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Home My WebLink About2026-147A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK DBPR ABT-6001 — Division of Alcoholic Beverages and Tobacco Application for New Alcoholic Beverage License STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 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& 71 local district office. Please submit your completed application and required fee(s) to your local district office. This application maybe 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 1 - CHECK LICENSE CATEGORY License Series Requested Type/Class Requested Do you wish to purchase a Temporary License? 4COP SFS E Yes El No Child License Requested Number of Child Licenses Requested GC 2 Retail Alcoholic Beverages ❑ Alcoholic Beverage Manufacturer ❑ Beer/Wine/Liquor Wholesaler ❑ Passenger Waiting Lounge Retail Tobacco Products Dealer Permit (must check one or more of the below) ❑ Pipes l Over the Counter ❑ Vending Machine 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 1772-579-5980 E -Mail Address (Optional) 59-6000674 laharrison@indianriver.gov Full Name of Applicant(s): (This is the name the license will be issued in) Department of State Document # Indian River County Business Name (D/B/A)Sandridge Golf Club Location Address (Street and Number) 5300 73rd Street City Vero Beach County State Zip Code Indian River FL 32967 Mailing Address (Street or P.O. Box) 5300 73rd Street City Vero Beach State Zip Code FL 32967 Contact Person - This section is optional, see application instructions for details Contact Person Telephone Number Alicia Williams 813-273-5130 ext. E -Mail Address (Optional) alicia.wiIliams@gray-robinson.com Mailing Address (Street or P.O. Box) c/o GrayRobinson P.A. - 101 E Kennedy Blvd., Suite 4000 City Tampa State Zip Code FL 33602 ABT District Office Received Date Stamp Auth. 61A�.010 & 61A-5.056, FAC A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK 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) Sandridge Golf Club 2. Full Name of Individual Deryl Loar Social Security Number* Home Telephone Number Date of Birth 592-03-4973 772-528-1856 10-09-1%7 Race Sex Height Weight Eye Color Hair Color white Idle 6 feet 230 lls. blue gray 3. Are you a U.S. citizen? Q0 Yes ❑ No If no, immigration card number or passport number: 4. Home Address (Street and Number) 190 21st Avue State Zip Code Vero Bed] 1 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 [O 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 [1 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? O Yes l 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 [O 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 A TRUE COPY r=RTIFICATION ON LAST PAGE !T' FR. CLERK 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 52 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 JNo 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 52No 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 F L1 JT _ -" COUNTY OF DDIAN FlyER APPLICANT SIGNA ••U;)tt�,�y Ova,. The foregoing was ( ) Sworn to and Subscribed OR (x) Acknowledged Before me this 1st Day of Scpte±er , 2026 , By Deryl Loar who is (x) personally (print name of person making statement) known to me OR ( ) who produced as identification. IM!s: KIMBERLY K. M0IRAN0 MYC0MMISSI0Nl } i Expires: April 9, 2027 Nota Public J[(4P AND LgGAL $UFJFICIENCY (ATTACH ADDITIONAL COPIES AS NECESSARY) BY *Social Security Number CHRISTOPHER A. HICKS Under the Federal Privacy Act, disclosure of Social Security numbemi5SISQIAt[ t9 S ' 1 TORNEY statute specifically requires it or allows states to collect the number. In this instan , disclosure of social security numbers is mandatory pursuant to Title 42 United States Code, Secti 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. Attest: Ryan L. Butler, Clerk of Circuit Court and Comptroller Auth. 61A-55.010 & 61A-5.056, FAC A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK SECTION 4- DESCRIPTION OF PREMISES TO BE LICENSED TO BE COMPLETED BY THE APPLICANT Business Name (D/B/A)Sandridge Golf Club 1. Yes ❑ No 2 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, b 1, F.S. or ❑ 561.20(2)(b)2, F.S. 4. Yes E1 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. Please See Attached { { Auth. 61A-5.010 & 61A-5.056, FAC A TRUE COPY CERTIFICATION ON LAST PAGE