Arizona > Statewide > Liquor Licenses And Control
Application For Extension Of Premises Patio Permit LIC 0105 - Arizona
| Application For Extension Of Premises Patio Permit Form. This is a Arizona form and can be used in Liquor Licenses And Control Statewide . |
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ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 800 W Washington 5th Floor Phoenix AZ 85007-2934 www.azliquor.gov (602) 542-5141 Date payment received __________ CSR Initials __________ APPLICATION FOR EXTENSION OF PREMISES/PATIO PERMIT THIS APPLICATION MUST BE RETURNED TO THE DEPARTMENT OF LIQUOR Permanent change of area of service. A non-refundable $50 fee will apply. Specific purpose for change: _____________ _______________________________________________________________________________________________ Temporary change for date(s) of: ___/____/____through ____/____/____ List specific purpose for change:___________ ________________________________________________________________________________________________ 1. Licensee's Name: ___________________________________________________________________________________ 2. Mailing Address: ____________________________________________________________________________________ 3. Business Name: _________________________________________________ LICENSE #:__________________________ 4. Business Address: __________________________________________________________________________________ 5. 6. 7. 8. 9. 10. Business Phone: (____) _____________________________ Residence Phone:(____) _____________________________ Do you understand Arizona Liquor Laws and Regulations? YES NO Fax #: (____) ___________________________ Have you received approved Liquor Law Training? NO YES If so, when does your Certificate expire? _____/____/____ What security precautions will be taken to prevent liquor violations in the extended area? ______________________________ YES NO Does this extension bring your premises within 300 feet of a church or school? IMPORTANT: ATTACH THE REVISED FLOOR PLAN CLEARLY DEPICTING YOUR LICENSED PREMISES AND WHAT YOU PROPOSE TO ADD. Barrier Exemption: an exception to the requirement of barriers surrounding a patio/outdoor serving area may be requested. Barrier exemptions are granted based on public safety, pedestrian traffic, and other factors unique to a licensed premises. List specific reasons for exemption: __________________________________________________________________ _______________________________________________________________________________________________ Investigation Recommendation Approval Disapproval by: ________________________________ Date: ___/___/___ City COUNTY State Zip City State Zip Last First Middle ****After completing sections 1-10, please take this application to your local Board of Supervisors, City Council or Designate for their recommendation. This recommendation is not binding on the Department of Liquor. This change in premises is RECOMMENDED by the local Board of Supervisors, City Council or Designate: ________________________________________ _______________________ _________________________________ (Authorized Signature) (Title) (Agency) I, _______________________________________________, being first duly sworn upon oath, hereby depose, swear and declare, under penalty of perjury, that I am the APPLICANT making the foregoing application. I have read this application and the contents and all statements are true, correct and complete. State of __________________County of ___________________ SUBSCRIBED IN MY PRESENCE AND SWORN TO before me this date X _______________________________________________ (Signature of Owner or Agent) (Print full name) _____________________________________________________ Day Month Year My commission expires on: ___/___/___ Investigation Recommendation 12/26/2012 _____________________________________________________ (Signature of NOTARY PUBLIC) Approval Disapproval by: ________________________________ Date: ___/___/___ Director Signature required for Disapprovals ________________________________________________ Date: ___/___/___ *Disabled individuals requiring special accommodation, please call the Department(602) 542-9027. American LegalNet, Inc. www.FormsWorkFlow.com
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