Fillable Office of Planning and Zoning lication for Adult (Lake County Board of County Commissioners)

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Office of Planning and Zoning lication for Adult (Lake County Board of County Commissioners)

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U.S.A. forms for Lake County Board of County Commissioners

BROWSE LAKE COUNTY BOARD OF COUNTY COMMISSIONERS (FL) FORMS

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_______________________________________________________________
________________________________________________________________
Office of
Planning and Zoning
A
pp
lication for Adult Entertainment License
DATE: _____________________________
I. THIS APPLICATION IS FOR: (Check only one)
(Application fee: $931.00 – Office of Planning and Zoning & Office of Building Services)
A
. A new license, or
B. Transfer of an existing license to the applicant from the current Licensee:
Name:
License # ____________________
II. CLASSIFICATION OF LICENSE BEING APPLIED FOR: This application is for a license in the
single classification of: (Check only one)
A. Adult Bookstore
B. Adult Theater
C. Adult Performance Establishment
D. ___ Escort Service
E. Physical Contact Parlor
III. LICENS
EE:
A. This application is for a license to be issued to: (check only one)
1. An individual person
2. A partnership
3. A corporation
B. Full legal name of licensee: ________________________________________
C.
Mailing address of licensee: _______________________________
________
IV. ESTABLISHMENT INFORMATION:
A. Name of the proposed establishment: ______________________________
Is the name of the proposed establishment a "Fictitious Name" under Section 865.09,
B.
Florida Statutes?
YES NO
C. If "Yes," state the County of registration: ________________________________
D. Street address and legal description of the proposed establishment:
Office of Planning & Zoning
Application for Adult Entertainment License
Revised 2017/10
Page 1 of 6
____________________________________________________________
____________________________________________________________
___________________________________________________________
___________________________________________________________
_____________________________________________________
V. REQUIRED INFORMATION:
A. Complete the following regarding the person making this application as an individual, or on
behalf of a Partnership or Corporation:
1. Full legal name: _______________________________________________
2. All aliases:___________________________________________________
3. Date of birth: _________________________________________________
4. Sex: ________________________________________________________
5. Residential address:____________________________________________
6. Residential telephone:__________________________________________
7. Business address: ____________________________________________
___________________________________________________________
8. Business telephone numbers: ___________________________________
9. Driver's License number or Identification Card number:
B. If the licensee is a Partnership, complete the following:
1. Full legal name of Partnership:
2. For each partner involved in the daily operations of the establishment: Full legal
name, residential address, and residential telephone number: (attach additional
sheets if necessary)
3. Date the Partnership was formed: _______________________________
4. Type of Partnership (e.g., General or Limited Partnership): ___________
5. Name, residential address, and residential telephone number of a person in Florida
authorized to accept service of process:
C. If the Licensee is a Corporation, complete the following:
Office of Planning & Zoning Revised 2017/10
Application for Adult Entertainment License Page 2 of 6
___________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
1. Full legal name of Corporation: _________________________________
2. Date of incorporation: _________________________________________
3. State of incorporation:_________________________________________
4. For each officer and director: Full legal name and capacity:
(Attach additional sheets if necessary)____________________________
5. The name of the corporation's Registered Agent, as well as the address and
telephone number of the Registered Office:
(Attach additional sheets if necessary)____________________________
6. The title or capacity of the person who makes the application on behalf of the
corporation (this person must be an officer or director):
VI. GENERAL INFORMATION:
A. Does the licensee own the real property upon which the proposed establishment is to be
located? YES NO
If, "no," state the full name, mailing address, and telephone number(s) of the owner(s) of
the property:
If, "No," describe the exact nature of the applicant's interest in the real property (e.g.,
lessee):
B. Does the applicant presently own or operate any other adult entertainment establishment
licensed under Lake County Adult Entertainment Code? YES NO
If "Yes," identify the other adult entertainment establishment(s), by stating for each: the
address of the other adult entertainment establishment(s), the classification of each of the
other adult entertainment establishment license(s), and the corresponding license
number(s):
(Attach additional sheets if necessary)____________________________________
C. Has the applicant or any partner, officer, or director of the applicant been convicted within
the last five (5) years of a felony or specified criminal act, as defined by the Lakee County
Adult Entertainment Code? YES NO
If "Yes," state for each conviction: the specified criminal act, the date of conviction, and the
place (e.g., state, county, or city) of conviction:
(Attach additional sheets if necessary)____________________________________