T LF ' rt.FRK } $t! i' f rsn rnutiio.at oen•a arc sots W ''I « $$eFl$B�fi� t • S$3� rnu+io�arwnvs $ ii I e' P��x � � 3 A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK SECTION 5— APPLICATION APPROVALS Full Name of Applicant: (This is the name the license will be issued in) Indian River County Business Name (D/B/A)Sandridge Golf Club Street Address 5300 73rd Street City Vero Beach County Indian River State FL Zip Code 32967 ZONING A. The location complies with zoning requirements for the sale of alcoholic beverages or wholesale tobacco products pursuant to this application for a Series: 4COP Type: SFS 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?" 52 Yes ❑ No Check either: Plea do not skip, this is important for license fee sharing ❑ Location is i n the city limits or 2 Location is in the unincorporated county Signed Date 9,l 1 L 12G Title 1?\ Mi AkcThis approval is valid for days. I 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. Sig Title This approval is valid for days. Date Department of Revenue Stamp 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 5 A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK SECTION 6— APPLICANT ENTITY FELONY CONVICTION Business Name (D/B/A) Sandridge Golf Club 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) 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 correspondin requirements for the license type sought. ❑ Quota Alcoholic Beverage License E Specialty Alcoholic Beverage License (e.g. § (S, etc) ❑ Club Alcoholic Beverage License This license is issued pursuant to , Florida Statutes or S cial Act, and as such we acknowledge the following requirements must be met and maintained: Please initia d date: Appli is Initials Date Auth. 61A.5.010 & 61A-5.056, FAC A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK Special License Requirements for Special Food Service — General Law — effective July 1, 2023 I •'• ===.= Please check the appropriate box of the license for which you are applying. FtP in the co responding requirements for the license type sought. 8 Quota Alcoholic Beverage License ® Spez alty Alcoholic Beverage License (e,g, SRX. S• etc) Club Alcoholic Beverage License This license is issued pursuant bo561.20(2)(a)(4) Florida Statutes or Special Act. and as such we acknowledge :he following requirements must be met and maintained. A bona fide food service establishment that has a minimum of 2,000 sq ft of service area, is equipped to serve meals to 120 persons atone Ume- has at least 120 physical seats available for patrons Louse during operating hours, holds itself out as a restaurant, and derives atleast 51 percent of its gross food and beverage revenue from the sale of food and nonalcoholic beverages. ***Continued below Please initial and date: St l iter 1, 2026 *'*during the first 120 -day operating period and the first 12 -month operating pe g period thereafter. Subsequent audit time fralnes:rush_r (; �:,��• be based upon the audit percentage established by the most recent audit and conducted on a staggered scale as follows: level 151•• •.i C •• percent to 60 percent, every year; level 2, 61 percent to 75 percent, every 2 years; level 3, 76 percent to 90 percent, every 3 years; and level 4, 91 percent to 100 percent, every 4 years. A licensee under this subparagraph may sell or deliver alcoholic beverages in a sealed container for off -premises consumption if the sale or delivery is accompanied by the sale of food within the same order. Such authorized sale or delivery includes wine -based and liquor -based beverages prepared by the licensee or its employee and packaged in a container sealed by the licensee or its employee. This subparagraph may not be construed to authorize public food service establishments licensed under this subparagraph to sell a bottle of distilled spirits sealed by a manufacturer. Any sale or delivery of matt beverages must comply with the container size, labeling, and filling requirements imposed under s. 563.06. Any delivery of an alcoholic beverage under this subparagraph must comply with s. 561.57. An alcoholic beverage drink prepared by the vendor and sold or delivered for consumption off the premises must be placed in a container securely sealed by the licensee or its employees with an unbroken seal that prevents the beverage from being immediately consumed before removal from