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6412 SW 59 PL_GREEN ALCOHOLIC LICENSE i Lightfoot, Marcus From: Brimo, Christopher Sent: Monday, April 02, 2012 9:54 AM To: Lightfoot, Marcus Subject: 6412 SW 59th# .- Liquor License P Marcus: In light of the additional information provided by the applicant related to their request for zoning approval of a ZAPS (beer/wine) alcohol license, it is evidenced that a liquor license has been active at this address for some time,and the current license is still in effect through March 31, 2012.The original approval of this request was resubmitted due to a notary error, prior to the expiration of the existing license. I will be providing zoning approval to the applicant DBA "Gigi's Convenience Store"for the license series(2APS). Chris Christopher Brimo,AICP Planning Director City of South Miami 6130 Sunset Drive South Miami, FL 33143 Tel: 305-663-6327 Fax: 305-668-7356 The City of South Miami is a public entity,subject to Chapter 119 of the Florida Statutes concerning public records. E-mail messages and their attachments are covered under such laws and thus subject to disclosure.All e-mail sent to and received at this address,is captured by our servers and kept as a public record. 1 DBPR ABT-6001 —Division of Alcoholic Beverages and Tobacco Application for New Alcoholic Beverage License and Tobacco Permit STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6001 Revised 09/2010 NOTE—This form must be submitted as part of an application packet If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&Ts page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district offices/licensing.html } _y °r�.SECTION 1'-CHECK LICENSE CATEGORX , v; r . . . b , r License Series Requested Type/Class Requested Do you wish to purchase a Temporary License? Yes ❑ No Child License Requested Number of Child Licenses Requested ]Betail Alcoholic Beverages El Alcoholic Beverage Manufacturer eer/Wine/Liquor etail Tobacco Products (must check one or more of the below) Wholesaler ❑Pipes Only 01:�jer the Counter.❑Vending Machine ❑ Passenger Waiting Lounge SEC -10,,, LICEN$ 1,,, `()FtIVIATI.ON o; tati If the applicant is a corporation or other legal entity, enter the name and the document number as registered with the Florida Department of State Division of Corporations on the line below. Fu f plic : (T is is t n the lic s will be iss i Department of State Document# ber usine Telephone Nu ber Locatio Address treet and Nu tpd City o ty State Zip Code C!�! FL 3 /� ocait er:tion i§within the cit li its or❑ Location is in the unincorporated county tt act Per n Telephone Nu ber 14 ext. E-Ma d r 1-jNz)'VLQ2V4--&1� ng ss or P.O. -51 ity to Zip Code 1-43 ABT District Office Received/Date Stamp Auth.61A-1.023&61A-5.056,FAC 5 SECTION.3-RELATED PARTY PERSONAL INFORMATION This section must be completed for each person directly connected with the .business, unless tFiey. } are a currentlicensee. 1. Busine am(/B/A) U UVO r 2. uIIN'J idual tZ Social Sec tuber* o e��Rio a umber Date Birt n x Height fight -. e Color r of c 3. a you a U.S. citizen? (�Yes ❑ No If no, immigration card number or passport number: 4. Home Address(Street and Number) 4-�X' Zip Code you currently o n or have an interest in any business selling :alcoho is beverages, wholesale cigarette or tobacco products, or a bottle club? 1 Yes ❑ No f es, provide the information re uested o-. The location address should include the city and state. si ess me(D/ ) License Number MJO L i ddres 6. Have you ha a ype o o lic eves or bottle club license, or cigarette, or tobacco permit refused, revoked or suspended anywhe in t past 15 years? . ❑ Yes No If y es provide the informs'on requested below. The location address should incl de the city and state. Business Name(D/B/A) A Date Xf Location Address 7. Have you been convicted of a felony within the past 15 years? ❑Yes ONo If yes, provide the information requested below and provide a Copy the Arrest Disposition, as requested in the Application Requirements checklist. Date Location Type of Offense to 8. Have you been convicted of an offense involving alcoholic beverages anywhere within the past 5 years? ❑Yes .❑ No If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as requested in he Applicat ion Requirements chec list. Date �d A Location Type of Offense /JCL Auth.61A-1.023&61A-5.056,FAC 2 J SECTION 5-APPLICATION APPROVALS F f �jcan . (Misi hi he I' ns b 's in) . e D/B/ dre Coun State Zip Code FL ZONING 4 TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series J Wf license. B. This approval includes outside areas which are contiguous tot a premises which are to be part of the premise ought o be licensed and are identified on the sketch?" Yes ❑ No Signed Date X12-1 Title SALES TAX TO BE COMPLETED BY THE DEPARTMENT OF REVENUE The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax. 1. This is to verify that the current owner as named in this application has filed all returns and that all outstanding billings and returns appear to have been paid through the period ending or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not constitute a certificate as contained in Section 212.10(1), F.S. (Not applicable if no transfer involved). 2. Furthermore,the named'applicant for an Alcoholic Beverage License has complied with Florida Statutes concerning registration for Sales and Use Tax, and has paid any applicable taxes due. Signed Date Title Department of Revenue Stamp HEALTH TO BE CO_MPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS OR COUNTY HEALTH AUTHORITY OR DEPARTMENT OF HEALTH, OR DEPARTMENT OF AGRICULTURE&CONSUMER SERVICES The above establishment complies with the requirements of the Florida Sanitary Code. Signed Date Title Agency Auth.61 A-1.023&61 A-5.056,FAC 5 ,SECTION 6'--CflN'� T$OR AGREEMENTS Business m /BIAI 1 l These ques s ust a swered about this for ev ry person or entity listed as the applicant and copies of ag eements must be submitted with this application. If the management, service, or other contractual agreement gives a person or entity control of the licensed premises or the sale of alcoholic beverages, disclosure of those persons must be made in the section labeled "DIRECT INTEREST" in the DISCLOSURE OF INTERESTED PARTIES section. They must also submit fingerprints and a related party personal information sheet. 