VILLAGE OF SOUTH ELGIN APPLICATION FOR LIQUOR LICENSE FOR INDIVIDUALS AND NON-INCORPORATED ENTITIES To: Local Liquor Commissioner, Village of South Elgin Pursuant to the provisions of Title XI, Chapter 111, of the South Elgin Municipal Code, as amended, regulating the sale of alcoholic liquors in the Village of South Elgin, Kane County, Illinois, the undersigned hereby makes application for a Class retail liquor license for the term ending December 31 and hereby certifies to the following facts, and agrees that any license issued shall be issued on the basis of the following facts, and that if any of the following facts are changed, without prior approval of the Local Liquor Commissioner, said license may be revoked or suspended at the sole discretion of the Local Liquor Commissioner. The undersigned hereby tenders the sum of $100.00 in accordance with the schedule of non-refundable application fees. Note: An additional fee of $50.00 for new applications shall be paid for each additional individual or authorized agent for which an investigation must be conducted. Additionally, the undersigned hereby tenders the sum of $ in accordance with the schedule of annual fees for liquor licenses as listed below: Class A Package Stores $1,200.00 Class B Tavern $1,500.00 Class C Club $125.00 Class D Restaurant with Cocktail Lounge $1,800.00 Class E Retail Sale of Beer and Wine with Food $1,200.00 Class F Special Event (not-for-profit entities) $25.00 Class G Package Stores - Beer and Wine Only $900.00 Class I Retail Wine with Limited Premises Service $1,300.00 Class A and I licensees desiring to conduct tastings as a promotional procedure shall apply for and obtain a permit before allowing any such product sampling on the premises. Is applicant applying for a Tasting Permit for a Class A or Class I license? yes/no. If yes, the undersigned hereby tenders the sum of $ in accordance with the schedule of annual fees for tasting permits as listed below: Type 1 Tasting Permit to conduct a tasting once-per-month for a period not to exceed three (3) consecutive days $ 100.00 Type II Tasting Permit - to conduct a tasting each week for a period not to exceed two (2) consecutive days $ 200.00 1
Class C and D licensees desiring to have live entertainment shall apply for and obtain a special restricted designation before permitting any such live entertainment on the premises. Is applicant applying for a Special Restricted Designation for a Class C or D license? yes/no. If yes, attach a detailed floor plan for approval by the Local Liquor Commissioner who shall consider, without limitation, at least the following elements in determining whether to grant such a designation: compatibility with surrounding uses; space available in the premises for live entertainment; traffic and parking relative to the premises; and licensee s history of compliance with Village ordinances. In support of my application for a special restricted designation for live entertainment on the premises, I offer the following information: 1. Description of the type of entertainment to be permitted: 2. Description of the sound amplification equipment to be used for live entertainment: 3. Maximum occupancy of the establishment: 4. Space available in the premises for live entertainment: (and attach a detailed floor plan) If applicant is applying for a Class A, D, E, F, G or I license, will all applicant s employees pass an alcohol training program approved by either the state or the Local Liquor Commissioner (i.e. BASSETT)? yes/no. Has applicant included a copy of the Certificate of Appropriateness for Alcohol Sales issued by the South Elgin Zoning Administrator? yes/no. List applicant s retail occupation tax (ROT) number: Has applicant included with this application a Certificate of Insurance as evidence of coverage demonstrating that applicant is in compliance with 111.03(E) of the South Elgin Municipal Code? yes/no. Has applicant included a copy of the Application of State of Illinois Retailer s Liquor License? yes/no. If your application for a State of Illinois liquor license has been denied, you must notify the Local Liquor Control Commissioner immediately in writing. A current copy of said license shall be on file with the Village at all times. 2
It is unlawful for any holder of a Class B, C, D, E or I license to employ or allow any person to sell, dispense or mix alcoholic liquor on behalf of such licensee, who is not the holder of an Employee Permit approved by the Chief of Police and issued by the Local Liquor Commissioner. Has applicant included with this application, employee permit applications for its employees? yes/no. Employee permits are issued only to persons 21 years of age and older. Holding a local liquor license does not guarantee that the establishment meets the State of Illinois video gaming license requirements (Application continues on the next page) 3
