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Application - Beer PermitPage 1 of 5 APPLICATION FOR A BEER PERMIT STATE OF TENNESSEE CITY OF LA VERGNE Application for (Check one): ON PREMISES PERMIT (Restaurant) OFF PREMISES PERMIT (Store) BEER MANUFACTURE BEER DISTRIBUTION I HEREBY MAKE APPLICATION FOR A PERMIT TO SELL, STORE, MANUFACTURE, OR DISTRIBUTE BEER OR OTHER BEVERAGES AUTHORIZED TO BE SOLD, STORED, MANUFACTURED OR DISTRIBUTED UNDER THE PROVISIONS OF TENNESSEE CODE ANNOTATED TITLE 57, CHAPTER 5, SECTION 101 ET SEQ. AND THE PROVISIONS IN TITLE 8, CHAPTER 3 OF THE LA VERGNE MUNICIPAL CODE AND I BASE MY APPLICATION UPON THE ANSWERS TO THE FOLLOWING QUESTIONS: CONTACT INFORMATION (Any correspondence from the city will be addressed to this individual.) Full Name: ____________________________ Cell Phone: ________________________ Address: ____________________________ Alternate Phone: ________________________ ____________________________ Email Address: ________________________ What is the best way to contact you? Mail Phone Email APPLICANT INFORMATION 1. Full name of Applicant (owner): _______________________________________________ Person Partnership Corporation Limited Liability Co. Association Other: _____________________________________ 2. List all persons, partnerships, corporations, or associations having at least a 5% ownership interest in the business: (Attach additional sheet, if necessary) _________________________________________________________________________ _________________________________________________________________________ 3. Present home address: _____________________________________________________ _________________________________________________________________________ Page 2 of 5 4. Previous address(es) within the last 10 years: ____________________________________ _________________________________________________________________________ 5. Home Telephone: _____________________ Business Telephone: _________________ 6. If you are an individual: American Citizen: or Legal Resident Alien: 7. If you are a Corporation: Date of Incorporation: __________________ State of Incorporation: ________________ BUSINESS INFORMATION 8. Under what name will this business operate? ____________________________________ 9. Location of business by street address or other geographical description: _________________________________________________________________________ _________________________________________________________________________ 10. Specify the identity and address of the person to receive the annual privilege tax notices and any other communication from the City of La Vergne: _________________________________________________________________________ _________________________________________________________________________ 11. Give the name and address of the property owner, if different than business owner: _________________________________________________________________________ _________________________________________________________________________ 12. Will the permit be used to operate two or more restaurants or other businesses under the same permit as permitted by Section 57-5-103 (a) (4) within the same building? Yes No. If Yes, specify number: ______. List the names of the restaurants or other businesses and describe their location: (Attach additional sheet, if necessary) _________________________________________________________________________ _________________________________________________________________________ 13. Give name, date of birth, and address of all manager(s) other than the applicant: (Attach additional sheet, if necessary) _________________________________________________________________________ _________________________________________________________________________ Page 3 of 5 14. Has any person having at least a 5% ownership interest, any of the managers listed in question 13, or any other employee of the business, been convicted of any violation of the beer or alcoholic beverage laws or any crime (other than minor traffic violations) within the last ten (10) years? Yes No. If so, give particulars of each charge, court, and date convicted: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 15. Has this owner or the owner’s organization had a beer permit revoked, suspended, or denied in the State of Tennessee? Yes No. If so, specify where, when, and why: _________________________________________________________________________ _________________________________________________________________________ 16. Give the name, relationship to applicant (if applicable) and address of the former beer permittee at this location: _________________________________________________________________________ _________________________________________________________________________ THE CITY OF LA VERGNE HAS ADOPTED AN ORDINANCE FORBIDDING THE SALE, STORAGE AND MANUFACTURE OF BEER AND LIKE BEVERAGES WITHIN 200 FEET OF ANY SCHOOL, CHURCH, LICENSED DAYCARE CENTER, OR PUBLIC PLAYGROUND OR PARK. 17. What is the name and address of the church (or other place of worship) nearest to your business? _________________________________________________________________________ _________________________________________________________________________ 18. What is the name and address of the school nearest to your business? _________________________________________________________________________ _________________________________________________________________________ 19. What is the name and address of the day care center nearest to your