Retail Liquor Dealer’s License Application | Village of Roscoe, Illinois

CHECK CLASS OF LICENSE APPLIED FOR

Class A: On & Off Premises (Full Liquor) - $4,000.00
Class C: Package Store (Full Liquor) - $3,000.00
Class D: Beer & Wine (on Premises) - $2,500.00
Class F: Full Liquor (on Premises Only) - $3,000.00
Class G: Package Store (Beer & Wine) - $2,000.00
Class T: Temporary (One Day) - $100.00
Class BL: Boutique Gaming - $6,000.00
Class BP: Brew Pub - $2,500.00
Class CT: Caterer Retailer (Full Liquor) - $500.00

SECTION 1: APPLICANT INFORMATION

Applicant

Primary Contact Person/Agent

First Name Middle Name Last Name

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Name

Premise Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone

Other Phone

Fax

CORPORATE INFORMATION (if applicable)

Illinois Corporate Registration Number

Date of Incorporation/Formation

Is corporation in good standing with Illinois Secretary of State

If foreign corporation, date qualified to do business in Illinois

GENERAL INFORMATION (applies to anyone listed in Section 2)

Owner of Premises

(if leased, attach a copy of the lease to the application)

Date applicant began liquor sales at this premise

Illinois Liquor License Number

Has applicant ever made application for a liquor license which was been denied?

YES
NO

Explain

Has applicant ever had any previous liquor license suspended or revoked?

YES
NO

Explain

Has applicant ever been convicted of a felony?

YES
NO

Explain

Has applicant ever been convicted of a gambling offense?

YES
NO

Explain

Do you possess a current federal wagering or gambling device stamp?

YES
NO

Explain

Are you, or is any other person, directly or indirectly in your place of business, a public official?

YES
NO

Explain

Indicate the anticipated percentage of total annual revenue from each of the following categories (Percentages must total 100%).

Alcohol Sales

Food Sales

General Merchandise (or other)

Net Terminal Income (gaming revenue)

DRAM SHOP COVERAGE

List dram insurance coverage including name and address of insurance company for the licensee and premises for which the alcoholic liquor will be sold for the duration of the license (attach a copy of the policy declaration to this application).

Insurance Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy Number

Coverage Limits

SECTION 2: OWNER & OFFICER INFORMATION

For every individual applicant, sole owner, partner, member, corporate officer, stockholder, or director (whether or not they own any stock), stockholder owning in the aggregate more than 5% of the stock (including, officers, directors, and stockholders of more than 5% for all corporate stockholders), manager or agent conducting the business please supply the following information. All not-for-profit organizations and associations must supply the requested information for all officers, directors, and managers. Indicate the total percentage of stock of the corporation, if any, which is held by persons who have less than 5% interest.

If additional space is needed, type or print information in the same format and attach the sheet to this application.

List

Name	Date of Birth	Driver's License No.	State	Title	% Ownership

SECTION 3: BASSET CERTIFICATION

All new and renewal applications for liquor licenses must be accompanied with proof of completion of a State certified Beverage Alcohol Sellers & Servers Education and Training (BASSET) course for all owners & personnel working at the liquor establishment. This includes all persons who sell or serve alcoholic beverages including all management personnel working on the premises and anyone whose job description entails checking of identification for the purchase of alcoholic beverages pursuant to that license.

Please list all current employees who are required to possess a BASSET certification, and the date the certification was issued. Please attach copies of BASSET certification cards to this application.

List

Employee Name	Certification Date	Expiration Date

I, the undersigned applicant or authorized agent thereof, swear or affirm that the matters in the foregoing application are true and correct, are made upon my personal knowledge and information, are, made for the purpose of requesting the VILLAGE OF ROSCOE to issue the license herein applied for. I further swear or affirm that the applicant will not violate any of the laws of the UNITED STATES of AMERICA, VILLAGE of ROSCOE, or the STATE of ILLINOIS, in particular, the LIQUOR CONTROL ACT AND THE CIVIL RIGHTS THEREOF.

I further swear or affirm that I have read and understood the Village of Roscoe Code of Ordinances, specifically as they relate to the control and sale of alcoholic beverages in the Village of Roscoe, including the revenue requirements for the requested liquor license classification and agree to abide by such laws and regulations.

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