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Application For State Of Illinois Special Use Permit Liquor License IL 567-0050 - Illinois
| Application For State Of Illinois Special Use Permit Liquor License Form. This is a Illinois form and can be used in Liquor Control Commission Statewide . |
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Illinois Liquor Control Commission Rod R. Blagojevich Governor 100 W. RANDOLPH ST. SUITE 7-801 CHICAGO, ILLINOIS 60601 TELEPHONE: 312-814-2206 FAX: 312-814-2241 TDD: 312-814-1844 101 W. JEFFERSON ST. SUITE 3-525 SPRINGFIELD, ILLINOIS 62702 TELEPHONE: 217-782-2136 FAX: 217-524-1911 WEB SITE: www.state.il.us/lcc APPLICATION FOR STATE OF ILLINOIS SPECIAL USE PERMIT LIQUOR LICENSE DEFINITION: The Special Use Permit Liquor License shall allow an Illinois-licensed liquor retailer to transfer a portion of its alcoholic liquor inventory from its licensed retail premises to a designated site for a special event. A Special Use Permit Liquor License must be obtained for each location and cannot exceed 15 days in duration. ELIGIBILITY: APPLICANT MUST ALREADY HOLD A STATE OF ILLINOIS RETAIL LIQUOR LICENSE. Local liquor licensing authority approval is required for this license. Dram shop insurance to the maximum limit is required for this license. FEE: $50.00 (1 DAY ONLY) PER EVENT LOCATION. EVENT DURATION MUST BE ONE DAY OR LESS AND THE APPLICATION MUST BE RECEIVED AT COMMISSION OFFICES AT LEAST 14 DAYS IN ADVANCE OF THE SCHEDULED EVENT. FEE: $100.00 (2-15 DAYS) PER EVENT LOCATION. EVENT DURATION CANNOT EXCEED 15 DAYS AND APPLICATION MUST BE RECEIVED AT COMMISSION OFFICES AT LEAST 14 DAYS PRIOR TO START OF EVENT. LATE FEE: ADD $25.00 ADD $25.00 TO EACH APPLICATION FEE IF YOU EXPECT THAT THE APPLICATION WILL NOT BE RECEIVED AT COMMISSION OFFICES AT LEAST 14 DAYS PRIOR TO THE SCHEDULED EVENT. THE COMMISSION REQUIRES THIS LEAD TIME IN ORDER TO SCHEDULE SITE INSPECTIONS. ON THE FOLLOWING PAGES, PLEASE PRINT OR TYPE THE INFORMATION REQUESTED IN THE SPACES PROVIDED. THE FORM MUST BEAR AN ORIGINAL SIGNATURE, THEREFORE NO FAXED SIGNATURES OR FORMS WITH PHOTOCOPIED/RUBBER STAMPED SIGNATURES WILL BE ACCEPTED. IMPORTANT NOTICE: THE ILLINOIS LIQUOR CONTROL COMMISSION IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY UNDER THE ILLINOIS LIQUOR CONTROL ACT (235 ILCS 5/1 ET SEQ.). DISCLOSURE OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE ANY INFORMATION WILL RESULT IN THE NON-ISSUANCE OF YOUR LICENSE. FORM APPROVED BY THE STATE FORMS MANAGEMENT CENTER. IL 567-0050 (07/2005) Printed on Recycled Paper Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com FOR OFFICIAL USE ONLY FOR OFFICE USE ONLY LICENSE NO. DATE ISSUED EXPIRATION DATE COUNTER ! Application for State of Illinois Special Use Permit Liquor License 1. APPLICANT INFORMATION Check here, if license and ILCC correspondence should be sent to this address. ! Provide your current State of Illinois Retail liquor license number; provide the corporate/organization name; provide the corporate/organization Federal Employer Identification Number (FEIN); provide your Illinois Department of Revenue IBT number (sales tax number); telephone number; provide your corporate/organization mailing address; and county. STATE LIQUOR LICENSE NO. NAME FEDERAL EMPLOYER ID NO. ILLINOIS BUSINESS TAX # AREA CODE/TELEPHONE NO. ( ADDRESS CITY ) STATE ZIP CODE COUNTY 2. BUSINESS PREMISE INFORMATION Check here, if license