"Il Liquor Control Commission Court Forms - PDF"
MAYOR TRUSTEES Lawrence M. Hanson Dennis B. Crosby Jay Jozwiak CLERK Scott A. Pierce Candi L. Rowe Ted P. Poulos George C. Sakas Michael W. Wolczyz Application for Liquor License Application Checklist Please make sure each requirement listed below is completed before submitting your application. For New Applicants Each new applicant must make an appointment with the Antioch Police Department to be fingerprinted. Each new applicant must turn in completed application with a non-refundable fee of $250.00. All Applicants must include: Copy of the Article’s of Incorporation provided by the Secretary of State’s Office (in the case of a corporation) If applicant does not own premises where the business will operate, a copy of the lease must be provided. Copy of Dram Shop Liquor Liability Insurance. A surety bond in the amount of $1,000 to the Village. BASSET training certificate(s) of completion. Copy of Food Service Permit from the Lake County Health Department (if food will be served on premises). Outdoor Requirement Submissions • Description of Premises: An accurate description of the location of each table and chair placed outdoors in the form of a site plan or reasonably legible and intelligible sketch. • Proof of Public Liability Insurance, including the village as an additional party insured and insuring the village against any and all liability resulting from the uses permitted under this section, in an amount of no less than one million dollars per occurrence (1,000,000.00), combined single limits. 874 Main Street | Antioch, IL 60002 | phone: (847) 395-1000 | fax: (847) 395-1920 | www.antioch.il.gov Village of Antioch Liquor License Application Business Information Business Name: Business Address: City, State, Zip: Federal Tax ID #: Illinois Business Tax #: Business Telephone: Business Fax: Website: Contact Email: If you would like licenses and correspondence sent to a different address than above: Correspondence Name: Correspondence Address: City, State, Zip Applicant Information Please check one of the following: □ Corporation □ Partnership □ Sole Ownership □ Other (Please Explain) For a Corporation: Corporation/Corporate Name: Corporate Address: City, State, Zip: DBA: The following information is required of any sole proprietors, and all partners, officers, directors, and shareholders owning more than 5% of stock: (additional pages may be attached to this application) Name: Date of Birth: Address: City, State, Zip: Social Security Number: % of ownership in business: Citizenship: If a naturalized citizen, the time and place of naturalization: Name: Date of Birth: Address: City, State, Zip: Social Security Number: % of ownership in business: Citizenship: If a naturalized citizen, the time and place of naturalization: Name: Date of Birth: Address: City, State, Zip: Social Security Number: % of ownership in business: Citizenship: If a naturalized citizen, the time and place of naturalization: Emergency Contact Information Name: Title: Address: City, State, Zip: Telephone: Alarm System Company: Keyholder: Home Phone: Address: Outdoor Sales Information Do you plan on having outdoor consumption of alcoholic liquor at your premises? □ Yes □ No If yes, please provide the following: ● An accurate description of the location of each table and chair placed outdoors in the form of a site plan or reasonably legible sketch. ● Evidence of of public liability insurance, naming the Village as an additional third party in an amount no less than $1,000,000 per occurrence. I have read and understand the requirements stated in Title 4, Chapter 2, Article A of the Liquor Code as it pertains to outdoor sales of alcoholic liquor. I agree to comply with all conditions stated in 4-2C-5 and 4-2C-6, and indemnify and hold harmless the village from all liability lawsuits and costs. Signature Date Liquor Information Describe the type and character of business (ex. Restaurant, tavern/pub, retail pkg, store): Length of time applicant has been in business of this character: Please list previous locations: Names of each governmental body from which the applicant has received a liquor license within ten years prior to the date of the present application: Does the applicant own or lease the premises for which this license is sought? □ Own □ Lease (Provide a copy of lease) Please circle Yes or No for the questions on the following page. In the case of a partnership, each partner shall provide answers to each statement. In the case of a corporation, each officer, manager or director and any stockholder controlling more than 5% shall provide answers to the statements listed. Liquor Information (continued) Does applicant qualify for or currently hold a license issued by the Illinois Liquor Control Commission? Yes No Has applicant ever been convicted of a felony under and Federal or State Law? Yes No Has applicant ever been convicted of a violation of any Federal or State law or local ordinance concerning the manufacture, possession, sale or dispensation of alcoholic liquor, or has ever forfeited his or her bond to appear in court to answer charges for any such violation? Yes No Has applicant ever been convicted of a gambling offense as proscribed by any State or Federal law or regulation? Yes No Has applicant had revoked a similar license issued under State or Federal law or under the ordinances of any municipality within ten (10) years immediately prior to the date of the present application? Yes No Has applicant had suspended more than once a similar license issued under State or Federal law or under the ordinances of any municipality within one year immediately prior to the present application? Yes No Is applicant a law enforcing official of the Village of Antioch or any other government or governmental agency? Yes No Does applicant hold public office in the Village of Antioch? Yes No Does premises