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Home My WebLink About967 Atlantic Boulevard SPEV26-0001 Application (Culhane's) INSTRUCTIONS FOR COMPLETING DBPR ABT—6029 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR EXTENSION OR AMENDED SKETCH OF LICENSED PREMISES If you have any questions or need assistance in completing this application,please contact the Division of Alcoholic Beverages& Tobacco's(AB&T)local district office. Please submit your completed application and required fee(s) to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T's web site at the link provided below. P vii _ im/dbpr/abt/district_offices/licensing.htmi GENERAL REQUIREMENTS This application must be submitted for approval when changes are made to the licensed premises whether the extension is permanent or temporary. Please complete all information. Incomplete applications will be returned. All questions are applicable and must be answered fully and truthfully. You must provide an original application and a copy of all supporting documentation. All signatures must be original. APPLICATION REQUIREMENTS Applicants for Temporary Extension of Premises Permits must submit the application at least seven(7)days prior to the first date of the event to insure the permit is issued by the event date. Zoning Approval—Applies to Permanent or Temporary Extension of Premises Only Zoning approval is executed by the city or county zoning authority in which the business to be licensed is located. This application is to be taken to the Zoning Department(City or County)that governs the location of your business. Health Approval—Applies to Permanent Extension of Premises Only Health approval is required on all applications for consumption on the premises. Businesses that serve food or are located on premises licensed by the Division of Hotels and Restaurants, must obtain approval from that division. Businesses that do not serve food must contact the County Health Authority or the Department of Health. Food service establishments located in grocery and convenience stores, bakeries or delicatessens must contact the Department of Agriculture and Consumer Services. Note: Health Approval is not required for a temporary extension of the licensed premises or amended sketch of the licensed premises. Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, each partner of a general partnership, a general partner of a general partnership of a limited partnership, a managing member, manager, or officer of a limited liability company, each partner of a limited liability partnership, or one of the officers of a corporate applicant. Sketch of Premises A complete sketch of the premises, drawn in ink or computer generated (letter size)which includes all permanent walls, doors,windows, counters, labeling each room and area. Include any outside areas where alcoholic beverages will be sold, consumed, or served. Due to the difficulty of scanning, no blueprints are accepted. Auth.61A-5.0017 1 Amended Sketch of Premises A complete sketch of the premises,drawn in ink or computer generated (letter size)which includes all permanent walls, doors, windows, counters, labeling each room and area. Changes may be made to the interior of the existing premises only; no additional rooms may be added. Note: Zoning Approval is not required for an amended sketch of premises. APPLICATION CHECKLIST Select the appropriate transaction below and comply with the corresponding application requirements. TRANSACTION APPLICATION REQUIREMENTS E a//Complete DBPR ABT-6029 Division of Alcoholic Beverages and Extension of Licensed acco Application for Extension or Amended Sketch of Licensed Premises remises Pay$100 fee for each temporary extension of licensed premises requested(make check payable to the Division of Alcoholic Beverages and Tobacco) Complete DBPR ABT-6029 Division of Alcoholic Beverages and Amended Sketch Tobacco Application for Extension or Amended Sketch of Licensed Premises Auth.61A-5.0017 2 DBPR ABT-6029-Division of Alcoholic Beverages and Tobacco Application for Extension or Amended Sketch of Licensed Premises STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6029 Revised 02/2013 If you have any questions or need assistance in completing this application,please contact the Division of Alcoholic Beverages& Tobacco's(AB&T)local district office. Please submit your completed application and required fee(s)to your local district office. This application may be submitted by mail, through appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T's web site at the link provided below. hfc://www.mvflorida.com/dbpr/abVdistrict offices/licensing.html SECTION 1 -CHECK TRANSACTION REQUESTED Transaction Type: ❑ Temporary Extension ❑ Amended Sketch ❑ Permanent Extension SECTION 2-LICENSE INFORMATION Licensee(as listed on alcoholic beverage license) p -S i2k S l-t f vl PS ! ^j L Business Name(D/B/A) r LtA L-1 C ��r✓ Location Address(Street) 5 City ,p L AVA-(C 6�.�� County ✓1 k J� State Zip �( JJ FL Alcoholic Beverage LiTumb , O S�eris Type/Class 5 Business Telephone Number Email A dress(Optional) Go ext. (,C( G��S 1✓1 C FOR TEMPORARY EXTENSIONS ONLY: Date(s)of Extension: ABT District Office Received/Date Stamp Auth.61A-5.0017 1 SECTION 3-ZONING APPROVAL TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION his section oni applies to a permanent or tem ora extension of licensed remises Location Street Address fCity County FL Zip Code Are there outside areas which are contiguous to the premises which are to be part of the premises sought to be licensed?" ❑Yes ❑ No i ❑ The PERMANENT extension of the licensed premises as shown in the sketch complies with zoning requirements for the sale of alcoholic beverages pursuant to this application. ❑ The TEMPORARY extension of the licensed premises as shown in the sketch complies with zoning requirements for the sale of alcoholic beverages pursuant to this application. Signed: Title: Date: This approval is valid until SECTION 4-HEALTH TO BE COMPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS I OR COUNTY HEALTH AUTHORITY OR DEPARTMENT OF HEALTH OR DEPARTMENT OF,AGRICULTURE&CONSUMER SERVICES The above establishment complies with the requirements of the Florida Sanitary Code. Signed Date Title Agency This approval is valid until Auth.61A-5.0017 2 SECTION 5-AFFIDAVIT OF APPLICANT _ NOTARIZATION REQUIRED Business Name(D/B/A) 1,the undersigned individually, or if a registered legal entity for itself, its officers and directors, hereby swear or affirm that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm that the attached sketch is a true and correct representation of the extended licensed premises and agree that the place of business may be inspected and searched during business hours or at any time business is being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages and Tobacco,the sheriff, his deputies, and police officers for the purposes of determining compliance with the beverage and cigarette laws." I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and 837.06, Florida Statutes that the foregoing information is true and correct." If applying for a temporary extension, check the box to confirm the following statement: ❑ "I understand that the premises must be restored to its original form at the conclusion of the authorized temporary event." STATE OF 410r, A-o Ek MAREN EVANS Notary Public-State of FloridaCommission#HH 381868COUNTY OF D,lh� My Comm.Expires May 27,2027 APPLICANT SI NATURE " Hr�L-Er r� APPLICANT SIGNATURE The foregoing was(V�Swom to and Subscribed OR( )Acknowledged Before me this i 1 Day of , 20 , ByMi r1 n e ��0, C L4(Vj&;AoC� who is( )personally (prin namY(s)of person(s)making statement) known to me OR(t4who produced as identification. Commission Expires: 5 Z Notary Public Auth.61A-5.0017 3 SECTION 6—DESCRIPTION OF PREMISES TO BE LICENSED Business Name(D/B/A) 1. Yes ❑ No ^- 1 fie proposed premises movable or able to be moved? 2. Yes ❑ No Is there any access through the premises to any area over which you do not Allive dominion and control? _ 3. Yes ❑ No Are there more than 3 separate rooms or enclosures with permanent bars or c tern? _ s the business located within a Specialty Center? If yes,check the applicable statute: 4. Yes ❑ No q, ❑ 561.20(2)(b)1, F.S.or❑ 561.20(2)(b)2, F.S. Neatly draw a floor plan of the premises in ink,including sidewalks and other outside areas which are contiguous to the premises,walls,doors,counters,sales areas,storage areas, restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed. A multi-story building where the entire building is to be licensed must show the details of each floor. � y�� Auth.61A-5.0017 4