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HomeMy WebLinkAbout2014-159it/011 u ty DBPR ABT-6014 — Division of Alcoholic Beverages and Tobacco Change of Location/Change g r in Series or Type Application 4 STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT -6014 Revised 07/30/2012 A6/4.157 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 Informa;*imay-an be found on AB&T's page of the DBPR web site at the link provided below. ,-;:i'FIGATION ON LAST PAGE JRIG,\ '\L -` C http.//www.myflorida.com/dbpr/abt/district offices/licensing.htmf 'j• r\IIIT•H CLERK SECTION 1 - CHECK TRANSACTION REQUESTED Transaction Type: ■ Change of Location ❑ Increase in Series ❑ Change in Series ❑ Decrease in Series Also include ❑ Change of Business Name ❑ Change of Officer/Stockholder/Amended Corporate Name ❑ Retail Tobacco Products (must check one or more) ❑ Pipes ❑ Over the Counter ❑ Vending Machine Do you wish to purchase a Temporary License? ❑ Yes ❑ No Series Requested Type/Class Requested 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 Full Name of Licensee (This is the name the license is issued in) BOARD OF COUNTY COMM OF INDIAN RIVER COUNTY Department of State Document # BEV4100436 FEIN Number* 59-6000674 Business Telephone Number 772-226-1410 ext Current Business Name (D/B/A) BOCC OF IRC / SANDRIDGE GOLF CLUB Current License # BEV4100436 Series 4COP Type/Class SCC New Business Name (D/B/A), if applicable Location Address (Street and Number) 5300 73RD STREET City VERO BEACH County INDIAN RIVER State FL Zip Code 32960 Check either ❑ Location is within the city limits or ■ Location is in the unincorporated county Contact Person (Optional) MICHAEL C ZITO, ASSISTANT CTY ADMINISTRATOR Telephone Number 772-226-1410 ext E -Mail Address (Optional) MZITO@IRCGOV COM Mailing Address (Street or P 0 Box) 1801 27TH STREET City VERO BEACH State FL Zip Code 32960 ABT District Office Received / Date Stamp Auth. 61A-3.020 & 61A-5.0017, FAC 1 Eff. 7/30/12 SECTION 3-- DESCRIPTIION>OF..PREMISES TO BE" LICENSED Business Name (D/B/A) .BoARt. of CDUur 6)/Y715sionl Street Address/79 % 9 5 Jr .5 8 A VENU E CityState VER Et -A04 V County �nilimi -Ft vER FL si Zip Code 1. Yes • No E Is the proposed premises movable or able to be moved? } 0. 2. Yes • No 15' Is there any access through the premises to any area over which o you do not have dominion and control? w 3 Neatly draw a floor plan of the premises in ink, including sidewalks and other outside areas which a 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. / W V _ 5ERv/Nc. / ffeCA K1 RI 3 l-) 2-"N D,AtJ ‘46'g LCUM7 it S o 1 FAJRGRoutt5 T T EXPO C4-NTEI ?2' 44 N W ti►, _y ,� N H A RpPro> ' /4 7.70 sr OPCAI AR C) eE 3 -ra(M / . -- - .2 ao The location complies with zoning requirements for the sale of alcoholic tobacco products pursuant to this application for a Series _ license Are there outside areas which are contiguous to the premises which are sought to be licensed?" ❑ Yes ❑ No beverages or wholesale to be part of the premises CC w —J U S cr3 Q 10/28/2014 APPLICANT. INDIAN RIVER COUNTY ATTN• MICHAEL ZITO 1801 27TH ST VERO BEACH, FL 32960 INDIAN RIVER COUNTY Environmental Planning & Code Enforcement Section 1801 27th Street, Vero Beach FL 32960 772-226-1249 / 772-978-1806 fax www. ircgov, coni ALCOHOLIC BEVERAGE LICENSE ZONING PERMIT PROJECT / PERMIT NO. PROJECT NAME: LOCATION OF ACTIVITY: PARCEL NUMBER: A TRUE COPY CERTIFICATION ON LAST PAGE J,R. SM1TH, CLERK 92090142 / 73498 INDIAN RIVER COUNTY FAIRGROUNDS 7955 58TH AV 31-39-32-00000-7000-00002.0 THIS ALCOHOLIC BEVERAGE LICENSE ZONING PERMIT is issued in accordance with the Indian River County Code of Laws and Ordinances. The above named applicant is authorized to perform the herein described activity in accordance with the specifications of applicable county regulations This permit does not absolve the applicant and/or property owner from the responsibility to satisfy state or federal regulations that may apply to the activity. SPECIFIC CONDITIONS (AS APPLICABLE): 1. The subject property is described as follows: SE 1/4, LESS SEI/4 OF SEI/4 OF SE1/4 & SW 1/4 OF SW 1/4 OF SE1/4 & LESS E 40 FT FOR RD R/W. 2 The subject property is currently zoned A-1, Agricultural District, which would allow for the issuance of a 4 -COP (beer, wine, and liquor on-site consumption) Alcoholic Beverage License. 