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Application For Manufacturer Brewpub Or Warehouse With Option For D6 Permit DLC 4174 - Ohio
| Application For Manufacturer Brewpub Or Warehouse With Option For D6 Permit Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
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Questions on Status of Application - (614) 644-3155 General Questions - (614) 644-2411 Office Hours - 8:00 - 5:00 Ohio Department of Commerce Division of Liquor Control 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio http://www.com.ohio.gov/liqr APPLICATION FOR MANUFACTURER, BREWPUB, OR WAREHOUSE (WITH OPTION FOR D6) PERMIT CAUTION: ALLOW 6 TO 8 WEEKS FOR PROCESSING THE FOLLOWING ITEMS MUST BE SUBMITTED FOR YOUR APPLICATION TO BE ACCEPTED FOR PROCESSING A. Application Processing Fee of $100.00 when filing for an A1, A1A, D6, A3, A3A, A4 or W. Class Fee. B. Application completed in its entirety, notarized and signed. C. If Individual, list Social Security Number on line provided. D. If Partnership, you must submit a completed DLC form 4031, along with a copy of the Partnership Agreement. E. If Corporation, you must submit a completed DLC form 4030. F. If Limited Liability Company, you must submit a completed DLC form 4032. 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. CHECK CLASSES APPLIED FOR: Class and Fee A-1 $3,906.00 - Manufacturer of Beer A-1-A $3,906.00 - Beer and any Intoxicating liquor on an A1 or A2 premises (With A1 or A2 only) A-2 $76.00 - Manufacturer of Wine A-3 $3,906.00 - Manufacturer, import and sell alcohol and spirituous liquor. *If the plant's annual production capacity is less than 500 wine barrels of 50 gallons each, the FEE is $2.00 per barrel. A-3A Annual production (wine barrels) x $2.00 = is the A-3 Permit fee. Variable - Manufacturer of less than 10,000 gallons of spirituous liquor and sale to a personal consumer. The class fee is based upon the estimated first year production of $2.00 per each 50 gallon barrel. This class may only be issued in Cuyahoga, Franklin, and Hamilton County. Estimated barrel (50 gal. each) production x $2.00 = is the A-3A Permit Fee. $3,906.00 - Manufacturer and sell certain prepared and bottled drinks, import for blending purposes. $25.00 - Sale to retail permit holders (With A2 only) $500.00 - Sunday Sales of Wine (With A-1A or A2 only) $25.00 - Sale of wine via mail order to a personal consumer - (With A2 only) $1,563.00 - Manufacturer or supplier to store beer or intoxicating liquor for sale to B permit holders, or customers outside this state. A-4 B-2A D-6 S W SECTION A Type of Business: SECTION B INDIVIDUAL PARTNERSHIP CORPORATION LLC OTHER Applicant (Individual, Corporation, Limited Liability Company or Partnership): DBA (doing business as): Township (if outside city limits): Residence Phone #: Mailing Address: (Name, Street Address, City & Zip): Address: Attorney's Name: City, State, & Zip: City: Permit Premises Address: Zip Code: Business Phone #: County: Phone # FOR DIVISION USE ONLY REMARKS: RCPT# Proc. Fee Pd: YES NO BCI Fee Amount Paid: $ _______ Bus. Type EOE/ADA SERVICE PROVIDER PAGE 1 FOR TTY USERS DIAL ORS 1-800-750-0750 REV. 12-2010 Coder: Taxing District: Permit Number Trans. Code DLC 4174 CLASS REVIEWER ACTION: American LegalNet, Inc. www.FormsWorkFlow.com SECTION C - SHOULD BE ANSWERED ONLY IF APPLYING FOR A B-2a or S 1. Is the Manufacturer of wine entitled to a tax credit under 27 C.F.R. 24.278? 2. Does the manufacturer of wine produce less than 250,000 gallons of wine per year? SECTION D 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 YES NO YES YES NO NO 2a. 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. 2b. 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. 7. Do you or any partner, office holder, managing member, 5% stockholder or member, spouse of any such person, employee, or other person interested in the permit own any stock or have any financial interest in a retail permit holder or wholesale distributor of alcoholic beverages? If YES, attach a written explanation. DELIBERATE MISREPRESENTATION OF ANY OF THE INFORMATION ON THE APPLICATION CAN RESULT IN THE DIVISION'S REFUSING TO APPROVE THIS APPLICATION. YES YES NO NO YES YES NO NO YES NO YES NO YES NO NOTE: Your permit certificate is issued for a permit period that expires October 1st each year and is renewed annually on that date. If your permit is issued after April 1st, you will receive a 50% refund of the class fees paid, not including the $100.00 application fee. State of Ohio, I, (Please Print) County, ss being first duly sworn, according to law, depose and say that the statements and answers made in the foregoing application are true. ___________________________________________________________________________ (Signature of Individual, Partner, Officer, Managing Member, or 5%
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