INDIVIDUALS AND NON-INCORPORATED ENTITIES In support of this application, the undersigned submits the following facts: 1. Applicant s full name: (If a partnership, list names of all general and limited partners owning more than 5% of the aggregate limited partner interest in such co-partnership) 2. Residence Address: (A) Phone Numbers: Home Cell email (B) Date of Birth: (C) Place of Birth: 3. If a limited liability company Date of registration as an LLC Business purpose for which the LLC was formed 4. Business Phone Number: 5. Location and description of place of business for which license is sought: (A) (Exact address by street and number) (Zip Code) (B) (Full description of location, place or premises, specifying floor, room, etc.) 6. State principal kind of business: 7. Name or style under which business is to be conducted: 8. Does applicant own premises for which this license is sought? If premises are leased, give: (A) Name of Lessor: (B) Address of Lessor: (C) Period covered by lease: 4
Note: Attach a copy of the lease or evidence that applicant is the owner of record of the property for which the license is sought. If the most recent copy of the lease is on-file with the Liquor Commission, check here. 9. A) State the names of each individual owner, partner, joint venturer, manager of an LLC or member of an LLC, owning more than a 5% interest therein, with their respective residence addresses, giving street and number, city and state: NAME (last, first, middle initial) (residence address) (date of birth) (place of birth) (citizenship) (if naturalized citizen, state city, state and date of naturalization) NAME (last, first, middle initial) (residence address) (date of birth) (place of birth) (citizenship) (if naturalized citizen, state city, state and date of naturalization) NAME (last, first, middle initial) (residence address) (date of birth) (place of birth) (citizenship) (if naturalized citizen, state city, state and date of naturalization) 5
9A). (Continued) NAME (last, first, middle initial) (residence address) (date of birth) (place of birth) (citizenship) (if naturalized citizen, state city, state and date of naturalization) NAME (last, first, middle initial (residence address) (date of birth) (place of birth) (citizenship) (if naturalized citizen, state city, state and date of naturalization) NAME (last, first, middle initial (residence address) (date of birth) (place of birth) (citizenship) (if naturalized citizen, state city, state and date of naturalization) 6
9.B. In the case of a corporation or limited liability company identified in 9A, provide a Certificate of Good Standing (not older than 6 months.) 9.C. Does each person identified in 9A have fingerprints on file with the Village of South Elgin for the purpose of this application? yes/no. If no, please obtain fingerprints conducted electronically and submit with a digital photograph to the Illinois Bureau of Identification who will forward to the Village of South Elgin. 10. Provide the name and address of the person within the Village s municipal limits upon whom service may be accomplished by the Liquor Commissioner. Name: Address:, South Elgin, IL 60177 (Application continues on the next page.) 7
11. Has any individual owner, partner, joint venturer, manager of an LLC, or member of an LLC owning more than a 5% interest therein: A. Ever been convicted of any felony under any federal or state law? yes/no If yes, give the name of the person so convicted, the date of conviction and describe the offense: B. Ever been convicted of a gambling offense as proscribed by any of subsections (a)(3) through (a)(11) of Section 28-1 of, or as proscribed by Section 28-1.1 or 28-3 of, the Criminal Code of 1961, or as proscribed by a statute replaced by any of the aforesaid statutory provisions? yes/no If yes, give the name of the person so convicted, the date of conviction and describe the offense: C. Ever been convicted of being the keeper of a house of ill fame; or of pandering or other crime of misdemeanor opposed to decency and morality? yes/no If yes, give the name of the person so convicted, the date conviction and describe the offense D. Ever been convicted of a violation of a federal, state or local liquor law? yes/no If yes, give the name of the person so convicted, the date of conviction and describe offense E. Ever permitted an appearance bond forfeiture for any of the violations mentioned above? yes/no F. Made application for any premises other than the premises described in this application? yes/no If yes, state the name of the applicant, the date, location of premises and disposition of that application G. Has any liquor license previously issued to you by state or local authorities been revoked? yes/no If yes, state the name of the licensee whose license was revoked, the date and reason(s) for the revocation: H. Has a federal wagering stamp been issued to you by the federal government? yes/no 8