1. Yes ❑ No I)b Is there a management contract, franchise agreement, or service agreement in connection with this business? 2. Yes ❑ No P9 Are there any agreements which require a payment of a percentage of gross or net receipts from the business operation? 3. Yes ❑ Nop Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from a manufacturer or wholesaler of alcoholic beverages? SECTIONI MAPPM11CANT 1 1 I'fYi�EEMNYWCONVIC71ON Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15 years? ❑Yes Q%o If the answer is "Yes," please list all details including the date of conviction, the crime for which the entity was convicted, and the city, county, state and court where the conviction took place. (Attach additional sheets if necessary) Auth.61 A-1.023&61 A-5.056,FAC 6 S) TtUN 9!—SPEC1Ai.ICNS2E0UIREMEIVT _ DOES NSJT.APP> Y, BEER AND WINE L10EN5E5 Business Name (D/B/A) Please check the appropriate"Special Alcoholic Beverage License" box of the license for which you are applying. Fill in the corresponding requirements for each Special License type. ❑ Quota Alcoholic Beverage License ❑ Special Alcoholic Beverage License ❑ Club Alcoholic Beverage License This license is issued pursuant to Florida Statutes or Special Act, and as such we acknowledge the following requirements must b met and maintained: Please initial and date: Applicant's Initials Date Auth.61A-1.023&61A-5.056,FAC 7 _ SECTI N 9 C?iSCL{?S,4)RE({ FJINTERESTEDIP'RTIES Note: Failure to disclose an interest, rector indirect, coul result in denial, suspension and/or revocation of our license. Business Name(D/B/ � i n e 1. When applicable, as comp) he appropriate set n below. Att h extra sheets if necessary. Title/Position Name Stock% CO PORA (CORP/INC) President Vice President Secretary Treasurer Director(s) Stockholder(s) LIMITED LIABILITY COMPANY LLC/LC Managing Member(s) and/or Managers Members (must be printed if there are no managing members or mana ers LIMITED PARTNERSHIP LTD/LP/LTDLLP General Partner(s) Limited Partner(s) Bar Manager(Fraternal Organizations of National Scope only): DIRECT INTEREST Name of Individual o ntity (If a legal a ti=y, list name under which the entity does business and its principles) E Title/Posi ion TEffEU I Name Stock% 2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan, or any person or entity who has loaned money to the business that is not a traditional lending institution? ❑Yes o If yes, and thlb terms create a direct interest in the business, you must list the person(s)or entity and indicate which of the below applies. Each directly interested person must submit fingerprints and a related party personal information sheet. Copies of a reements must be submitted with this application. Name Guarantor Co-signer Lender Interest Rate List ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ I ❑ Auth.61A-1.023&61A-5.056,FAC 8 r SECTION 11"'-CURRENT LICENSEE t}ADATE DATA SHEET- This section is to be completed for all current alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date inf mation is captured. Business Name(D/B/A) Last Name First M.1. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.1. Current Alcohol Beverage and/or T bacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.1. Current Alcohol Beverage and/or Tob cco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.1. Current Alcohol Beverage and/or T"bacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.1. Current Alcohol Beverage an /or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Auth.61 A-1.023&61 A-5.056,FAC 10 9. Have you been arrested or issued a notice to appear in any state of the United States or its territories within the past 15 years? ❑Yes No If yes, provide the information reque ted below and a Copy of the Arrest Disposition. Attach additional sheet if necessary. Date Location Type of Offense �A 10. Are you an official with State police powers granted by the Florida Legislature? El Yes 9 No OTARIZATIOt STATEME 7' "I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in the Disclosure of Interested Parties of this application. I further swear or affirm that the foregoing information is true and correct." STATE OF r O✓►L COUNTY OF l�'�1�1n(•1D� APPLICANT SIGNATURE� The foregoing was( )Sworn to and Subscribed OR ( )Acknowledged Before me this Q �°'j Day of 1 t wv 241— By r Q'ay le S 1 �' who is( )personally (printHame of person making statement) known to me OR(1/"who produced 1-lor1 J,11 1-v colsP as identification. , e% ° r,• KENGA A.PAYN Commission Ex `= MY-OMMISSION#EE133 2 2� Notary Pub i .. (ATTACH ADDITION A COPIES AS NECESSARY) *Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(1). This information is used to identify licensees for tax administration purposes. Auth.61A-1.023&61A-5.056,FAC 3 • SECTION,�fl-AEI=11 'AVIT F APPLICANT NOTARIZATION REOI)IREE3. Business Name(D/B/A) "I, the undersigned individually, or if a registered legal entity for itself and its related parties, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a true and correct representation of the premises to be licensed and agree that the place of business, if licensed, may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the beverage and retail tobacco laws." "I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that the foregoing information is true and that no other person or entity except as indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license and/or tobacco permit." STATE OF 7- ✓1��- COUNTY OF In 0441-�1417L' APPLICANT SIGNATURE APPLICANT SIGNATURE The foregoing was( ) Sworn to and Subscribed OR Acknowledged Before me this � � Day of 20_�Q ; By G4i 414„ J J t/ who is( ) personally (print