the premises. Such alcoholic beverage also must be placed in a bag or other container that is secured in such a manner that it is visibly apparent if the container has been subsequently opened or tampered with, and a dated receipt for the alcoholic beverage and food must be provided by the licensee and attached to the bag or container. If transported in a motor vehicle, an alcoholic beverage that is not in a container sealed by the manufacturer must be placed in a locked compartment, a locked trunk, or the area behind the last upright seat of a motor vehicle. It is a violation of the prohibition in s. 562.11 to allow any person under the age of 21 to deliver alcoholic beverages on behalf of a vendor. The vendor or the agent or employee of the vendor must verify the age of the person making the delivery of the alcoholic beverage before allowing any person to take possession of an alcoholic beverage for the purpose of making a delivery on behalf of a vendor under this section. A food service establishment granted a special license on or after January 1, 1958, pursuant to general or special law may not operate as a package store and may not sell intoxicating beverages under such license after the hours of serving or consumption of food have elapsed. Failure by a licensee to meet the required percentage of food and nonalcoholic beverage gross revenues during the covered operating period shall result in revocation of the license or denial of the pending license application. A licensee whose license is revoked or an applicant whose pending application is denied, or any person required to qualify on the special license application, is ineligible to have any interest in a subsequent application for such a license for a period of 120 days after the date of the final denial or revocation; Attest: Ryan L. Butler, Clerk of Circuit Court and Comptroller By: puty Clerk A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK 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) Sandridge Golf Club 1. When applicable, complete the appropriate section below. Attach extra sheets if necessary. Title/Position I Name Stock % GORPORATION List all effleers, directors, and skholders County Commissioners Chairman Deryl Loar 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 rson or entity listed as the applicant 1. Are there any persons or entities not disclosed who have loaned money to the business? ❑ Yes [1 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 bevera es or is exem t b statute or rule? ❑ Yes [1 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 [1 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 E1 No 6. Are there any persons or entities not disclosed who have co-signed the lease or loan? ❑ Yes [O 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 [3 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 A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK SECTION 9 - AFFIDAVIT OF APPLICANT NOTARIZATION REQUIRED 'Business Name (D/B/A) Sandridge Golf Club I II "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 fl RIfl\ COUNTY OF ] JAN R1VFR Dery1 Q- t tf �Fps* ` APPROVED AS TO FORM E► APPLICANT/AUTHORIZED EPRESENT 1IVE=NAM ' 7 ANTGAIENCY B ICKS APPLICANT/AUTHORIZED REPRESENTATI 4 ,yG A� ASSITORNEY !'DER C The foregoing was ( ) Sworn to and Subscribed OR (x) Acknowledged Before me this 1st Day of SEPtm pr- , 20 2 , By known to me OR ( ) who produced Dervl Loar (print name(s) of person(s) making statement) is (x) personally as identification. k&'/►70�s. d Commission Expires:1 9, 2027 Notary Public KIMBERLY K MOIRANO MY COMMISSION # HH 368125 EXPIRES: April 8, 2027 Attest: Ryan L. Butter, Clerk of Circuit Court and Comptroller Auth. 61A-5.010 & 61A-5.056, FAC A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK 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)Sandridge Golf Club 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 Auth. 61 A-5.010 & 61A-5.056, FAC —r. a .y, a QTY :x; ' 3y,R 37aiiCe aol r 3dt "i, il4 JAt7 a k? 34, 4O =10� N'1i Ihx':dFi \ 4 h t 14 1 .f. roiM�'�{ �' Z'., �, �f.} S�'��1 i r°�. i F4 . �K ro: F, F . y dr !_ *rF1F; ,} qp� r ,yF'' �� .°� f } $ ,yt v , I' A 41 II, } YA' [ S ,¢ Ey' *1 1 'F 1 '�*'f x. < aa:' IF e x kr k .. f 4 'F � a4 F .. �.qJ 'V a 7' IA w 1 A r F d(t k 4 i t � . ,,t ,.s 'F'''F' 'F i y,, N dk '+ § P xp� •y 1 Rf 3 ty .1.„ F 'F - tY _