12. Is a law enforcing public official, including members of local liquor control commissions, any mayor, alderman, or member of the city council or commission, any president of the village board of trustees, any member of a village board of trustees, or any president or any member of a county board, directly interested in the business for which this license is sought? yes/no 13. Does applicant hold any other current business licenses issued by the Village of South Elgin? If so, what type of license does applicant currently hold and what is the address of the licensed premises? _ Type Address 14. Each applicant must designate at least one individual who shall serve as liquor manager for the applicant. Please supply the following information: (A) Name of liquor manager: Residence address: Home Phone Cell Phone email (B) Authority conferred upon the liquor manager by the owner or partnership [or other person or entity that has the ability to convey such authority] with relation to the operation or management of the business for which this license is sought? (C) Has the liquor manager been fingerprinted for the purpose of this application? yes/no If yes, where and when: (D) Please have the liquor manager complete a Statement of Liquor Manager Conducting Business for an Individual, Partnership, LLC, or Joint Venture Applicant, and attach as part of this application? 15. Is the location of applicant s business for which the license is sought within 100 feet of any church, school (other than an institution of higher learning), hospital, home for aged or indigent persons or for veterans, their spouses or children or any military or naval station? yes/no 16. Does applicant seek a license to sell alcoholic liquor upon premises as a restaurant or club? yes/no If yes, are the premises: (A) Maintained and held out to the public as a place where meals are actually and regularly served? (B) Provided with adequate and sanitary kitchen and dining room equipment and capacity with sufficient employees to prepare, cook and serve suitable food? (C) What is seating capacity of the restaurant? 9
17. Has any manufacturer, importing distributor or distributor directly or indirectly paid or agreed to pay for this license, advanced money or anything of value, or any credit (other than merchandising credit in the ordinary course of business for a period not to exceed 30 days), or is such person directly or indirectly interested in the ownership, conduct or operation of the place of business? yes/no 18. Is the applicant or any affiliate, associate, subsidiary, officer, director or other agent engaged in the manufacture of alcoholic liquors? yes/no If yes, at what location or locations? 19. Is applicant engaged in the business of an importing distributor or distributor of alcoholic liquors? yes/no If yes, at what location or locations? (Application continues on the next page) 10
AFFIDAVIT FOR INDIVIDUALS State of Illinois ) County of Kane ) I (or we) swear (or affirm) that I (or we) shall not violate any of the ordinances of the Village of South Elgin or the laws of the State of Illinois or the laws of the United States of America, in the conduct of the place of business described herein and that the statements contained in this application are true and correct to the best of my (our) knowledge and belief. I (or we) further swear (or affirm) that I (or we) shall conduct my (or our) business in a manner consistent with all representations made in this application and consistent with any representations made in this application and consistent with any representations made before the South Elgin Local Liquor Commissioner. Subscribed and sworn to before me this day of 20 Notary Public (Seal) 11
AFFIDAVIT FOR INDIVIDUALS State of Illinois ) County of Kane ) Each applicant, officer, director, manager, proposed liquor manager, proposed manager of the premises, individual owner, partner, joint venture, and each LLC manager, and each LLC member owning in the aggregate more than 5% interest therein shall complete and sign the following investigation authorization. I hereby authorize the Chief of Police of the Village of South Elgin to conduct a background investigation, including the authorization to receive reports from other law enforcement agencies necessary to verify the information included in this application and to verify compliance with applicable state and federal liquor laws. I hereby release the Village of South Elgin, its officers, employees and agents, from any and all liability which may arise as a result of such background investigation. Printed Name: Printed Name: Printed Name: Subscribed and sworn to before me this day of 20 Printed Name: Notary Public (Seal) 12