Ndme(s)of person(s) making statement) known to me OR(11r who produced 7C 6(1 v /iU ion. PIKENGA A. PAY MY COMMISSION#EE13 2. Commission Expi " ••,,,,, ' 5 otary Public a07 39"m t Auth.61A-1.023&61A-5.056,FAC 9 Licensing Portal - License Search Pagel of 1 1:24:05 PM 3WO12 Data Contained In Search Results Is Current As Of 03/02/2012 01:22 PM. Search Results Please see our glossary of terms for an explanation of the license status shown in these search results. For additional information, including any complaints or discipline, click on the name. f N.i3CIl1"e x tC£!r1e License T ep l axfrie Number/ Stati�sJ9X 49s � e Retail Beverage CHICO'S GOOD N PLENTY DBA BEV2327450 Current, Active 1APS 03/31/2012 License Location Address*: 6412 SW 59TH PLACE MIAMI,FL 33143 Main Address*: 1095 NW 58TH TERRACE MIAMI,FL 33127 CHICO'S GOOD N PLENTY BEV2327450 Current, Active Retail Beverage IN:C Primary 1ARS 03/31/201'2 License Location.Address*: 6412 SW 59TH PLACE MIAMI,_FL 33143 Main Address*: 1095 NW 58TH TERRACE MIAMI,FL 33127 *denotes Main Address-This address is the Primary Address on file. Mailing Address-This is the address where the mail associated with a particular license will be sent(if different from the Main or License Location addresses). License Location Address-This is the address where the place of business is physically located. Contact Us :: 1940 North Monroe Street,Tallahassee FL 32399 :: Call.Center@dbpr.state.fl.us :: Customer Contact Center: 850.487.1395 The State of Florida is an AA/EEO employer.Copyright 2007-2010 State of Florida.Privacy Statement Under Florida law,e-mail addresses are public records.If you do not want your e-mail address released In response to a public-records request,do not send electronic mail to this entity.Instead,contact the office by phone or by traditional mail.If you have any questions regarding DBPR's ADA web accessibility,please contact our Web Master at webmaster@dbor.state.fl.us. 1 Miami-Dade My Home Page 1 of 2 My Home ,c} �y 7 t� MIAMI- ASE 1111=td1ttetWt�t !pj' 4t A q 94 ilAkm Is I= Show Me: .................._...............__......_ Property Information Legend _ ... , w. Search By Property Select Item PEI", Boundary q Selected th rs m SW°G36tDF Property Text only �+ Property Appraiser Tax Estimator n _ � ,�. Street , Property Appraiser Tax , ^0 Highway Comparison y �$T HARD£E o: 5T; Aft Miami-Dade t1AitD£E-t)f21AftDEP�Q ig County Summary Details: Water Folio No.: 09-4025-010-0150 ..; Property: 6412 SW 59 PL Mailing RICHARD ROBINSON&W Address: CARRIET "TER" W E 760 SW 83 ST MIAMI FL n S 3173-4043 '� Property Information: ,_ Primary Zone: 6100 RESTRICTED COMMERCIAL CLUC: 0011 RETAIL OUTLET € Beds/Baths: 0/0 Floors: _ 1 Livin Units: 0 d'Sq Footage: 1,170 ` Lot Size: 13,143 SQ FT Year Built: 11959 Aerial Photography-2009 0 112 ft FRANKLIN SUB PB 5-34 N1/2 OF LOT 15&PORT OF LOT 14 DESC BEG Legal 35FTE&20FTS OF NW Description: COR OF LOT 14 TH My Home I Property Information I Property Taxes El5.61FT SELY AD I My Neighborhood I Property Appraiser 2.44FT W42.93FT N30FT TO POB BLK 3 Home I Using Our Site I Phone Directory I Privacy I Disclaimer Assessment Information: Year: 2011 2010 Land Value: $65,689 $65,689 Market Value: $43,790 $44,434 If you experience technical difficulties with the Property Information application, Market Value: . $109,479 $110,123 or wish to send us your comments,questions or suggestions Assessed Value: $109,479 $110,12 3 please email us at Webmaster. Taxable Value Information: Year: 2011 2010 Applied Applied Web Site axing Authority: Exemption/ Exemption/ ©2002 Miami-Dade County.Taxable Taxable All rights reserved. Value: Value: Regional: $0/$109,479$0/$110,123 County: $0/$109,479$0/$110,123 Cill : 1$0/$109,4791$0/$110,12 School Board: 1$0/$109,4791$0/$110,12 Sale Information: Sale Date: 1/1999 Sale Amount: $0 Sale O/R: 18446-1795 Sales Sales which are Qualification disqualified as a result of Description: examination of the deed View Additional Sales Additional Information: Click here to see more information for this ro ert : Community Develnnment District http://glsims2.miamidade.gov/myhome/propmap.asp 3/1/2012 Miami-Dade My Home Page 2 of 2 Community Redevelopment Area Empowerment Zone Enterprise Zone Zoning Land Use Urban Development Boundary Zoning Non-Ad Valorem Assessments Environmental Considerations http://gisims2.miamidade.gov/myhome/propmap.asp 3/1/2012 Miami-Dade My Home Page 1 of 1 My Home i •s„ J :._ ... .v..,v._. MIAMI•aADE Show Me: _... ......... Property Information , Bf Legend Search By Property Select Item t ' ' Boundary /. r o ,/ Selected M y Property Search Results: No match found for Address:6412 SW 59 AVE ''' ' Street Other possible matches: Click on Folio to select property. " ` /- r /✓ Highway / Miami-Dade Folio:0940250150800 �/�`fr �,f,�,�� �&` County Owner:WILLIE MYERS(EST r Water 1 OF)& c Address:6411 SW 59 AVE /' / N / //jr F Folio:0940250150640 2 Owner:ERIC MORALES Address:6420 SW 58 PL �a"v4 S Folio:0940250100580 3 Owner:MILDRED F MITCHELL Address:6445 SW 59 CT " Folio:0940250580060 u 4 Owner:JULIA M HOLTON LE Address:6335 SW 59 AVE Aerial Photography-2009 0 30761 ft My Home I Property Information I PropertV Taxes I MV Neighborhood I Property Appraiser Home I Using Our Site I Phone Directory I Privacy I Disclaimer If you experience technical difficulties with the Property Information application, or wish to send us your comments,questions or suggestions please email us at Webmaster. Web Site ©2002 Miami-Dade County. All rights reserved. G http://gisims2.miamidade.gov/myhome/Propmap.asp 3/1/2012 f Brimo, Christopher From: Brimo, Christopher Sent: Friday, March 09, 2012 12:33 PM To: Lightfoot, Marcus Subject: FW: 6412 SW 59th Avenue-Alcohol License Marcus: In light of the-addWo-nalinforma#ion provided by the applicant related to their request for zoning approval of a 1APS (beer only)alcohol license, it is evidenced that a liquor license has been active at this address for some time, and the current license is still in effect through March 31, 2012. 