Office of Planning & Zoning Revised 2017/10
Application for Adult Entertainment License Page 3 of 6
D. Has the applicant or any partner, officer, or director of the applicant had a license under
the Adult Entertainment Code denied, suspended or revoked? YES NO
If "Yes," list the date of each denial, suspension and/or revocation, and the license(s) for
which each such denial, suspension or revocation applied:
(Attach additional sheets if necessary)___________________________________
E. Provide, for each person who has the right or authority to manage or control the day-to-day
operation of the establishment, the name, mailing address, residential address, business
address, residential telephone number, and business telephone number. If any part of this
answer is a corporation, provide the specified information for the officers and directors of
the corporation:
(Attach additional sheets if necessary)___________________________________
VII. ATTACHMENTS:
A. Attach to this application a current site plan, drawn to appropriate scale, of the proposed
establishment, including, but not limited to, the following:
1. all current property lines, rights-of-way, and the location of buildings, parking areas
and spaces, curb cuts, and driveways and distances from surrounding
property/uses;
2. all current windows, doors, entrances and exits, fixed structural features, walls,
stages, partitions, projection booths, admission booths, concession booths, stands,
counters, similar structures; and
3. all proposed improvements or enlargements to be made, which shall be indicated
and calculated in terms of percentage of increase in floor size.
B. Attach a recent photograph of the person making this application.
C. Attach a photocopy of either the driver's license or state or federally issued identification
card for the person making this application.
D. If the application is for a corporation, attach a photocopy of the articles of incorporation and
by-laws of the corporation or, if the application is for a partnership, attach a photocopy of
the partnership agreement. Attached ______ Yes ______ No
E. If the application is for a transfer of a license, attach a notarized affidavit by the current
licensee evidencing consent to the transfer and any applicable contract or bill of sale.
Attached ______ Yes ______ No
F. If the applicant is not the owner of the property, attach a notarized affidavit of the property
owner evidencing consent and approval to the application for an adult entertainment license
and a copy of the lease or rental agreement along with any related documentation.
Attached ______ Yes ______ No
Office of Planning & Zoning Revised 2017/10
Application for Adult Entertainment License Page 4 of 6
____________________________
____________________________
____________________________
AUTHORIZATION and CERTIFICATION:
I hereby authorize the Building Services Division, Health Department, Fire and Rescue Services
Division, Sheriff's Office, Office of Planning & Zoning, and Tax Collector to obtain all data and information
needed to examine and review this application and the proposed establishment. I hereby authorize each
of the above-referenced departments to conduct an inspection or inspections of the proposed location of
the proposed establishment.
I hereby swear under penalty of perjury that I am authorized by the named applicant to make this
application and that the foregoing statements are true and correct. I understand that, in the event a license
is granted based upon false information, misrepresentation of fact, or mistake of fact, the Lake County
Code provides that the license shall be revoked.
Signature of Applicant
Capacity
Print name
County of __________________,
State of Florida
SWORN to and SUBSCRIBED by the person named above who took and oath and is (1)
personally known to me, or (2) produced as identification before me this day
of , 20____.
NOTARY PUBLIC, State of Florida
Office of Planning & Zoning Revised 2017/10
Application for Adult Entertainment License Page 5 of 6
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_________________________________________________________
*** THIS PAGE FOR OFFICIAL USE ONLY ***
License must be granted or denied within 30 days.
Notification of grant or denial must be sent to applicant within seven days.
Notifications must be sent by certified mail, return receipt requested.
I. Date application received in Occupational Licensing: Name:___________
II. Date application forwarded to departments for review: Name:___________
A. Building Division: Date Responded: Name:___________
B. Planning & Zoning: Date Responded: Name:___________
C. Health Department: Date Responded: Name:___________
D. Fire and Rescue: Date Responded: Name:___________
E. Sheriff's Office: Date Responded: Name:___________
F. Code Enforcement Date Responded: _________Name:___________
III. Granted licenses:
A. Date license was issued: License No.: _____
B. Classification of license:_______________________________________
C. Name of Licensee: __________________________________________
D. Date of notification to applicant of new license being granted: __
E. Name of official issuing license and notice: _______________________
IV. Denied licenses:
A. Date license was denied: ____________________________________
B. Date of notification to applicant of license being denied:_____________
C. Name of official sending notice of license being denied:
Office of Planning & Zoning Revised 2017/10
Application for Adult Entertainment License Page 6 of 6
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Office of Planning and Zoning lication for Adult (Lake County Board of County Commissioners)

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Completed 18 July 2020

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