AFFIDAVIT FOR INDIVIDUALS State of Illinois ) County of Kane ) The undersigned agree that I (or we) shall notify the Village of South Elgin in writing within 24 hours of when I (or we) cease to operate as a business and/or if there is a bulk transfer of the assets of my (or our) assets as defined in Article 6 of the Uniform Commercial Code, or if there has been a change in ownership as set forth in Section 111.06(B) of the South Elgin Municipal Code. Subscribed and sworn to before me this day of 20 Notary Public (Seal) 13
STATEMENT OF LIQUOR MANAGER CONDUCTING BUSINESS FOR AN INDIVIDUAL, PARTNERSHIP, LLC OR JOINT VENTURE APPLICANT The statements contained herein, from and are hereby made a part of the information on the day of, 20, by (name of liquor manager) for the issuance of a village retailer s license for the sale of alcoholic liquor at (address as shown on application) 1. Name of liquor manager: NAME (last, first, middle initial) 2. Residence address: How long have you resided at this residence? (If you have resided at this address for less than one year, list your previous residence address) Date of birth: Place of birth: Driver s license number: Telephone numbers: Home: Business: Cell: email 3. Have you been fingerprinted for the purpose of this application? yes/no If yes, where and when: Fingerprinting completed by the South Elgin Police Department. Fingerprints will only be conducted electronically (per Bureau of Identification guidelines). Individuals who are not able to be fingerprinted a the South Elgin Police Department must contact the local police department or a biometrics agency, at their expense, to have their fingerprints taken electronically using South Elgin s ORI# IL045130L. The fingerprints must be accompanied with an electronic photograph. 4. Have you ever been convicted of any felony under any federal or state law? yes/no If yes, give date of the conviction and describe the offense 5. Have you ever been convicted of being the keeper of a house of ill fame, or of pandering or other crime or misdemeanor opposed to decency and morality? yes/no If yes, give the date of the conviction and describe the offense: 14
6. Have you ever been convicted of a violation of any federal, state or local liquor law? yes/no If yes, give date and describe the offense 7. Have you ever permitted an appearance bond forfeiture for any of the violations mentioned in questions 5, and 6? yes/no If yes, state particulars 8. Has any license previously issued to you by state, federal or local authorities been revoked? yes/no If yes, state reasons therefore and date of revocation: 9. In what capacity are you appointed by the applicant? 10. Give name of person who appointed you in your present capacity: Date of appointment: 11. List employer, address, type of employment and manager for past five years: 12. List all prior experience that you have in managing the sale of alcoholic liquor and/or in conducting any business which is similar in nature to the business which you will be engaged in pursuant to this application _ (If you need more space, attach additional explanation sheet) 13. List any other experience and education that you have which you believe qualifies you to act as a liquor manager _ 14. How many hours per week will you be physically present at the premises to be licensed? 15
AFFIDAVIT OF LIQUOR MANAGER CONDUCTING BUSINESS FOR AN INDIVIDUAL, PARTNERSHIP, LLC OR JOINT VENTURE APPLICANT STATE OF ILLINOIS ) COUNTY OF KANE ) I hereby authorize the Chief of Police of the Village of South Elgin to conduct a background investigation, including the authorization to receive reports from other law enforcement agencies necessary to verify the information included in this application and to verify compliance with applicable state and federal liquor laws. I hereby release the Village of South Elgin, its officers, employees and agents, from any and all liability which may arise as a result of such background investigation. I swear (or affirm) that I shall not violate any of the ordinances of the Village of South Elgin or the laws of the State of Illinois or the laws of the United States of America, in the conduct of the place of business described herein; that I have read the understand the South Elgin ordinances, and that the statements contained herein are true and correct. I further swear (or affirm) that I shall conduct my business in a manner consistent with all representations made in this application and consistent with any representations made before the Local Liquor Commissioner. _ Signature of Liquor Manager Printed Name of Liquor Manager SUBSCRIBED and SWORN to before me this day of, 20 NOTARY PUBLIC (Seal) 16