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Local ABT District Licensing Offices DBPR ABT-6001 Division (MyFloridaLicense)

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Auth. 61A-5.010 & 61A-5.056, FAC 1
DBPR ABT-6001 – Division of Alcoholic Beverages and Tobacco
Application for New Alcoholic Beverage License
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DBPR Form
ABT-6001
Revised 08/2013
If you have any questions or need assistance in completing this application, please contact the Division of
Alcoholic Beverages & Tobacco’s (AB&T) local district office. Please submit your completed application
and required fee(s) 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 web site at the link provided below:
Local ABT District Licensing Offices
SECTION 2 – LICENSE INFORMATION
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.
FEIN Number
Business Telephone Number
E-Mail Address (Optional)
Full Name of Applicant(s): (This is the name the license will be issued in)
Business Name (D/B/A)
Location Address (Street and Number)
City
.
.
County
State
FL
Zip Code
Mailing Address (Street or P.O. Box)
City
State
Zip Code
Contact Person - This section is optional, see application instructions for details
Contact Person
Telephone Number
ext.
E-Mail Address (Optional)
Mailing Address (Street or P.O. Box)
City
State
Zip Code
ABT District Office Received Date Stamp
SECTION 1 - CHECK LICENSE CATEGORY
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
Beer/Wine/Liquor Wholesaler
Alcoholic Beverage Manufacturer
Passenger Waiting Lounge
Retail Tobacco Products Dealer Permit (must check one or more of the below)
Pipes Over the Counter Vending Machine
Auth. 61A-5.010 & 61A-5.056, FAC 2
SECTION 3 – RELATED PARTY PERSONAL INFORMATION
This section must be completed for each person directly connected with the business, unless they
are a current licensee.
1.
Business Name (D/B/A)
2.
Full Name of Individual
Social Security Number*
Home Telephone Number
Date of Birth
Race
Sex
Height
Weight
Eye Color
Hair Color
3.
Are you a U.S. citizen?
Yes No
If no, immigration card number or passport number:
4.
Home Address (Street and Number)
City
State
Zip Code
5.
Do you currently own or have an interest in any business selling alcoholic beverages, wholesale
cigarette or tobacco products, or a bottle club?
Yes No
If yes, provide the information requested below. The location address should include the city and state.
Business Name (D/B/A)
License Number
Location Address
6.
Have you had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit
refused, revoked or suspended anywhere in the past 15 years?
Yes No
If yes, provide the information requested below. The location address should include the city and state.
Business Name (D/B/A)
Date
Location Address
7.
Have you been convicted of a felony within the past 15 years? Yes No
If yes, provide the information requested below and provide a Copy of the Arrest Disposition, as
requested in the Application Requirements checklist.
Date
Location
Type of Offense
8.
Have you been convicted of an offense involving alcoholic beverages or tobacco products 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 the Application Requirements checklist.
Date
Location
Type of Offense
Auth. 61A-5.010 & 61A-5.056, FAC 3
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 requested below and a Copy of the Arrest Disposition.
Attach additional sheet if necessary.
Date
Location
Type of Offense
10.
Do you meet the standards of the moral character rule?
Yes No
11.
Are you an officer or employee of the Division of Alcoholic Beverages and Tobacco; are you a sheriff or
other state, county, or municipal officer, including reserve or auxiliary officers, certified by the state as
such, with arrest powers, whose certification is current and active?
Yes No
NOTARIZATION STATEMENT
“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___________________ _________________________________________________
APPLICANT SIGNATURE
The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ___________Day
of_______________, 20_____, By _______________________________________who is ( ) personally
(print name of person making statement)
known to me OR ( ) who produced ___________________________________________as identification.
_______________________________________________ Commission Expires: ___________________
Notary Public
(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)(I). This information is used to identify licensees for tax
administration purposes. This information is used to identify licensees for tax administration purposes,
and the division will redact the information from any public records request.
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Auth. 61A-5.010 & 61A-5.056, FAC 4
SECTION 4 – DESCRIPTION OF PREMISES TO BE LICENSED
TO BE COMPLETED BY THE APPLICANT
Business Name (D/B/A)
1.
Yes
No
Is the proposed premises movable or able 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.
Yes
No
Is the business located within a Specialty Center? If yes, check the applicable statute:
561.20(2)(b)1, F.S. or 561.20(2)(b)2, F.S.
4.
Yes
No
Are there any mobile vehicles used to sell or serve alcoholic beverages?
5.
Yes
No
Are there more than 3 separate rooms or enclosures with permanent bars or
counters?