for which license is sought comprises a store or other place of business where the majority of customers are under the age of 21 years or where the principal business transacted consists of the sale of school books, school supplies, food, lunches or drinks for such customers? Yes No Will retail sale of alcohol on the premises for which license is sought violate any provision of the Antioch Zoning Code or the Antioch Municipal Code? Yes No Is premises for which license is sought within 100 feet of any school, hospital, senior citizen housing, daycare center, orphanage, transitional service facility, nursing or personal care facility, home for veterans and their spouses or children, or any military or naval station, or within 100 feet of the nearest part of any church building used for worship or educational purposes? Yes No If sole ownership or partnership, is applicant(s) a permanent resident of the Village? (Not applicable for Corporations) Yes No Does applicant beneficially own the premises for which a license is sought or have a lease for the full period for which the license is to be issued? Yes No Is applicant the beneficial owner of the business to be licensed? Yes No Will the applicant be personally, actively involved in the operation of the business to be licensed? Yes No Will the business be managed by a manager or agent? Yes No Is applicant disqualified from receiving a license by reason of any matter or item contained in the laws of the State of Illinois, or the Village of Antioch Code? Yes No Does any applicant owe tax to the municipality, county or State in which the applicant is located? Yes No Has the owner, manager or any employee of the business passed a BASSET class? If so, please provide names of employee(s) and date of certification. Yes No Affidavit and Acknowledgement I, the undersigned applicant or authorized agent thereof, swear or affirm under penalties of perjury that the matters stated in the forgoing application are true and correct, are made upon my personal knowledge and information,and are made for the purpose of requesting the Village of Antioch to issue the license herein applied for. I further swear or affirm that I have not omitted any information which is required to be made in these disclosures, that the matters stated herein are not misleading in light of the purposes for which application is made, and that the applicant is qualified and eligible to obtain the license applied for. I further swear or affirm that the applicant is eligible for a state retail liquor dealer's license. I further swear or affirm that the applicant will not violate any of the laws of the United States of America, the State of Illinois or the Village of Antioch, in particular, the Liquor Control Act and all laws and ordinances pertaining to the sale of liquor and civil rights section thereof. By applying for a license pursuant to Article 4, Chapter 2 of the Village Code and by executing this application, each applicant hereby authorizes any person to disclose, and the Village to investigate all information pertinent or germane to such applicant's application. Each applicant hereby waives any and all claims against the village and hereby agrees to indemnify and hold harmless the Village and its elected and appointed offices, officers, boards, comissioners, attorneys, employees and agents from any and all claims resulting from, or arising out of, or alleged to result from or arise out of any and all investigative activities. Signature of Applicant or Authorized Agent Signature of Applicant or Authorized Agent Title or Position Title or Position Date Signed Date Signed Note: If the license is to be issued to a partnership, two partners must sign. If the license is to be issued to a corporation, the president and secretary of the corporation must sign. STATE OF ILLINOIS ) ) SS COUNTY OF LAKE ) Subscribed and sworn to before me this __________ day of _________________, 20______ Notary Public Seal Note: This application is valid only for the fiscal year noted below. All license renewals for consecutive fiscal years must be accompanied by a new completed application, or at the discretion of the Village, a statement under oath the factual statements in the application previously filed have not changed in the past year. Period for which license application is made: June 1, 20_______ to May 31, 20_____ License Classes and Fees Class of License for which applicant is applying: Total Fee: $ Appication Fee (for initial applications only): $ License Class Description 2010 Fee Fee if paid by May 15, 2010: Class "A" Restaurant Full Service License $ 600.00 $ 570.00 Class "A-1" Restaurant Outdoor Café Full Service $ 250.00 $ 237.50 Class "B" Restaurant Limited Service License $ 500.00 $ 475.00 Class "B-1" Restaurant Outdoor Café Limited Service $ 250.00 $ 237.50 Class "C" Retail Package Sales License $ 1,000.00 $ 950.00 Class "D" Gas Station Convenience Store License $ 400.00 $ 380.00 Class "E" Bar and Tavern License $ 700.00 $ 665.00 Class "E-1" Bar and Tavern Outside Service $ 500.00 $ 475.00 Class "E-2" Wine Shop License $ 2,000.00 $ 1,900.00 Class "F" Club License $ 200.00 $ 190.00 Class "H" Hotel License $ 600.00 $ 570.00 Additional Licenses (check all that apply) □ Restaurant License $ 50.00 □ Food Dealers License $ 50.00 □ Amusement Devices (price per device) $ 100.00 QTY: □ Bowling Alley / Pool Hall $ 25.00 □ Coin Operated pool Table (price per table) $ 25.00 QTY: NOTE: By law you are required to notify the Village in writing of any changes in the information listed in this application within 10 days. The applicant will supply on request any additional information which is considered pertinent by the Liquor Commissioner. For Office Use Only License # Date Issued: Expires: Total Fee: Date Paid: Building Department Official: Date: Fire Department Official: Date: Fingerprinting Card Sent: Additional Comments: