Ohio > Statewide > Department Of Commerce > Division Of Liquor Control
Application For Class A-1-A Manufacturers Permit DLC 4175 - Ohio
| Application For Class A-1-A Manufacturers Permit 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) 644-2411 Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio http://www.com.state.oh.us Office hours 8:00 a.m. to 4:45 p.m. APPLICATION FOR CLASS "A-1-A" MANUFACTURERS PERMIT CAUTION: ALLOW 6 TO 8 WEEKS FOR PROCESSING THE FOLLOWING ITEMS MUST BE SUBMITTED ALONG WITH THIS APPLICATION FOR PROCESSING Application Processing Fee of $100.00 Application completed in its entirety, notarized and signed. If Individual, list Social Security Number on line provided. ______________________________________. If Partnership, you must submit a completed DLC form 4031, along with a copy of the Partnership Agreement. If Corporation, you must submit a completed DLC form 4030. If Limited Liability Company, you must submit a completed DLC form 4032. A. B. C. D. E. F. Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. FAILURE TO RESPOND TO ALL QUESTIONS WILL RESULT IN THE RETURN OF YOUR APPLICATION. SECTION A Check the appropriate class(es) and submit the corresponding fee(s): A-1-A $3,906.00 (Issued with A1 or A2) D-6 $ 500.00 -Sunday sales of wine, mixed beverages and spirituous liquor Check which class the A1A is to be issued in conjunction with: A1 - Brewery A2 - Winery SECTION B Individual, Corporation, Limited Liability Company or Partnership Name DBA (doing business as) Business Address Township (if outside city or village limits) Telephone: City Zip Code County Residence ( Business ( ) ____________________________ ) ____________________________ Mailing Address (if different from above) Attorney's Name Address Telephone Number ( ) FOR DIVISION USE ONLY Coder: Taxing District: Permit Number CLASS RCPT# REMARKS: REVIEWER ACTION: Trans. Code DLC 4175 Bus. Type EOE/ADA SERVICE PROVIDER PAGE 1 FOR TTY USERS DIAL ORS 1-800-750-0750 REV. 7-22-04 American LegalNet, Inc. www.FormsWorkflow.com SECTION B 1. Do you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit hold or have any interest in another permit business? If YES, Give permit number & address on the line provided ______________________________________ _______________________________________________________________________________________ 2. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been convicted of a felony or misdemeanor, including any alcohol-related offenses? If YES, attach a written explanation. If applicant is a sole proprietor or partnership, will spouse work on the permit premises? If YES, indicate spouse's full name__________________________________________________ 3. Have you or any partner, office holder, managing member, 5% stockholder or member, spouse, or other person involved in this permit ever been refused a permit, denied a renewal, or had a permit revoked from another state, by this Division, or the Liquor Commission? If YES, attach a written explanation. 4. 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). 5. 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. 6. 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. YES NO YES YES NO NO YES YES NO NO YES NO YES NO 7. Is there an existing building? If NO, on what date will construction begin? ____________________________________ If YES, give the approximate date the business will begin operation. ___________________________________ 8. Do you or any partner, office holder, managing member, stockholder, member, employee, spouse, or other person involved in this permit own any stock or have any interest in the business of another manufacturer, any wholesale distributor of alcoholic beverages, or any retail permit holder? If YES, attach a written explanation. 9. If you are filing as an individual or partnership, have you or all partners resided in the State of Ohio for 1 yr.? 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 THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT(S): State of Ohio, ______________________________________________________________County, ss I, ____________________________________________________________________ being first duly sworn, according to law, depose and say (Please Print) that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5% or more Stockholder or Member) _____________________ (Title) _______________ (Date) _____________________________________ (Residence Address) __________________ (City) _____________ (State) ___________ _______________________ (Zip Code) (Area Code & Telephone Number) (To be completed by NotaryPublic) Sworn to before me and subscribed in my presence this ______________day of _____________________________________, 20 _____________. ________________________________________ (Notary Public) _______________ (Notary Expiration) NOTE: ALL DOCUMENTS BECOME PART OF THE PERMIT FILE AND WILL NOT BE RETURNED PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com IMPORTANT - PLEASE READ FIRST Dear Applicant: The Division of Liquor Control is eager to process your application. In order to process your application in a timely and efficient manner it will be necessary for you to file a complete package in accor
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