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 the details of each floor.
Auth. 61A-5.010 & 61A-5.056, FAC 5
SECTION 5 – APPLICATION APPROVALS
Full Name of Applicant: (This is the name the license will be issued in)
Business Name (D/B/A)
Street Address
City
.
.
County
State
FL
Zip Code
ZONING
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: Type: 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
Check either: Please do not skip, this is important for license fee sharing
Location is within the city limits or Location is in the unincorporated county
Signed____________________________________________________Date__________________
Title_________________________________________ This approval is valid for days.
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 213.758 (4), 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
This approval is valid for days.
HEALTH
TO BE COMPLETED 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____________________________
This approval is valid for days.
Auth. 61A-5.010 & 61A-5.056, FAC 6
SECTION 7 – SPECIAL LICENSE REQUIREMENTS
(DOES NOT APPLY TO BEER AND WINE LICENSES)
Please check the appropriate box of the license for which you are applying. Fill in the corresponding
requirements for the license type sought.
Quota Alcoholic Beverage License Specialty Alcoholic Beverage License (e.g. SRX, S, etc)
Club Alcoholic Beverage License
This license is issued pursuant to , Florida Statutes or Special Act, and as such we
acknowledge the following requirements must be met and maintained:
Please initial and date:
Applicant’s Initials____________________________________ Date______________________________
SECTION 6 – APPLICANT ENTITY FELONY CONVICTION
Business Name (D/B/A)
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 No
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-5.010 & 61A-5.056, FAC 7
SECTION 8 – DISCLOSURE OF INTERESTED PARTIES
Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your license.
You MUST list all persons and entities in the entire ownership structure. To determine which of those persons
must submit fingerprints and a Related Party Personal Information, sheet, see the fingerprint section in the
application instructions.
Business Name (D/B/A)
1. When applicable, complete the appropriate section below. Attach extra sheets if necessary.
Title/Position
Name
Stock %
CORPORATION– List all officers, directors, and stockholders
GENERAL PARTNERSHIP – List all general partners
LIMITED LIABILITY COMPANY – List all managers (member & non-member), directors, officers, and members
LIMITED PARTNERSHIP – List all general and limited partners.
LIMITED LIABILITY PARTNERSHIP – List all partners
Bar Manager (Fraternal Organizations of National Scope only):
OTHER INTERESTS
These questions must be answered about this business for every person or entity listed as the applicant
1. Are there any persons or entities not disclosed who have loaned money to the business?
Yes No
2. Are there any persons or entities not disclosed that derive revenue from the license solely
through a contractual relationship with the licensee, the substance of which is not related to the
control of the sale of alcoholic beverages, or is exempt by statute or rule?
Yes No
3. Are there any persons or entities not disclosed that have the right to receive revenue based on
a contractual relationship related to the control of the sale of alcoholic beverages?
Yes No
4. Are there any persons or entities not disclosed who have a right to a percentage payment from
the proceeds of the business pursuant to the lease?
Yes No
5. Are there any persons or entities not disclosed who have guaranteed the lease or loan?
Yes No
6. Are there any persons or entities not disclosed who have co-signed the lease or loan?
Yes No
7. Is there a management contract, franchise agreement, or concession agreement in connection
with this business?
Yes No
8. Have you or anyone listed on this application, accepted money, equipment or anything of
value in connection with this business from any industry member as described in 61A-1.010,
Florida Administrative Code?
Yes No
If you answered yes to any of the above questions, a copy of the agreement must be submitted with this
application. The terms of the agreement may require the interested persons or parties related to an entity to
submit fingerprints and a related party personal information sheet.
Auth. 61A-5.010 & 61A-5.056, FAC 8
SECTION 9 - AFFIDAVIT OF APPLICANT
NOTARIZATION REQUIRED
Business Name (D/B/A)
“I, the undersigned individually, or on behalf of a legal entity, 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 entire area and 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________________________
COUNTY OF______________________
_________________________________________________
APPLICANT/AUTHORIZED REPRESENTATIVE NAME
_________________________________________________
APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE
The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this ___________Day
of_______________, 20_____, By _______________________________________who is ( ) personally
(print name(s) of person(s) making statement)
known to me OR ( ) who produced ___________________________________________as identification.
________________________________________________ Commission Expires: ___________________
Notary Public
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Auth. 61A-5.010 & 61A-5.056, FAC 9
SECTION 10 - CURRENT LICENSEE UPDATE 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 information is captured.
Business Name (D/B/A)
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
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
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
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
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
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