Fillable Off Premise Prequalification (Texas Secretary of State)

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Off Premise Prequalification (Texas Secretary of State)

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Page 1 of 4
L-OFF (12/2019)
OFF-PREMISE
PREQUALIFICATION PACKET
L-OFF (12/2019)
Submit this packet to the proper governmental entities to obtain certification for the type of license/permit for which
you are applying as required by Sections 11.37, 11.39, 11.46(b), 61.37, 61.38, 61.42 and Rule §33.13
All statutory and rule references mentioned in this application refer to and can be found in the Texas Alcoholic Beverage
Code or Rules located on our website. www.tabc.texas.gov/laws/code_and_rules.asp
LOCATION INFORMATION
1.
Application for: Original
Reinstatement Reinstatement and Change of Trade Name License/Permit Number
Change of Location Change of Location and Trade Name License/Permit Number
2.
Type of Off-Premise License/Permit
BQ Wine and Beer Retailer’s Off-Premise Permit
LP Local Distributor’s Permit
BF Beer Retail Dealer’s Off-Premise License
E Local Cartage Permit
P Package Store Permit
ET Local Cartage Transfer Permit
Q Wine Only Package Store Permit
PS Package Store Tasting Permit
3.
Indicate Primary Business at this Location
Grocery/Market
Liquor Store
Convenience Store without Gas
Miscellaneous __________________________________
Convenience Store with Gas
4.
Trade Name of Location (Name of store, business, etc.)
5.
Location Address
County
State
Zip Code
6.
Mailing Address
City
State
Zip Code
7.
Business Phone No.
Alternate Phone No.
E-mail Address
OWNER INFORMATION
8.
Type of Owner
Individual
Corporation
City/County/University
Partnership
Limited Liability Company
Other
Limited Partnership
Joint Venture
Limited Liability Partnership
Trust
9.
Owner of Business /Applicant (Name of Corporation, LLC, etc.)
PRIMARY CONTACT PERSON
The primary contact person should be a person who can answer questions TABC may have about the application. The contact phone and email are
mandatory and must be active and updated regularly. If additional information is needed, it will be requested from this contact person. Delays in
responding to requests may delay the processing and approval of your permit/license.
10.
Contact Person:
Relation to Business:
Phone (mandatory):
Email (mandatory):
TABC DATESTAMP
______________
______________
____________________
Page 2 of 4
L-OFF (12/2019)
MEASUREMENT INFORMATION
Section 109.31 et. seq.
14.
Will your business be located within 300 feet of a church or public hospital?
Yes No
NOTE:
For churches or public hospitals measure from front door to front door, along the property lines of the street
fronts and in a direct line across intersections.
15.
Will your business be located within 300 feet of any private/public school?
Yes No
NOTE:
NOTE:
For private/public schools measure in a direct line from the nearest property line of the school to the nearest
property line of the place of business, and in a direct line across intersections.
If located on or above the fifth story of a multistory building: measure in a direct line from the property line of the
private/public school to property line of your place of business in a direct line across intersections vertically up
the building at the property line to the base of the floor on which your business is located.
16.
Will your business be located within 1,000 feet of a private school?
Yes No
17.
Will your business be located within 1,000 feet of a public school?
Yes No
PACKAGE STORE ACQUISITIONS ONLY
18.
Has the business being acquired been in operation in the same county for more than one
year before the acquisition?
Yes No
If Yes, provide permit number for existing package store: ______________
If No, this does not qualify as an acquisition, and will be considered a new location.
ALL APPLICANTS
19. CHECK HERE IF NOT IN CITY LIMITS
I, the applicant, have confirmed the location is not located within city limits, therefore city certifications are not required.
COMPLETE THE FOLLOWING CHECKLIST BEFORE SUBMITTING YOUR APPLICATION
Per Sec. 102.01, a tied house is defined as any overlapping ownership between those engaged in the alcoholic beverage industry at different levels of the
three-tier system. No person having an interest in a permit issued by TABC may secure or hold, directly or indirectly, an ownership interest in a business on a
different level.
All required forms have been completed.
Yes No
I have reviewed all forms to ensure they are complete.
Yes No
I have obtained all required local and state certifications (pages 3-4).
Yes No
All application packets have been notarized.
Yes No
Phone numbers and email address for Contact Person are up to date.
Yes No
All additional documentation as required by the application packets is attached
Yes No
If required, out of state criminal history checks are attached (PHS #7).
Yes No N/A
Certification of publication in local newspaper has been completed (page 4).
Yes No N/A
A copy of the newspaper publication is attached (page 4).
