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Application - Certificate of Compliance - Wine in Grocery Store1 City of La Vergne, Tennessee 5093 Murfreesboro Road, La Vergne, TN 37086  (615) 793-6295 APPLICATION FOR A CERTIFICATE OF COMPLIANCE FOR WINE IN A GROCERY STORE In compliance with T.C.A. 57-3-801, the actual license will be issued by the Tennessee Alcoholic Beverage Commission (TABC). Prior to such a license being issued, the applicant must obtain a “City of La Vergne Certificate of Compliance” which is required by Tennessee Code Annotated §57-3-806 (a) and (b). Application Procedure: 1) The applicant completes the following application. The application, when properly completed, executed and sworn to before a Notary Public, is to be filed with the City Recorder’s office. 2) The applicant may provide the necessary background check(s) or pays the city a $29.00 non-refundable fee for each background check the city needs to acquire. 3) The applicant submits proof that the location meets the current zoning ordinance requirements. 4) Once submitted and verified, the form will be presented to the Mayor for signing. 5) The executed document is given to the applicant to submit to the TABC. 2 City of La Vergne, Tennessee 5093 Murfreesboro Road, La Vergne, TN 37086  (615) 793-6295 APPLICATION FOR A CERTIFICATE OF COMPLIANCE FOR WINE IN A GROCERY STORE APPLICANT CONTACT INFORMATION 1. Full Name: _____________________________________ 2. Address: _____________________________________ _____________________________________ 3. Telephone #: _____________________________________ 4. Email Address: _____________________________________ 5. Please select type of Applicant: INDIVIDUAL - Continue to Section A below PARTNERSHIP - Skip to Section B on Page 3 CORPORATION - Skip to Section C on Page 4 A. FOR AN INDIVIDUAL (Any Correspondence will be addressed to the Applicant Contact Person.) 6. Have you been convicted of a felony within the past ten (10) years? YES or NO 7. Please list the name of any person who will have any interest, direct or indirect, in the business of the applicant or in the profits thereof and the nature and extent thereof. _____________________________________________________________________ _____________________________________________________________________ Skip to Section D - Page 5 3 B. FOR A PARTNERSHIP (Any Correspondence will be addressed to the Applicant Contact Person.) Managing Partner Information 6. Full Name: ______________________________________ 7. Address: _______________________________________ _______________________________________ 8. Phone Number: ______________________________________ 9. Email Address: ______________________________________ 10. List all individual partners and the following information: Name Address Phone Number Date of Birth (If additional space is needed, please use an additional sheet of paper.) 9. List all individual partners and the following information: Name General or Limited Partner Profit Sharing Percentage in Partnership Business or Occupation (If additional space is needed, please use an additional sheet of paper.) 10. Has the Managing Partner or any of the Individual Partners been convicted of a felony within the past ten (10) years? YES or NO Skip to Section D - Page 5 4 C. FOR A CORPORATION (Any Correspondence will be addressed to the Applicant Contact Person.) 6. List all Executive Officers of the Corporation with the following information: Name Address Phone Number Date of Birth (If additional space is needed, please use an additional sheet of paper.) 7. Have any Executive Officers of this Corporation been convicted of a felony within the last ten (10) years? YES or NO Go to Section D - Page 5 5 D. STORE INFORMATION 1. Name of Store: _________________________________________________ 2. Address of Store: _________________________________________________ 3. Zoning District of Store: _________________________________________________ E. OATH OF APPLICANT In making this application for a certificate of compliance, I certify that to the best of my knowledge, all information on this application is true and complete. I understand that if any information is found to be untrue, it may disqualify me from any further consideration for a Certificate of Compliance. I further agree to comply with all Federal and State Laws and the Rules and Regulations of the Tennessee Alcoholic Beverage Commission, as well as the Ordinances and Municipal Code of the City of La Vergne, Tennessee. I further agree to allow the City of La Vergne to conduct an investigation of my background and do hereby release the City of La Vergne from any liability or any change which may result from furnishing the information requested. ___________________________________________ Date: ____________________ Applicant Signature This application shall be verified by the oath of the applicant and in the event the applicant is a Partnership, it shall be verified by the oath of the managing general partner or if the applicant is a Corporation, it shall be verified by the oath of an Officer of the Corporation who shall be in control of this store. The Oath shall must be signed before a Notary Public to be valid. 6 Notary Public Certification: STATE OF TENNESSEE ) COUNTY OF _____________________ ) Personally appeared before me, ___________________________, a Notary Public in and for said county and state, that _________________________, personally known to me, or proved to me with identification, who, upon oath, acknowledge that he / she did execute the attached application for a Certificate of Compliance and that the facts and representations contained therein are true. Witness my hand and seal at office this _________ day of ___________, 20___. _______________________________________ Notary Public My Commission expires: ___________________ (Seal) This application was filed with the City of La Vergne City Recorder this the _______ day of ____________, 20____, at __________ A.M. / P.M. _______________________________________ City Recorder Office