Fillable CITY OF DECATUR, ILLINOIS (City of Decatur Illinois)

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CITY OF DECATUR, ILLINOIS (City of Decatur Illinois)

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CORPORATION APPLICATION FOR ALCOHOLIC LIQUOR LICENSE:
LICENSE EXPIRES: JUNE 30, 2021 ANNUAL FEE: $2,200.00 - Class A, B, C, D, E, G, H, I, J, K, L, M, & O
ANNUAL FEE: $1,400.00 - Class N
ANNUAL FEE: $6,000.00 – Class P
ANNUAL FEE: $725.00 - Class F
RENEWAL LATE FEE: $100.00 + $20.00/day after July 31, 2020
PROCESSING FEE: $100.00 (New and/or Transfer)
CLASS OF LIQUOR LICENSE APPLIED FOR: __________
DESCRIPTION OF BUSINESS_____________________________________________________________
CORPORATION NAME__________________________________________________________________
D/B/A__________________________________________________________________________________
LOCAL BUSINESS ADDRESS_____________________________________________ZIP CODE_______
BUSINESS TELEPHONE NUMBER_____________________________
EMAIL ADDRESS______________________________
MANAGER OF LICENSED PREMISES:
NAME_____________________________________________________DATE OF BIRTH_____________
HOME ADDRESS__________________________________________________ZIP CODE____________
(MUST RESIDE WITHIN DECATUR CITY LIMITS & PROVIDE COPY OF VALID ILLINOIS DRIVER’S
LICENSE OR STATE ID) Illinois Liquor Control Act of 1934, 5/6-2, Persons Ineligible to be Licensed: A person who
is not a resident of any City in which the premises covered by license are located.
TELEPHONE NUMBER_____________________________
EMAIL ADDRESS_________________________________________________
OFFICERS AND DIRECTORS OF CORPORATION (please print or type all information):
A. NAME_________________________________________TITLE________________________________
DATE OF BIRTH________________ TELEPHONE NUMBER __________________________________
HOME ADDRESS (INCLUDE CITY & ZIP CODE) ____________________________________________
CITY OF DECATUR, ILLINOIS
City Clerk
#1 Gary K. Anderson Plaza Decatur, IL 62523-1106
Phone: 217-424-2708
Fax: 217-450-2297
DRIVER’S LICENSE NUMBER OR STATE ID NUMBER_______________________________________
OFFICERS AND DIRECTORS OF CORPORATION (please print or type all information) continued:
B. NAME_________________________________________TITLE________________________________
DATE OF BIRTH________________ TELEPHONE NUMBER __________________________________
HOME ADDRESS (INCLUDE CITY & ZIP CODE) ____________________________________________
DRIVER’S LICENSE NUMBER OR STATE ID NUMBER_______________________________________
C. NAME_________________________________________TITLE________________________________
DATE OF BIRTH________________ TELEPHONE NUMBER __________________________________
HOME ADDRESS (INCLUDE CITY & ZIP CODE) ____________________________________________
DRIVER’S LICENSE NUMBER OR STATE ID NUMBER_______________________________________
D. NAME_________________________________________TITLE________________________________
DATE OF BIRTH________________ TELEPHONE NUMBER __________________________________
HOME ADDRESS (INCLUDE CITY & ZIP CODE) ____________________________________________
DRIVER’S LICENSE NUMBER OR STATE ID NUMBER_______________________________________
(Please use additional sheet of paper, if more than four.)
SHAREHOLDERS OWNING MORE THAN 5% OF CORPORATION STOCK:
(DO NOT INCLUDE SHAREHOLDERS OWNING LESS THAN 5% OF CORPORATION STOCK)
1. NAME______________________________________TITLE________________________________
DATE OF BIRTH________________ TELEPHONE NUMBER __________________________________
HOME ADDRESS (INCLUDE CITY & ZIP CODE) ____________________________________________
DRIVER’S LICENSE NUMBER OR STATE ID NUMBER_______________________________________
2. NAME______________________________________TITLE________________________________
DATE OF BIRTH________________ TELEPHONE NUMBER __________________________________
HOME ADDRESS (INCLUDE CITY & ZIP CODE) ____________________________________________
DRIVER’S LICENSE NUMBER OR STATE ID NUMBER_______________________________________
3. NAME______________________________________TITLE________________________________
DATE OF BIRTH________________ TELEPHONE NUMBER __________________________________
HOME ADDRESS (INCLUDE CITY & ZIP CODE) ____________________________________________
DRIVER’S LICENSE NUMBER OR STATE ID NUMBER_______________________________________
4. NAME______________________________________TITLE________________________________
DATE OF BIRTH________________ TELEPHONE NUMBER __________________________________
HOME ADDRESS (INCLUDE CITY & ZIP CODE) ____________________________________________
DRIVER’S LICENSE NUMBER OR STATE ID NUMBER_______________________________________
(Please use additional sheet of paper, if more than four.)
REGISTERED AGENT OF CORPORATION (AS FILED WITH SECRETARY OF STATE):
NAME_______________________________________
TELEPHONE NUMBER: ____________________________
ADDRESS OF REGISTERED OFFICE (INCLUDE CITY & ZIP CODE) ____________________________
_______________________________________________________________________________________.
OWNER/LANDLORD OF PREMISES TO BE LICENSED:
NAME_____________________________
ADDRESS (INCLUDE CITY & ZIP CODE) ___________________________________________________
TELEPHONE NUMBER: _________________________
LIQUOR LICENSE WILL BE MAILED TO THE ESTABLISHMENT
AFFIDAVIT OF APPLICANT
ON OATH, I HEREBY STATE AND AVER, THAT:
1) The facts asserted in the foregoing application for a liquor license are true, on information and belief.
2) I have authority to comply with the requirements of the liquor license, and bind the applicant
corporation.
3) The corporation is duly organized and in good standing and not ineligible for a City liquor license.
4) The corporation is not indebted to the State of Illinois or City of Decatur, Illinois.
5) The manager’s affidavit and affidavits of all corporation officers, directors, and shareholders holding
more than five percent (5%) of the shares of said corporation are attached.
6) The corporation has not had its liquor license revoked for cause.
7) No law enforcing public official, Mayor or member of the City Council is interested in any way
directly in the corporation or the business to be licensed.
8) I am qualified, as required by law and ordinance, for issuance of a liquor license.
Print Name: ___________________________________
Title: ________________________________________
_____________________________________________
Signature
Signature must be notarized before returning this form to the City Clerk’s office.
_____________________________________________
Date
STATE OF ILLINOIS )
)SS
COUNTY OF MACON)
SUBSCRIBED AND SWORN TO BEFORE ME THIS ____ DAY OF _______________, ________
(SEAL) ________________________________________________
NOTARY PUBLIC
______________________________________________________________________________________
DATE APPROVED_____________________________________
SIGNATURE OF LIQUOR COMMISSIONER______________________________________
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CITY OF DECATUR, ILLINOIS (City of Decatur Illinois)

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Completed 15 February 2021

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