Maine > Statewide > Liquor Licensing And Inspection Division
On Premise License Application - Maine
| On Premise License Application Form. This is a Maine form and can be used in Liquor Licensing And Inspection Division Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
NOTICE To avoid any delay in the processing of your application and issuance of your liquor license, please make sure that: 1. You have completed the application in full. 2. Application is signed by the owner (s), Corporate Officer or Club Officer. 3. The municipal officers have signed the application. 4. The license fee is correct and you have included the $10.00 filing fee. 5. A diagram of the premises to be licensed accompanies the application. 6. If business is located in an unorganized township. The application must be approved by the County Commissioners and the $10.00 filing fee paid to them. SPECIAL NOTE Limited Liability Companies, Limited Partnerships and Corporations must complete and submit the Supplementary Corporate Questionnaire. Stock ownership in non-publicly traded companies must add up to 100% Private Clubs and Fraternal Organizations must complete and submit the Supplementary Questionnaire for club applicants. 164 State House Station Augusta Me 04333-0164 Tel: 207-624-7220 Fax: 207-287-3424 OnPremiseApp.doc / 2003 American LegalNet, Inc. www.FormsWorkFlow.com Department of Public Safety Division Promise by any person that he or she can expedite a liquor license through influence should be completely disregarded. To avoid possible financial loss an applicant, or prospective applicant, should consult with the Division before making any substantial investment in an establishment that now is, or may be, attended by a liquor license. Liquor Licensing & Inspection BUREAU USE ONLY License No. Assigned: Class: Deposit Date: PRESENT LICENSE EXPIRES ________________ INDICATE TYPE OF PRIVILEGE: MALT SPIRITUOUS Amt. Deposited: VINOUS INDICATE TYPE OF LICENSE: RESTAURANT (Class I,II,III,IV) RESTAURANT/LOUNGE (Class XI) HOTEL-OPTIONAL FOOD (Class I-A) HOTEL (Class I,II,III,IV) CLASS A LOUNGE (Class X) CLUB-ON PREMISE CATERING (Class I) CLUB (Class V) GOLF CLUB (Class I,II,III,IV) TAVERN (Class IV) OTHER: _______________________________ REFER TO PAGE 3 FOR FEE SCHEDULE ALL QUESTIONS MUST BE ANSWERED IN FULL 1. APPLICANT(S) (Sole Proprietor, Corporation, Limited Liability Co., etc.) DOB: 2. Business Name (D/B/A) DOB: DOB: Location (Street Address) Address City/Town State Zip Code Mailing Address City/Town State Zip Code City/Town State Zip Code Telephone Number Fax Number Business Telephone Number Fax Number Federal I.D. # Seller Certificate # 3. If premises are a hotel, indicate number of rooms available for transient guests: ________ 4. State amount of gross income from period of last license: ROOMS $ _______ FOOD $ _______ LIQUOR $_______ 5. Is applicant a corporation, limited liability company or limited partnership? YES NO complete Supplementary Questionnaire ,If YES 6. Do you permit dancing or entertainment on the licensed premises? YES NO 7. If manager is to be employed, give name: _____________________________________________________________ 8. If business is NEW or under new ownership, indicate starting date: __________________ Requested inspection date: ___________________ Business hours: _______________ 9. Business records are located at: _____________________________________________________________________ 10. Is/are applicants(s) citizens of the United States? YES NO American LegalNet, Inc. www.FormsWorkFlow.com 11. Is/are applicant(s) residents of the State of Maine? YES NO 12. List name, date of birth, and place of birth for all applicants, managers, and bar managers. Give maiden name, if married: Use a separate sheet of paper if necessary. Name in Full (Print Clearly) DOB Place of Birth Residence address on all of the above for previous 5 years (Limit answer to city & state 13. Has/have applicant(s) or manager ever been convicted of any violation of the law, other then minor traffic violations, of any State of the United States? YES NO Name: ______________________________________________ Offense: ____________________________________________ Disposition: _________________________________________ 14. Will any law enforcement official benefit financially either directly or indirectly in your license, if issued? Yes No If Yes, give name: _____________________________________________________________ 15. Has/have applicant(s) formerly held a Maine liquor license? 16. Does/do applicant(s) own the premises? Yes No YES NO Date of Conviction: _______________________ Location: ________________________________ If No give name and address of owner: ______________ ___________________________________________________________________________________________________________________________________ 17. Describe in detail the premises to be licensed: (Supplemental Diagram Required) _____________________________ ___________________________________________________________________________________________________________________________________ 18. Does/do applicant(s) have all the necessary permits required by the State Department of Human Services? YES NO Applied for: ______________________ 19. What is the distance from the premises to the NEAREST school, school dormitory, church, chapel or parish house, measured from the main entrance of the premises to the main entrance of the school, school dormitory, church, chapel or parish house by the ordinary course of travel? __________ Which of the above is nearest? __________________ 20. Have you received any assistance financially or otherwise (including any mortgages) from any source other than yourself in the establishment of your business? YES NO If YES, give details: _____________________________________________________________________________ The Division of Liquor Licensing & Inspection is hereby authorized to obtain and examine all books, records and tax returns pertaining to the business, for which this liquor license is requested, and also such books, records and returns during the year in which any liquor license is in effect. NOTE: "I understand that false statements made on this form are punishable by law. Knowingly supplying false information on this form is a Class D offense under the Criminal Code, punishable by confinement of up to one year or by monetary fine of up to $2,000 or both." Dated at: _______________________________________ on _________________________, 20 _____ Town/City, State Date Please sign in blue ink _____________________________________________________ ____________________________________________________ Signature of Applicant or Corporate Officer(s) ______________________________________ Signatur
|
|||||||