Yes No N/A
11.
Is the applicant, a veteran-owned business?
Yes No
12.
Is the applicant, a Historically Underutilized Business (HUB)?
Yes No
13.
As indicated on the chart, enter the individuals that pertain to your business type:
(For additional space, use Form L-OIC)
Individual/Individual Owner
Limited Liability Company/All Officers or Managers
Partnership/All Partners
Joint Venture/Venturers
Limited Partnership/All General Partners
Trust/Trustee(s)
Corporation/All Officers
City, County, University/Official
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Page 3 of 4
L-OFF (12/2019)
WARNING AND
SIGNATURE
If Applicant Is/Must Sign
Individual/Individual Owner
Corporation/Officer
Partnership/Partner
Limited Liability Company/ Officer or Manager
Limited Partnership/General Partner
WARNING: Section 101.69 of the Texas Alcoholic Beverage Code states: “…a person who makes a false statement or
false representation in an application for a permit or license or in a statement, report, or other instrument to be filed with
the Commission and required to be sworn commits an offense punishable by imprisonment in the Texas Department of
Criminal Justice for not less than 2 nor more than 10 years.”
BY SIGNING YOU ARE SWEARING TO ALL INFORMATION AND ATTACHMENTS TO THIS PACKET.
PRINT
NAME
SIGN
HERE
TITLE
Before me, the undersigned authority, on this day of , 20 , the
person whose name is signed to the foregoing application personally appeared and, duly sworn by me, states under oath
that he or she has read the said application and that all the facts therein set forth are true and correct.
SIGN
HERE
NOTARY PUBLIC
S E A L
CERTIFICATE OF CITY SECRETARY (FOR P, Q, BF & BQ)
Sections 11.37 & 61.37
I hereby certify on this day of , 20 , that the location for which the
license/permit is sought is inside the boundaries of this city or town, in a “wet” area for such license/permit, and not
prohibited by charter or ordinance in reference to the sale of such alcoholic beverages.
SIGN
HERE , TEXAS
City Secretary/Clerk City
S E A L
CERTIFICATE OF COUNTY CLERK (FOR P, Q & BF)
Sections 11.37 & 61.37
I hereby certify on this day of , 20 , that the location for which the
license/permit is sought is in a “wet” area for such license/permit, and is not prohibited by any valid order of the
Commissioner’s Court.
SIGN
HERE COUNTY
County Clerk
S E A L
Page 4 of 4
L-OFF (12/2019)
CERTIFICATE OF COUNTY CLERK (FOR BQ)
Section 11.37
I hereby certify on this day of , 20 , that the location for which the
license/permit is sought as the place of business is in a “wet” area and is not prohibited by any valid order of
the Commissioner’s Court for a Wine and Beer Retailer’s Off-Premise Permit.
Most current election for given location was held for:
legal sale of all alcoholic beverages for off-premise consumption
legal sale of all alcoholic beverages
legal sale of all alcoholic beverages except mixed beverages
legal sale of all alcoholic beverages including mixed beverages
legal sale of mixed beverages
legal sale of mixed beverages in restaurants by food and beverage certificate holders
legal sale of wine on the premises of a holder of a winery permit
legal sale of beer/wine (17%) on-premise or beer/wine off-premise AFTER Sept. 1,1999
legal sale of beer/wine (14%) on-premise or beer/wine off-premise BEFORE Sept. 1,1999
SIGN
HERE COUNTY
County Clerk
S E A L
COMPTROLLER OF PUBLIC ACCOUNTS CERTIFICATE
Sections 11.46(b) & 61.42(b)
This is to certify on this day of , 20 , the applicant holds or has applied
for and satisfies all legal requirements for the issuance of a Sales Tax Permit under the Limited Sales, Excise and Use Tax
Act or the applicant as of this date is not required to hold a Sales Tax Permit.
Sales Tax Permit Number Outlet Number
Print Name of Comptroller Employee
Print Title of Comptroller Employee
SIGN
HERE FIELD OFFICE
S E A L
PUBLISHER’S AFFIDAVIT (FOR BQ, BF, P & Q)
Sections 11.39 & 61.38
Name of newspaper
ATTACH PRINTED
COPY OF THE
NOTICE HERE
Hover over to see example
City, County
Dates notice published in daily/weekly
newspaper (MM/DD/YYYY)
Publisher or designee certifies attached notice was published in newspaper stated on dates shown.
Signature of publisher or designee
Sworn to and subscribed
before me on this date
Signature of Notary Public
S E A L
Page 1 of 1
Form L-OIC (12/2019)
OWNERSHIP INFORMATION
Continued for Prequalification Packet
L-OIC
(12/2019)
LOCATION INFORMATION
1.
Trade Name of Location
2.
Location Address
City
County
State
Zip Code
OWNER INFORMATION
3.
Type of Owner
Individual
Corporation
City/County/University
Partnership
Limited Liability Company
Other
Limited Partnership
Joint Venture
Limited Liability Partnership
Trust
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
Last Name
First Name
MI
Title
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Off Premise Prequalification (Texas Secretary of State)

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Completed 18 July 2020

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