1 will be providing zoning approval to the applicant DBA"Gigi's Sub Shop" for the same license series (1APS). Chris ,Q VV N Christopher Brimo,AICP �ju\ Planning Director City of South Miami 6130 Sunset Drive South Miami, FL 33143 Tel: 305-663-6327 Fax: 305-668-7356 The City of South Miami is a public entity,subject to Chapter 119 of the Florida Statutes concerning public records.E-mail messages and their attachments are covered under such laws and thus subject to disclosure.All e-mail sent to and received at this address,is captured by our servers and kept as a public record. From: Brimo, Christopher Sent: Thursday, March 01, 2012 11:57 AM To: Lightfoot, Marcus Cc: David, Stephen Subject: 6412 SW 59th Avenue -Alcohol License Marcus: I have reviewed the request for a zoning verification for a liquor license at the referenced location. Pursuant to Article 1, Section 4.2 of the City Code of Ordinances,there is a five-hundred (500)foot distance requirement from existing churches schools and residential property for a an approved liquor license.The proposed business location for this license does not meet the minimum distance requirement from churches and residential property in this neighborhood. Therefore,the application for City of South Miami zoning approval for a liquor license at the referenced location cannot be approved. Chris Christopher Brimo,AICP Planning Director City of South Miami 6130 Sunset Drive South Miami, FL 33143 Tel: 305-663-6327 Fax: 305-668-7356 i t� f. .. 6.igt►c.. Y f F I y } Licensing Portal License Search Page 1 of 1 4 24 60M 3!2/2012 Data Contained In Search Results Is Current As Of 03/02/2012 01:22 PM. Search Results Please see our glossary of terms for an explanation of the license status shown in these search results. For additional information, including any complaints or discipline, click on the name. L>icetlse � License Type dameT Numberj, Status/l�xpires #' yP ltartk a Retail Beverage CHICO'S GOOD N PLENTY DBA BEV2327450 Current, Active 1APS 03/31/2012 License Location Address*: 6412 SW 59TH PLACE MIAMI,FL 33143 Main Address*: 1095 NW 58TH TERRACE MIAMI,FL 33127 CHICO'S GOOD N PLENTY BEV2327450 Current,,-Active Retail Beverage INC Primary 1APS 03/31/2012 License Location.Address*: 6412 SW 59TH PLACE MIAMI,_FL'33143'• Main Address*: 1095 NW 58TH TERRACE MIAMI,FL 33127 *denotes Main Address-This address is the Primary Address on file. Mailing Address-This is the address where the mail associated with a particular license will be sent(if different from the Main or License Location addresses). License Location Address-This is the address where the place of business Is physically located. Contact Us :: 1940 North Monroe Street Tallahassee FL 32399 :: Call.Center@dbar.state.fLus :: Customer Contact Center: 850.487.1395 The State of Florida is an AA/EEO employer.Copyright 2007-2010 State of Florida.Privacy Statement Under Florida law,e-mail addresses are public records.If you do not want your e-mail address released in response to a public-records request,do not send electronic mail to this entity.Instead,contact the office by phone or by traditional mail.If you have any questions regarding DBPR's ADA web accessibility,please contact our Web Master at webmaster @dbpr.state,fl.us. 1 Brimo, Christopher From: Brimo, Christopher Sent: Thursday, March 01, 2012 11:57 AM To: Lightfoot, Marcus Cc: David, Stephen Subject: 6412 SW 59th Avenue-Alcohol License Marcus: I have reviewed the request for a zoning verification for a liquor license at the ferenced location. Pursuant to Article 1, Section 4.2 of the City Code of Ordinances,there is a five-hundred (500)foo distance requirement from existing churches schools and residential property for a an approved liquor licens .The proposed business location for this license does not meet the minimum distance requirement from churc sand residential property in this neighborhood. Therefore,the application for City of South Miami zoning approval f a liquor license at the referenced location cannot be approved. Chris Christopher Brimo,AICP Planning Director City of South Miami 6130 Sunset Drive �V South Miami, FL 33143 Tel:305-663-6327 Fax: 305-668-7356 The City of South Miami is a public entity,subject t Chapter 119 of the Florida Statutes conceming public records.E-mail messages and their attachments are covered under such laws and t s subject to disclosure.All e-mail sent to and received at this address,is captured by our servers and kept as a public record. DBPR ABT-6001 —Division of Alcoholic Beverages and Tobacco Application for New Alcoholic Beverage License and Tobacco Permit STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6001 Revised 0912010 NOTE This form must be submitted as part of an application packet If you have any questions or need assistance in completing this application,please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T's page of the DBPR web site at the link provided below. http://www.myflorida.com/dbpr/abt/district offices/licensing.html vr.., + ra.»... ,..r-. �'r SECT OIV 1 'K ICEN3�CA EGCIRY' t `' ° ?� 7e t't S - ' kk�Y �-•.�i..'q `-.. ,.raaa ,� .,:-r.+ _,I.a.f r,b:.>.e:.,.#ate oaa,., .._.h.�+ d aft- ""TZ License Series Requested Type/Class Requested Do you wish to purchase a Temporary License? ❑ Yes No Child License Requested Number of Child Licenses Requested ❑ Retail Alcoholic Beverages ❑ Alcoholic Beverage Manufacturer ❑ Beer/Wine/Liquor ❑ Retail Tobacco Products(must check one or more of the below) Wholesaler []Pipes Only ❑Over the Counter []Vending Machine ❑ Passenger Waiting Lounge ,r � _ If the applicant is a corporation or other legal entity er the name and the document number as registered with the Florida Dep ment of State Division of C rpor tions on the line below. Full Name of Appli nt: (T is' the name t 'c se in) Department of State Document# Business Name ? Y FEIN Number? Business Telephone Number Location Ad ess r et and u e City / `� CQu ,u tn'�_ State Zip Code / /✓ FL Check either: ❑ Location js withi he city limi o ❑ Location is in the unincorporated county Co t Pe son T lephone N ber 7 A.