3. Reference Indian River County Site Plan Numbers SP -MA -83-06-074 and SP -MA -90-05-32 for site location and use 4 There are no established schools within the five hundred (500) foot seperation distance as required by County Code Section 300.05(1) DATE OF PERMIT ISSUANCE: 10/28/2014 abev letter proj/permit no 92090142/73498 SIG ATURE OF AUTHORIZATION: ell Cod E 'cement Officer In . an River County SECTION 4 — APPLICATION APPROVALS Full Name of Licensee BOARD OF COUNTY COMMISSION OF INDIAN RIVER COUNTY, FLORIDA Business Name (D/B/A) Street Address 1801 27TH STREET City VERO BEACH County INDIAN RIVER COUNTY State FL Zip Code 32960 A. The location complies with zoning requirements for the sale f tobacco products pursuant to this application for a Series lco lic beverages or wholesale COv 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 Date Zg% Signed Stan Boling, AICP Title Community Development Director 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 COMPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS OR COUNTY HEALTH AUTHORITY OR DEPARTMENT OF HEALTH OR DEPA TMENT OF AGRICULTURE & CONSUMER SERVICES e requirements of the Florida Sanitary Code Date Agency Auth. 61A-3.020 & 61A-5.0017, FAC 3 Eff. 7/30/12 SECTION 5 — CONTRACTS OR AGREEMENTS ' Business Name (D/B/A) These copies agreement disclosure INTERESTED sheet. questions of agreements gives of those PARTIES must be answered about this business for every person or entity listed as the applicant and must be submitted with this application If the management, service, or other contractual a person or entity control of the licensed premises or the sale of alcoholic beverages, persons must be made in the section labeled "DIRECT INTEREST" in the DISCLOSURE OF section They must also submit fingerprints and a related party personal information / 1 No © Is there a management contract, franchise agreement, or service agreement in connection with this business? Yes • Please sign and date Applicant's Signature Date 2. Are there any agreements which require a payment of a percentage of gross or net receipts from the business operation? Yes • No ri 3 No la 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'? Yes • SECTION 6 —SPECIAL LICENSE REQUIREMENTS (DOES NOT.APPLY TO BEER AND WINE LICENSES) 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 be met and maintained Please sign and date Applicant's Signature Date Auth. 61A-3.020 & 61A-5.0017, FAC 4 Eff. 7/30/12 SECTION 7 — DISCLOSURE'OFI INTERESTED PARTIES. Note Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of your 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) 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 Entity (If a legal entity, list name under which the entity does business and its principles) Title/Position 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 ❑ No If yes, and the 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 agreements must be submitted with this application Name Guarantor Co-signer Lender Interest Rate (List) [- n ❑ n - ❑ ❑ ❑ n Auth. 61A-3.020 & 61A-5.0017, FAC 5 Eff. 7/30/12 SECTION 8 - AFFIDAVIT OF APPLICANT NOTARIZATION:REQUIRED Business Name (D/B/A) BOARD OF COUNTY COMMISSION OF INDIAN RIVER COUNTY "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 FLORIDA INDIAN RIVER COU OF _ ••.Gfl.,�MI.... * Peter D. O'Bryan, Chairman APPLICANT SIGNATURE i •,53.2 o! • C '•aNRiVER D �" The foregoing was ( ) Sworn to and Subscribed OR (11 -Acknowledged Before me this ' Day of 1`101tvey.bcr , 20 I'1 , By tit D. d Bcv ilY1 who is (y) -personally ( not name(s) of person(s5 making statement) known to me OR ( ) who produced as identification ?e-ZN, I U1RA E. VASQUEZ * MY COMMISSION A EE 123140 Commission Expires / STATE OF FLORIDA INDIAN RIVER COUNTY THIS IS TO CERTIFY T AT THIS IS A TRUE AND CORRE C . ' Y THE ORIGI L 0 OFFICE J SMITH Auth. 61A-3.020 & 61A-5.0017, FAC 6 Eff. 7/30/12