and ILCC correspondence should be sent to this address. ! Provide business name (Doing Business As/DBA), telephone number, address and county. NAME (DOING BUSINESS AS D/B/A ) AREA CODE/TELEPHONE NO. ( ADDRESS CITY STATE ZIP CODE ) COUNTY 3. FEDERAL TAX STAMP DOCUMENT CONTROL NUMBER Provide the Federal Tax Stamp Document Control Number in the space provided below. This number indicates that the business has been approved by the Alcohol and Tobacco Tax and Trade Bureau (TTB) to sell alcoholic beverages. This number can be obtained by calling TTB at 800-937-8864. FEDERAL TAX STAMP DOCUMENT CONTROL NO. IL 567-0050 (07/2005) Printed on Recycled Paper Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com 4. SPECIAL EVENT DETAIL · · · · · Provide the date(s) and time(s) that the event will be held. When you receive your printed license certificate from the Commission, times will be listed in military time; i.e. "0200" = 2AM, "1200" = noon"; "2400" = midnight; etc. Provide the address/location of the event. If an address is not available, provide specific instructions to enable our investigators to find the event. Please note: Only one location is allowed per application. Provide the name/type of the event; i.e. neighborhood festival, Octoberfest, fish fry, spaghetti dinner, etc. Determine the total number of event themes/event types for which approval is requested. Use a separate application for each event theme/event type. Determine the total number of days and locations covered by the event. For example, if your special event is held on three successive Fridays at the same location, you are only required to fill out a single application and pay a single application fee since the total duration is 15 days or less and the location is the same. If the location changes weekly in the aforementioned example, however, you will be required to fill out three applications and pay three fees. EVENT TIME: TIME FROM ( AM/PM ) DATE OF EVENT: EVENT ENDS (MONTH/DAY/YR) EVENT TIME: TIME TO ( AM/PM ) LOCATION OF EVENT: STREET ADDRESS CITY/STATE/ZIP EVENT THEME: TYPE OF EVENT DATE OF EVENT: EVENT STARTS (MONTH/DAY/YR) 5. CORPORATE/ORGANIZATION OFFICER INFORMATION The individual signing this application at the bottom of page 4 MUST be listed in this section. NAME (LAST, FIRST, MIDDLE INITIAL) HOME ADDRESS CITY STATE ZIP SOCIAL SECURITY NO. DATE OF BIRTH SEX TITLE/POSITION AREA CODE/TELEPHONE NO. % OWNED ( ) NAME (LAST, FIRST, MIDDLE INITIAL) HOME ADDRESS CITY STATE ZIP SOCIAL SECURITY NO. DATE OF BIRTH SEX TITLE/POSITION AREA CODE/TELEPHONE NO. % OWNED ( ) NAME (LAST, FIRST, MIDDLE INITIAL) HOME ADDRESS CITY STATE ZIP SOCIAL SECURITY NO. DATE OF BIRTH SEX TITLE/POSITION AREA CODE/TELEPHONE NO. % OWNED ( ) IL 567-0050 (07/2005) Printed on Recycled Paper Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com 6. PRIOR LIQUOR LICENSE INFORMATION A. Has the organization ever applied for and been denied a liquor license? Yes No a complete written explanation of the circumstances on a separate sheet of paper. If "yes", provide B. No Has the organization had any previous Special Use Liquor License suspended or revoked? Yes If "yes", provide a complete written explanation of the circumstances on a separate sheet of paper. 7. LOCAL AUTHORITY APPROVAL You MUST submit proof of local authority approval for your special event. Generally, your local municipality will issue
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