-IwoP64 Mel, 0)gI6 ,�3 ext. E-M l A dr We p Ua���J n d (Str or ' yBox) 6 City J� odJ ABT District Office Received/Date Stamp Auth.61A-1.023&61A-5.056,FAC 5 ` 1. 1 Business Name (D/B 2. Full Name of I ivid r 71Trj&);MJ1 ' Social Sec��'�� - (-Hor-oeT epho h/ e-Jre4 ei or a vou If no, immigration card number or passport number: 4. Home ITZ7V�`6�2 Citr 710 Code 5. —6 you curren% have �n interest in any business selling alcoholic beverages, jkh-'d7e`saIe cigarette or tobacco products, or a bottle club? If*ye's, provide the infornj4tiortApqLjested bWow. The locatiQ6 adAess should include the city and state. Business Name License Number D" A n 6. Have you had any type of al mrage, 4 0 0 refused, revoked or suspended anywhere in the perst 15 years? El YesU!TNo If Ves, prSvide the information riquested below. The location address should include citv and state. Business Name (D/B/A) Date A/A I Location Address L 1A 7. Have you d of a felony within the past 15 years? El Yes If yes, provide the information requested below and provide a Copy of Iffie Arrest Disposition, as Date Location Type of Offense IL 1 (4 8. Have you been c o n yffrZet of an offense involving alcoholic beverages anywhere within the past 5 years? Ej Yes %LaXo If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as reques e id the Application Requirqmqnts checklist. Date U-A I Location 64 Type of Offense ' PC pO 3ECTION4 01, DESCRIPTION,btF ?REMISESTO BELI�ENSED F } y d; .;. _s .� .` T,, �B`E COMPL ED BYkTHE:fAPP N ;'. Business Name (D/B/ 1. Yes ❑ Is the proposed premises mov a or jible to be moved? 2. Yes ❑ No Is there any access through the premises to any area over which you do not have dominion and control? 3. Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the premises,walls, doors, counters, sales areas, storage areas, restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show each floor plan. Auth.61A-1.023&61A-5.056,FAC 4 -' �SECTION10��AFFIDA1/ITOF4PP<LICAN�7i:.: } � r NOTAF�I7A'TIO.�:�EQUIRED� ; F "Y Business Name (D/B/A) "1,the undersigned individually, or if a registered legal entity for itself and its related parties, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a true and correct representation of the premises to be licensed and agree that the place of business, if licensed, may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies,and Police Officers for the purposes of determining compliance with the beverage and retail tobacco laws." "I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes,that the foregoing information is true and that no other person or entity except as, indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license and/or tobacco permit." STATE OF COU OF `���111tt111U!ltl���'i l f `�. MYcWM f APPLIC SI NATURE = No. 1,2016 No..E EE 108281 ; (P• UBO APPLICANT SIGNATURE 5v ,O'FIFO,�````��� The foregoing was ( )Sworn to and Subscribed OR( )Acknowledged Before me this /3 Day of 20 /Z , By <.(ate eL Lew I'Sk; who is personally (print name(s)of person(s)making statement) known to me OR( )who produced as identification. Commission Expires: M a Pu lic Auth.61A-1.023&61A-5.056,FAC 9 9. Have you been arrested or issued a n e to appear in any state of the United States or its territories within the past 15 years? ❑Yes o If yes, provide the information reque ed below and a Copy of the Arrest Disposition. Attach ad itional sheet if necessary.. Date Locatio k1l A I Type of O ense 110. Are you a off ' I with State police powers granted by the Florida Legislature? Yes ` � -� � NOT�►�tyiT'lON�ST�►Y� ENT" �� "I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in the Disclosure of Interested Parties of this application. I further swear or affirm that the foregoing information is true and correct." STATE OF r COUNTY OF PLICANT SIGNATURE The foregoing was ( )Sworn to and Subscribed OR( )Acknowledged Before me this 13'0' Day of Grua. ,20172, , By s fe4 Le6lid,-sbi who is ()6 personally (print name of person making statement) known to me OR( )who produced -,%%%%,;iA LEIw;�%. as identification. dMnl9�'i � r P blic Juna26,2015 C (ATTACH ADDITIONAL COPIES AS NECESSARY) Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C.405(c)(2)(C)(1). This information is used to identify licensees for tax administration purposes. Auth.61A-1.023&61A-5.056,FAC 3 1A ; 49M O;f- " RAC;TS:ORAGREEMENTS Business Name (D/B/A) These questions must be answered about this business for every person or entity listed as the applicant and copies of agreements must be submitted with this application. If the management, service, or other contractual agreement gives a person or entity control of the licensed premises or the sale of alcoholic beverages, disclosure of those persons must be made in the section labeled "DIRECT INTEREST" in the DISCLOSURE OF INTERESTED PARTIES section. They must also submit fingerprints and a related parry personal information sheet. 1. Yes ❑ No UV Is there a management contract, franchise agreement, or service agreement in connection with this business? 2. Yes ❑ No& Are there any agreements which require a payment of a percentage of gross or!net receipts from the business operation? 3. Yes ❑ No Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from a manufacturer or wholesaler of alcoholic beverages? SEc'n70N 'PLIG IV E TI7YyFELaI�1�?