing fee of: · $20.00 per card for BCI background checks, or · $39.25 per card for FBI background checks. In the case of a