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Application For Off Premise Caterer Permit - Connecticut

Application For Off Premise Caterer Permit Form. This is a Connecticut form and can be used in Liquor Control Division Department Of Consumer Protection Statewide .
 Fillable pdf Last Modified 9/17/2009
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STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Fax: (860) 706-1345 Website: http://www.ct.gov/dcp APPLICATION FOR OFF PREMISE CATERER PERMIT Section A: BUSINESS INFORMATION 1. Trade Name (Name of Business) 3. City: 6. Is there currently a liquor permit? YES NO State: Zip Code: 2. Street Address & Number: 4. Business Telephone: ( ) 5. Business Fax: ( ) 7. If yes, current permit number: 8. Will you provide food and beverages at private gatherings or special events?: YES NO Section B: APPLICANT INFORMATION 9. Permittee Name (First, Middle, Last) 10. Date of Birth 11. Residence Street Address 12. City State Zip Code 13.Home Telephone Number ( ) 14. Home Fax Number ( ) 15. E-mail: Sections C, D, E: BACKER/OWNER INFORMATION * Each backer must also complete the "Personal History Form" that accompanies this application 16. Business Structure: Please select the box that best describes how your business/organization is structured: Sole Proprietorship Partnership Corporation Limited Liability Company Limited Liability Partnership Unincorporated Association 17. Name of backer individual or business entity: 19. City: State: Zip Code: 18. Street address & number: 20. Telephone: ( ) Fax: ( ) 21. Backers: List individuals associated with ownership of backer business/organization (i.e. sole owner/corporate officers/partners/LLP members) a. Name: (First, Middle, Last) b. Name: (First, Middle, Last) Title: Title: % of ownership or # of shares: % of ownership or # of shares: American LegalNet, Inc. www.FormsWorkFlow.com c. Name: (First, Middle, Last) d. Name: (First, Middle, Last) e. Name(First, Middle, Last) f. Name: (First, Middle, Last) Title: Title: Title: Title: % of ownership or # of shares: % of ownership or # of shares: % of ownership or # of shares: % of ownership or # of shares: Section F: CURRENT LIQUOR PERMITS WITH WHICH PERMITTEE, BACKER, OR IMMEDIATE FAMLY ARE ASSOCIATED This section applies to the permittee applicant, and to each backer who is a sole proprietor, partner or a member of a partnership organization, corporations, members of a limited liability organization or unincorporated associations. In the case of package store permits, it also applies to ownership by members of the permittee applicant's or backer's immediate family. Immediate family includes parents, children and spouse ­ Attach a separate sheet if needed. 22a.Type of other liquor permit held: (i.e. cafe) Liquor permit number: Name of business: Name of backer or permittee or immediate family associated with other permit: Are you a backer or permittee of other business? Backer Permittee 22b. Type of liquor permit held: (i.e. cafe) Liquor permit number: Name of business: Name of backer or permittee or immediate family associated with other permit: 23. Have any of the previous permits listed above been revoked, suspended or denied in CT or any other state? YES NO Are you a backer or permittee of other business? Permittee Backer If yes, attach a statement detailing the enforcement action(s) taken including violations, dates, and the circumstances involved. Section G: PREVIOUS LIQUOR PERMITS WITH WHICH PERMITTEE OR BACKER WERE ASSOCIATED This section applies to the permittee applicant, and to each backer who is a sole proprietor, partner or a member of a partnership organization, corporation, limited liability organization or unincorporated association. 24a. Type of liquor Liquor permit State in which Name of business: permit held: (i.e. cafe) number: issued: Name of backer or permittee associated with previous permit: Were you a backer or permittee of previous business? Backer Permittee American LegalNet, Inc. www.FormsWorkFlow.com List all liquor permits previously held in CT or any other state - Attach a separate sheet if needed. 24b. Type of liquor permit held: (i.e. cafe) Liquor permit number: State in which issued: Name of business: Name of backer or permittee associated with previous permit: Were you a backer or permittee of previous business? Backer Permittee 25. Have any of the previous permits listed above been revoked, suspended or denied in CT or any other state? YES NO If yes, attach a statement detailing the enforcement action(s) taken including violations, dates, and the circumstances involved. Section H: APPOINTMENT OF APPLICANT AS PRINCIPAL REPRESENTATIVE (If applicant is not to be sole backer) The backers of the proposed applicant agree to appoint him as principal representative on the premises where the sale of alcoholic liquor is to be and to vest in him/her the same full authority and control of these premises and of the conduct of all business therein relative to the sale of alcoholic liquors backers could in any way have and exercise; and the applicant agrees to accept such authority and control. 26. Name of backer or authorized representative of the backer: 27. Street Address: City: State: Zip code: Section I: CERTIFICATION OF PERMITTEE APPLICANT AND BACKER OR AUTHORIZED REPRESENTATIVE OF BACKER 28. Permittee Certification: (To be signed by permittee applicant, identified in "Section B" of this application) I certify that the information provided in this application is true to the best of my knowledge. 29. Backer Certification: (To be signed by backer or the authorized representative of the backer) I certify that the information provided in this application is true to the best of my knowledge and that the permittee applicant identified in "Section A" of this application is designated as my principal representative on the premises for which this application is being submitted. Signed by Permittee Applicant: Date: X______________________________________ Signed by Backer or Authorized Representative of Backer: X______________________________________ 34. Print name of Backer or Representative: 35. Title of Backer or Representative: Date: Subscribed and affirmed before me: Signed X (Commissioner of Superior Court, Notary Public, Justice of Peace) Date American LegalNet, Inc. www.FormsWorkFlow.com
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