�CO1JVIrC `IUN'`` Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15 ye rs? El Yes [ o If the answer is "Yes," please list all details including the date of conviction, the crime for which the entity was convicted, and the city, county, state and court where the conviction took place. (Attach additional sheets if necessary) Auth.61A-1.023&61A-5.056,FAC 6 SECTIIV9;":DISCL"OSURE_OFINTERESTED:'PARTIES Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of our license. Business Name (D/B/A) 1. When applicable, please complete the appropriate section below. Attach extra sheets if necessary. Title/Position Name Stock% CORPORATI N (CORP/INC) President Vice President Secretary Treasurer Director(s) Stockholder(s) LIMITED LIABILITY COMPANY LLC/LC Managing Member(s) and/or Managers Members (must be printed if there are no managing members or managers) LIMITED PARTNERSHIP LTD/LP/LTDLLP General Partner(s) Limited Partner(s) Bar Manager(Fraternal Organizations of National Scope only): DIRECT INTEREST Name of Individual or Ent' (If a legal entity, list name under which the entity does business and its principles) Title/Position t Warne Stock% 2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan,or any person or entity who has loaned money to the business that is not a traditional lending institution? ❑Yes o If yes, and th terms create a direct interest in the business,you must list the person(s)or entity and indicate which of the below applies. Each directly interested person must submit fingerprints and a related party ersonal information sheet. Copies of a reements must be submitted with this a pplication. Name Guarantor Co-signer Lender Interest Rate List ❑ ❑ ❑ ❑ °❑ ❑ Auth.61A-1.023&61A•5.056,FAC 8 • .�''-'.0 .,;has �«,:s., 7s,.`` ,} :^'ats, '+�{a1}, 3v`�s.+ �ru�' a..4A:y�rT���.- �`tk� .sP.,..�,r� ,� �.ur .z Full Name of A licant: (T isAlthe nam t license wi I iWs a n) Business Nam Street Addres City ounty State ig� e FL WON a � M r A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series I A PS, license. B. This approval includes outside areas which are contiguous to the premises which are to be part of the premises ug be licensed and are identified on the sketch?" ❑ Yes No Signed Date 3I Title 3t3E s 1p.-vWx b .a. 8W The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax. 1. This is to verify that the current owner as named in this application has filed all returns and that all outstanding billings and returns appear to have been paid through the period ending or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not constitute a certificate as contained in Section 212.10 (1), F.S. (Not applicable if no transfer involved). 2. Furthermore,the named applicant for an Alcoholic Beverage License has complied with Florida Statutes concerning registration for Sales and Use Tax, and has paid any applicable taxes due. Signed Date Title Department of Revenue Stamp A tJR'D PARTt�I)II � OFiOC. CCUMTURO SU The above establishment complies with the requirements of the Florida Sanitary Code. Signed Date Title Agency Auth.61A-1.023 61A-5.056,FAC 5 Mg" PECIIAt L t-oEN8EREOU1REMENI DOES NOTAPPLY'T ``EEEa1A1D,1N1k1ELfCENSESa, � Business Name (D/B/A) Please check the appropriate "Special Alcoholic Beverage License"box of the license for which you are applying. Fill in the corresponding requirements for each Special License type. ❑ Quota Alcoholic Beverage License ❑ Special Alcoholic Beverage License ❑ Club Alcoholic Beverage License This license is issued pursuant to , Florida Statutes or Special Act, and as such we acknowledge the following requirements must b met and maintained: Z,j Please initial and date: Applicant's Initials Date Auth.61A-1.023&61A-5.056,FAC 7 SECTION x '�CUI�R�NT WC ENSEE:,U'PDATE D 'TA SHEET J.y , :, � .. t R This section is to be completed for all curre alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date ipformation is captured. Business Name (D/B/A) ` Last Name First M.I. Current Alcohol Beverage and/or jobacco License Permit/Number(s) Date of Birth 7Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobagoo License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco L' ense Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco L' ense Permit/Number(s) Date of Birth j� Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Auth.61 A-1.023&61 A-5.056,FAC 10 i 3 -- 1 ` nIL \ 2 t LL KD Ij vt . Lal k jay/ � t ,•'" �,�p,:� -- v. ��.. . ` 25 IV -. Brimo, Christopher From: Brimo, Christopher Sent: Thursday, March 01, 2012 11:57 AM To: Lightfoot, Marcus Cc: David, Stephen Subject: 6412 SW 59th Avenue-Alcohol License Marcus: I have reviewed the request for a zoning verification for a liquor license at the referenced cation. Pursuant to Article 1, Section 4.2 of the City Code of Ordinances,there is a five-hundred (500)foot distance r uirement from existing churches schools and residential property for a an approved liquor license.The prop ed business location for this license does not meet the minimum distance requirement from churches and resi ntial property in this neighborhood. Therefore,the application for City of South Miami zoning approval for a liquor ' ense at the referenced location cannot be approved. Chris Christopher Brimo,AICP Planning Director City of South Miami 6130 Sunset Drive \� South Miami, FL 33143 Tel: 305-663-6327 Fax: 305-668-7356 The City of South Miami is a public entity,subject to C ter 119 of the Florida Statutes concerning public records.E-mail messages and their attachments are covered under such laws and thus ject to disclosure.All e-mail sent to and received at this address,is captured by our servers and kept as a public record. 1 DBPR ABT-6001 —Division of Alcoholic Beverages and Tobacco Application for New Alcoholic Beverage License and Tobacco Permit STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6001 Revised 09/2010 NOTE This form must be submitted as part of an application packet If you have any questions or need assistance in completing this application,please contact the Department of Business and Professional Regulation or your local district office. Please submit your completed application to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T's page of the DBPR web site at the link provided below. htti)://www.mvflorida.com/dbpr/abt/district offices/licensing.html OR 7Se affibme 01 Licenses�Requested Type/Class Requested Do you wish to purchase a Temporary License? ❑ Yes No Child License Requested Number of Child Licenses Requested ❑ Retail Alcoholic Beverages ❑ Alcoholic Beverage Manufacturer ❑ Beer/Wine/Liquor ❑ Retail Tobacco Products(must check one or more of the below) Wholesaler ❑Pipes Only ❑Over the Counter ❑Vending Machine ❑ Passenger Waiting Lounge .fl " -3 �'5E+ `1IC3 '}. lIG1=NS IIUF()RiWATt JN #M If the applicant is a corporation or other legal entity er the name and the document numbe7as eg istered with the Florida Dep ment of State Division of C rpor tions on the line below. Full Name of Appli nt: (T is' the name t is nse 4o in) Department of State Document# Business Name FEIN Number Business Telephone Number Location Ad ess r et and u e City f C ,� ,'_ State Zip Code l / TFL Check either: ❑ Location js withig4he city limi o ❑ Location is in the unincorporated county Co t Pe on T Irilephone N ber 4, ov M a �t3 ext. E-M 'I A dr s �e (�)x� in d (St r or �ox) City - p ode ) ABT District Office Received/Date Stamp Auth.61A-1.023&61A-5.056,FAC 5 ,` ;'fix °., � ? SI=CTION 3."