business? _________________________________________________________________________ _________________________________________________________________________ Page 4 of 5 20. What is the name and address of the public playground or park nearest to your business? _________________________________________________________________________ _________________________________________________________________________ VERIFICATION STATE OF __________________________ ) ) COUNTY OF __________________________ ) I, ____________________________________, the applicant herein, hereby state under oath the following: I hereby certify that no person having at least a 5% ownership interest, nor any person to be employed in the distribution, sale, or manufacture of beer in my establishment, has been convicted of any violation of the laws of the State of Tennessee against the sale, manufacture, possession, or transportation of beer of intoxicating liquors or any misdemeanor or felony within the past ten years. I certify that I am also aware that I shall not be issued a permit or my permit shall be revoked if my business location causes traffic congestion or interferes with schools, churches, or other places of public gathering, or otherwise interferes with public health, safety and morals. I also certify that I have received a copy of the City of La Vergne Beer Ordinance. I state that I have read and understand the Beer Ordinance. I further state that I am familiar with and understand the laws of the State of Tennessee related to the sale of beer. I further agree to abide by the City of La Vergne Beer Ordinance and the laws of the State of Tennessee related to the sale of beer. I further state that the information provided herein is true and correct. I understand that the information I have provided is subject to verification. By my signature below, I authorize and give consent for the City of La Vergne to perform or obtain from a third party or outside agency a background check. This includes the following:  Criminal background records/information  Addresses  Social Security Verification I, the undersigned, authorize this information to be obtained either in writing or via telephone in connection with this beer permit application. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization’s guidelines and to the extent permitted under state law; however I acknowledge that any and all information obtained and maintained in connection with my application is subject to the Public Page 5 of 5 Record Act embodied in Tennessee Code Annotated §10-7-101 et seq. I further release the City of La Vergne, and its agents, assigns, and employees, from any and all claims of liability related to the acquisition and/or dissemination of information as to this background report. I understand that providing false information or failing to update the information contained within this application as required by the City of La Vergne Beer Ordinance may cause my beer permit to be suspended or revoked. I understand that the beer permits are not transferable to a different location, and if there is any change in ownership, I may have to apply for a new beer permit. __________________________________________________ __________________ Signature of Applicant/Owner (or authorized corporate officer) Date Sworn to and subscribed before me this _______ day of __________________, 20___. ______________________________________________________ Notary Public My Commission Expires: _________________________________ NOTICE: A non-refundable $250 fee must accompany this application. Any applicant making false statements in this application shall forfeit their permit and shall not be eligible to receive any permit for a period of ten (10) years. If an application for a beer permit has been considered and denied by the beer board, the beer board shall not consider another application from the same individual to sell beer at the same location until the expiration of a ninety (90) day period. A privilege tax of $100 is imposed on the business of selling, distributing, storing or manufacturing beer in this state effective January 1, 1994 and each successive January 1. Any holder of a beer permit issued after January 1, 1994 shall pay a pro rate portion of this annual tax when the permit is issued. LA VERGNE POLICE DEPARTMENT PERSONAL HISTORY SHEET FOR A BACKGROUND CHECK If information does not apply to you, please insert N/A in the blank. If you need more space, please attach an additional sheet. Name: ______________________________________ Home Phone: ___________________ Home Address: ______________________________________ Cell Phone: ___________________ ______________________________________ Description: Date of Birth: _________ Birthdate and Place: _________________________________ Color: ________ Sex: _________ Social Sec. #: ______________________________________ Height: ________ Weight: _________ Military Serial #: ______________________________________ Hair: ________ Eyes: _________ Scars / Tattoos: _________________________________________________________________________ Driver's License No. and State: _____________________________________________________________ Automobile Info - Make: _____________ Model: _____________ Year: _________ Tag #: ___________ Education: _________________________________________________________________________ Occupation: _________________________________________________________________________ Criminal Record: _________________________________________________________________________ Relatives: Name Address Phone Number Associates: Name Address Phone Number