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Application For Transfer Of Location DLC 4118 - Ohio
| Application For Transfer Of Location Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
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For Questions call (614) 644-3156 Office Hours 8:00 a.m. - 5:00 p.m. Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005 Reynoldsburg, Ohio 43068-9005 http://www.com.ohio.gov/liqr APPLICATION FOR TRANSFER OF LOCATION OF ALL PERMIT CLASSES LISTED BELOW CAUTION: ALLOW 6 TO 8 WEEKS FOR PROCESSING. RETURN TO ADDRESS ABOVE PROCESSING FEE $100.00 PRINT OR TYPE ALL INFORMATION, EXCEPT SIGNATURES NOTE: You may NOT sell alcoholic beverages at the new location until the PERMIT(S) have been issued to you at that location. Permit Holder (Individual, Corporation, Partnership or LLC) Current Permit # PRESENT PERMIT LOCATION INFORMATION: DBA (doing business as): NEW PERMIT LOCATION INFORMATION: DBA (doing business as): Permit Premises Address: Township (If outside City Limits): County: State Zip Code: Permit Premises Address: Township (If outside City Limits): County: State Zip Code: City: OH City: OH Attorney's Name: Address: Phone # Mailing Address: (Name, Street Address, City & Zip): CHECK Classes of Permit(s) Being Transferred: A-1 B-4 D-3A S A-1A B-5 D-3X W A-2 C-1 D-4 A-3 C-2 D-5 A-4 C-2X D-5J* B-1 D-1 D-6 B-2 D-2 D-7 B-2A D-2X G B-3 D-3 I *Only within the boundaries of the Community Entertainment District ("CED") Data Entry Initials: ________________ CODER FOR PRESENT LOCATION RECEIPT NUMBER OLD TAXING DISTRICT FOR DIVISION USE ONLY Data Entry Action: Comments/Notes: Proc. Fee Pd: YES NO OLD PERMIT # NEW TAXING DISTRICT NEW LOCATION PERMIT # DLC4118 EOE/ADA SERVICE PROVIDER Page 1 FOR TTY USERS DIAL ORS 1-800-750-0750 Rev. 09/2010 American LegalNet, Inc. www.FormsWorkFlow.com 1. Do you own the real estate on which the proposed business will be located? If NO, return a completed a signed and dated copy of your LEASE OR RENTAL CONTRACT, OR SUMMARY OF TENANCY RIGHTS form (DLC form 4085). 2. Will the applicant be the sole owner of the business and equipment? If NO, and the fixtures or equipment are rented, submit signed and dated copy of rental agreement. 3. Will any person, partnership, LLC, or corporation, excluding banks or building and loan associations, have ANY financial interest (such as money, loans, installment contracts, property or other interest) or share in the profits in your business or your property, real or personal? If YES, attach an affidavit with details. NOTE: Ohio Revised Code Section 4303.293 provides a criminal penalty for failure to answer this question completely and correctly. 4. Is there an existing building? If NO, give approximate date construction will begin: ________________________________ 5. Are you applying to transfer all the permit classes being used at your present location to the proposed location? If NO, attach a written explanation for not doing so. DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THE APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION. YES NO YES NO YES NO YES NO YES NO State of Ohio, ____________________County, ss I, _____________________________________________being first duly sworn, according to law, depose and say that the (Please Print) statements and answers made in the foregoing application are true. X____________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) _____________________ (Title) ________ (Date) ______________________________________ ______________________ ________ (Residence Address) (City) (State) _____________ _______________________ (Zip Code) (Area Code & Phone Number) (To be completed by NotaryPublic) Sworn to before me and subscribed in my presence this __________day of _______________________________, 20 _____________. ________________________________________ (Notary Public) _______________ (Notary Expiration) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com REQUIRED DOCUMENTS FOR ACCEPTANCE OF A TRANSFER OF LOCATION APPLICATION Please use the list below to check off all items as you complete them, to submit with the application packet CAUTION: ALLOW 6 TO 8 WEEKS FOR PROCESSING. REQUIRED FOR ALL TYPES OF ENTITIES Application: Application Processing Fee: Background Check: Personal History Background Form (DLC4121): Lease or Tenancy Agreement: Application must be completed in full, all questions answered, signed, and notarized. $100.00 - Check made payable to Division of Liquor Control. PLEASE READ "BACKGROUND CHECK INFORMATION" DLC4191 Section A. ONLY must be completed in full for each stockholder or officer for whom a background check will be performed by the Ohio Bureau of Identification and Investigation (BCI&I). Submit copy of signed and dated lease, tenacy agreement, or may submit DLC Form 4085 "Summary of Tenancy Rights" completed in full. REQUIRED DOCUMENTS TO BE FILED WITH INDIVIDUALS ONLY See list above "Required for All Types of Entities". No other documents are needed, unless requested during processing. REQUIRED DOCUMENT TO BE FILED WITH NON PROFIT ENTITIES 4029 Form: To be filed with Governmental or Educational entities, or other non-profit businesses. Form must be completed in full. List the top five officer, including social security numbers. This form must be notarized. REQUIRED DOCUMENTS TO BE FILED WITH CORPORATIONS ONLY 4030 Form (Corporation): Form must be completed in full. List the top five officers, including social security numbers. Indicate all stock holders over 5% including social security numbers. Indicate total shares issued. Must be notarized. If not incorporated in the State of Ohio, submit a copy of CERTIFICATE OF AUTHORITY TO DO BUSINESS IN OHIO, issued by the Ohio Secretary of State. If corporation is nonprofit, submit a Certificate of CONTINUED EXISTENCE from the Ohio Secretary of State. Ohio Secretary of State: (614) 466-3910 or 1-877-767-3453 - www.sos.state.oh.us Certificate of Good Standing From the Secretary of State: REQUIRED DOCUMENTS TO BE FILED WITH PARTNERSHIPS 4031 Form (Partnership): Form must be completed in full. Indicate all partners including social security and/or Tax ID numbers. Limited Partnerships need only indicate general partners. Must be notarized. REQUIRED DOCUMENTS TO BE FILED WITH LIMITED LIABILITY COMPANIES 4032 Form (LLC): Form must be completed in full, indicating all members with 5% or more membership or voting interest, all managing members, and officers, if applicable, including social security numbers. Must be notarized. Ohio Secretary of State: (614) 466-3910
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