=#REIATED PART1(:PERSt7NAL,INFORMATIONSd...: ;:,.; , "rh .0-6tityrr must bKet compute f ch-person d rectlyaconneicted r l iE(fie't usiness,runless they are,e�cirrentliceiSee Pk ��, ,3� a:�}, , , 1. Business Name (D/B/ 2. Full Name of I divid Social Secur' a Ho e C eph um r ate irth py e S Hei ht or Ha' 3. r ou a U.S. citizen? )Pj W" jLVYes ❑ No If no, immigration card number or passport number: 4. Home Adjdr s tree ksnd um er City / ate 71n Code 5. 07-you currently own have an interest in any business selling alcoholic beverages, ho esale cigarette or tobacco products, or a bottle club? C2-13s ❑ No es, provide the inforn- ,AtiioMQqt4ested b ow. The logptiQ6 ad mess should include the city and state. Business Name D/B License Number Location Address 6. Have you had any type of alto olic beverage, bottle cl , or cigarette, or tobacco permit refused, revoked or suspended anywhere in the p st 15 years? ❑ Yes(VT)No If ves, PrSvide the information r uested below. The location address should include a citV and state. Business Name (D/B/A) n Date Location Address P- 7. Have you been convicted of a felony within the past 15 years? ❑Yes VV If yes, provide the information requested below and provide a Copy of e Arrest Disposition, as requested in the ppjication Requirements phWklist. Date 4 1 1 Location Type of Offense 1 (4 8. Have you been con a of an offense involving alcoholic beverages anywhere within the past 5 years? ❑Yes W10 If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as re uested id the Application Re uir m nts checklist. Date Location n Type of Offense �} Auth.61A-1.023&61A-5.056,FAC 2 SECTION� DES�RIfjTIONOFPREMISES'mTCFJ}BELICENSED ' r qA '� .t 7 s61r-°CO11� 1 EC1fiBY THE,APP t� `r�� - „M . M Business Name (D/B/ 1. Yes ❑ 4te pro posed premises mov a or Ale to be moved? 2. Yes ❑ No Is there any access through the premises to any area over which you do not have dominion and control? 3. Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which are contiguous to the premises,walls, doors, counters, sales areas, storage areas, restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show each floor plan. Auth.61A-1.023&61A-5.056,FAC 4 R Till AFFID 1lITtOF PP CANT ' Business Name (D/B/A) "I,the undersigned individually, or if a registered legal entity for itself and its related parties, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a true and correct representation of the premises to be licensed and agree that the place of business, if licensed, may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for the purposes of determining compliance with the beverage and retail tobacco laws." "I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes,that the foregoing information is true and that no other person or entity except as. indicated herein has an interest in the alcoholic beverage license and/or tobacco permit, and all of the above listed persons or entities meet the qualifications necessary to hold an interest in the alcoholic beverage license and/or tobacco permit." STATE OF COU OF . O. l Z 0 _ • M,,COMM,FOr.s _ APPLICAkl SI NATURE AM 26,2015 _ No.EE 108281 N• :x ice••'pUB10C:•• 4�. APPLICANT SIGNATURE "F•OF �Q�`` 0111111111►111\\ The foregoing was ( )Sworn to and Subscribed OR( )Acknowledged Before me this /3 Day Of re'"'X 20 /Z , By More j L Le—+-sk, who is()6 personally (print name(s)of person(s)making statement) known to me OR( )who produced as identification.. Commission Expires: a Pu Iic Auth.61A-1.023&61A-5.056,FAC 9 9. Have you been arrested or issued a i2ptipe to appear in any state of the United States or its territories within the past 15 years? ❑Yes o If yes, provide the information reque ed b low and a Copy of the Arrest Disposition. Attach ad itional sheet if necessary.. Date Locatio k1l IQ I Type of O ense K t 10. Are you a off ' I with State police powers granted by the Florida Legislature? Yes "I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791,562.45 and 837.06, Florida Statutes, that I have fully disclosed any and all parties financially and or contractually interested in this business and that the parties are disclosed in the Disclosure of Interested Parties of this application. I further swear or affirm that the foregoing information is true and correct." STATE OF COUNTY OF A PLICANT SIGNATURE The foregoing was( )Sworn to and Subscribed OR( )Acknowledged Before me this 131t4' Day of e6rva. _, 20 /Z , By Z:s&62 . who is()6 personally (print name of person making statement) ���1 IIII1111/lr11' known to me OR( )who produced _��� � LE i, as identification. dc 2 dfinIG419�'ipjresc 17-4 hZV P blic a-3- 0 Jur926,2o15 N p � (ATTACH ADDITIONAL COPIES AS NECESSARY) Q.'�`�� *Social Security Number Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number. In this instance, disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 409.2577, 409.2598, and 559.79, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996(Welfare Reform Act), 104 Pub.L.193, Sec. 317. The State of Florida is authorized to collect the social security number of licensees pursuant to the Social Security Act, 42 U.S.C.405(c)(2)(C)(1). This information is used to identify licensees for tax administration purposes. Auth.61 A-1.023&61 A-5.056,FAC 3 ' � SEC3T.ION 6 '`�ONZRACTS OR�AGREEMENTS Business Name (D/B/A) These questions must be answered about this business for every person or entity listed as the applicant and copies of agreements must be submitted with this application. If the management, service, or other contractual agreement gives a person or entity control of the licensed premises or the sale of alcoholic beverages, disclosure of those persons must be made in the section labeled "DIRECT INTEREST" in the DISCLOSURE OF INTERESTED PARTIES section. They must also submit fingerprints and a related party personal information sheet. 1. Yes ❑ No Is there a management contract, franchise agreement,or service agreement in connection with this business? 2. Yes ❑ NoW Are there any agreements which require a payment of a percentage of gross or net receipts from the business operation? 3. Yes ❑ No Have you or anyone listed on this application, accepted money, equipment or anything of value in connection with this business from a manufacturer or wholesaler of alcoholic beverages? Sre-00M,W `PP;lrf ?iN Eii�i ll'Y FEL N CONVICTI N � b'S t P Y A- S} � .i•..�.. Has the applicant entity been convicted of a felony in this state, any other state, or by the United States in the last 15 ye rs? ❑Yes [ 4 o If the answer is "Yes," please list all details including the date of conviction, the crime for which the entity was convicted, and the city, county, state and court where the conviction took place. (Attach additional sheets if necessary) Auth.61A-1.023&61A-5.056,FAC 6 S'ECTIONt9=D1SCLVSURE,iOF�;INTERESTEDiPA9,TIESM;'' 4: Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of our license. Business Name (D/B/A) 1. When applicable, please complete the appropriate section below. Attach extra sheets if necessary. Title/Position Name Stock% CORPORATION (CORP/INC) President Vice President Secretary Treasurer Director(s) Stockholder(s) LIMITED LIABILITY COMPANY LLC/LC Managing Member(s) tiG and/or Managers Members (must be printed if there are no managing members or mana ers LIMITED PARTNERSHIP LTD/LP/LTDLLP) General Partner(s) Limited Partner(s) Bar Manager(Fraternal Organizations of National Scope only): DIRECT INTEREST Name of Individual or Enti (If a legal entity, list name under which the entity does business and its principles) Title/Position t Alame Stock% Caw'Ile N 2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan,or any person or entity who has loaned money to the business that is not a traditional lending institution? ❑Yes o If yes, and th terms create a direct interest in the business,you must list the person(s)or entity and indicate which of the below applies. Each directly interested person must submit fingerprints and a related party ersonal information sheet. Copies of a reements must be submitted with this a pplication. Name Guarantor Co-signer Lender Interest Rate List El El El ❑ ❑ ❑ El El 0 ❑ ❑ ❑ Auth.61A-1:023&61A-5.056,FAC 8 PROVALS a CTIONS} A ,LICAl'IONAP W" Full Name of A licant: (T i the nam license wi I i�snen) Ge Z Business Nam , Street Address City ounty State ip,Ce •�' / D FL •� I: IM -1 -: MOM A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series license. B. This approval includes outside areas which are contiguous to the premises which are to be part of the premises sought to be licensed and are identified on the sketch?" ❑ Yes ❑ No Signed Date Title � E ME L> ST R _ The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax. 1. This is to verify that the current owner as named in this application has filed all returns and that all outstanding billings and returns appear to have been paid through the period ending or the liability has been acknowledged and agreed to be paid by the applicant. This verification does not constitute a certificate as contained in Section 212.10(1), F.S. (Not applicable if no transfer involved). 2. Furthermore,the named applicant for an Alcoholic Beverage License has complied with Florida Statutes concerning registration for Sales and Use Tax, and has paid any applicable taxes due. Signed Date_ Title Department of Revenue Stamp Ni- �_TO CBE O: 'DI ; O JOF HOTELS�Nb`RCSiUR1�1�T$ ` l :OUFII ;UTH m 0 �EP' `R ;MENt wOF E,tfiLVl " w`��.-' The above establishment complies with the requirements of the Florida Sanitary Code. Signed Date Title Agency Auth.61A-1.023&61A-5.056,FAC 5 $ SPr:CIAtLCENSE�tEQ�11REMENS Ls.I MR1 , PAC1�T�7rBEEf ! ►I�DIVINEfI'CS Business Name (D/B/A) Please check the appropriate"Special Alcoholic Beverage License"box of the license for which you are applying. Fill in the corresponding requirements for each Special License type. ❑ Quota Alcoholic Beverage License ❑ Special Alcoholic Beverage License ❑ Club Alcoholic Beverage License This license is issued pursuant to , Florida Statutes or Special Act,and as such we acknowledge the following requirements m�uslt b met and maintained: ZA Please initial and date: Applicant's Initials Date Auth.61A-1.023&61A-5.056,FAC 7 x mo t= 'SEC 10 'I �CU:RRENT LICEN.S,E UPtDay I.DATA �y r�yY This section is to be completed for all curve alcoholic beverage and/or tobacco license holders listed on the application to ensure the most up to date ipformation is captured. Business Name (D/B/A) Last Name First M.1. Current Alcohol Beverage and/or iobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.1. Current Alcohol Beverage and/or Toba o License Permit/Number(s) 14J" Date of Birth Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco L' ense Permit/Number(s) Date of Birth j Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco L' ense Permit/Number(s) Date of Birth / Social Security Number* Street Address City State Zip Code Last Name First M.I. Current Alcohol Beverage and/or Tobacco License Permit/Number(s) Date of Birth Social Security Number* Street Address City State Zip Code Auth.M-1.023&61A-5.056,FAC 10 e ' i _ 1 fv Ail N - LO