Abc Banquet License Form – Fill Out and Use This PDF

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

INSTRUCTIONS FOR RETAIL LICENSE APPLICATION

INSTRUCTIONS

RETAIL LICENSE FEES

Type of License	Type of Establishment		Fee
Beer On Premises	Restaurant, hotel, tax-exempt private club, food concessions at coliseum
	and stadium, resort complex	$	145.00
Beer Off Premises*	Grocery store, delicatessen, drugstore, marina store	$	120.00
Beer Off Premises and Keg*	Grocery store, delicatessen, drugstore, marina store	$	185.00
Beer On and Off Premises*	Restaurant, hotel, tax-exempt private club, grocery store	$	300.00
Beer On and Off Premises and Keg*	Restaurant, hotel, tax-exempt private club, grocery store	$	365.00
Wine and Beer On Premises	Restaurant, hotel, hotel–limited service, tax-exempt private club,
	food concessions at coliseum and stadium, resort complex	$	300.00
	Hospitals	$	145.00
Day Spa (Wine & Beer On)	Commercial establishment offering both massage therapy and
	cosmetology services	$	100.00
Meal Assembly Kitchen (Wine & Beer On)	Commercial establishment offering ingredients for the preparation of meals	$	100.00
Wine and Beer Off Premises*	Grocery store, convenience grocery store, delicatessen, drugstore,
	gift shop, gourmet shop	$	230.00
Wine and Beer Off Premises and Keg*	Grocery store, convenience grocery store, delicatessen, drugstore,
	gift shop, gourmet shop	$	295.00
NOTES: If you do not find your establishment type listed here, you may call License Records Management at (804) 213-4577.		(continued)

*A Delivery Permit (in state) may be added to the license types noted above at no additional cost. Such permittees shall report on a monthly basis names and addresses of pur- chasers to whom wine and beer is delivered. If no deliveries occur in one month, no report is due; however, every permittee must submit an annual report even if no deliveries occur. Contact your agent for more detailed information.

805-52i (rev. 07/2018). This is an official state document and all information contained or submitted	Retail License Application Instructions, page 1
therein is public information. Refer to Privacy Statement on page 3 regarding personal/tax information.

Trade name (for office use only):

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

Failure to disclose ownership interest in your business or falsification and/or misrepresentation of information

may result in refusal of your license and/or criminal charges, which may include the Class 5 felony of perjury.

RETAIL LICENSE APPLICATION—PART 1

Please refer to instructions, which are provided separately. Answer each question. If a question does not apply to your business, mark "N/A" (not applicable). Type or print using black ink. (Note: Electronic version can be filled in and printed, but not saved for future use.)

PRIVACY STATEMENT

OWNERSHIP TYPE

1. Indicate the ownership type for your business (check only one):

Sole proprietor. An unincorporated business that is owned and operated by one person. This person receives all the profits and is personally liable for all the losses. (Does not have to register with the Virginia State Corporation Commission.)

General partnership. A relationship existing between two or more persons who join together to carry on a trade or business. Each partner contributes money, property, labor and/or skills, and agrees to share in the profits or losses of the business. (Registering with the Virginia State Corporation Commission is optional.)

Limited partnership (LP). Created to obtain additional funds. Limited partners' liability is limited to the extent of their investment. (Must regis- ter with the Virginia State Corporation Commission.)

Limited liability partnership (LLP). A status granted to a general partnership or limited partnership that has registered as a limited liability partnership in its home state. (Must register with the Virginia State Corporation Commission.)

Limited liability company (LLC). An unincorporated association usually having one or more members. It is a separate legal entity that limits the personal liability of all its owners. (Must register with the Virginia State Corporation Commission.)

Corporation. An entity with a legal existence apart from its owners. Corporations are classified as “stock” or “non-stock” and “domestic” or “foreign.” It consists of a group of people authorized to perform certain professional services in the corporate form. (Must register with the Virginia State Corporation Commission.)

Association. A group of individuals or companies in a specific business or industry organized to promote common interests. (Does not have to register with the Virginia State Corporation Commission.)

Tax-exempt private club. A nonprofit organization approved by the IRS and operated solely for a national, social, patriotic, political, athletic or similar purpose. (Does not have to register with the Virginia State Corporation Commission.)

805-52i (rev. 07/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 3
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.

License number (for office use only):

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

RETAIL LICENSE APPLICATION—PART 1

OWNER INFORMATION

2.	Does owner currently hold an ABC license at this location?	Yes	No If Yes, provide license number: __________________________
3.	Owner's name: ____________________________________________________________________________________________________________________________________________________________________________

If general partnership, enter partners’ names or name of partnership. If LP, LLP, LLC or corporation, enter name as recorded with the State Corporation Commission. If association or tax-exempt private club, enter name. Only if a sole proprietor, enter first, middle and last name.

4.	Owner's address: (street) __________________________________________________________________________________________________________
	(city/town)__________________________________________________________________ (state) __________ (zip + 4) ______________________
5.	Day phone: (_______) __________________________________________	6.	Alternate phone: (_______) __________________________________
7.	Fax: (_______)__________________________________________________________________________________	8.	Email: ________________________________________________________________
9.	Type of license(s) applied for: ____________________________________________________________________________________________
	License type(s) must be filled in before your application will be accepted. (See “Retail License Fees” on pgs. 1–2 for license types.)

GENERAL BUSINESS INFORMATION

10.Trade name of business: ________________________________________________________________________________________________

11.Physical address where business will trade: (street) __________________________________________________________________________

	(city/town) ________________________________ (state) ______ (zip + 4) ____________			(county, if applicable) ____________________________
12.	Day phone: (_______) __________________________________	13.	Alternate phone:	(_______) ____________________________________________________________________________________
14.	Fax: (_______) ________________________________________	15.	Email: ________________________________________________________

16.Type of business (check only one):

Banquet facility	Delicatessen	Grocery	Resort complex
Bed and breakfast	Delivery permit (out-of-state)	Hotel	Restaurant
Brewery	Distillery	Hotel–Limited service	Shipper
Carrier (airplane, boat, train)	Drug store	Importer	Tax-exempt private club
Caterer	Food concessions (coliseum, stadium)	Internet wine retailer	Wholesaler
Continuing care community	Gift shop	Marina	Winery
Convenience store	Gourmet brewing shop	Meal assembly kitchen
Day spa	Gourmet shop	Out-of-bond permit

	Other: ____________________________________________________________________________________________________________
17.	Who will operate the business? (check only one)	Owner	Management company	Franchisee
18.	Is this business property owned or leased?	Owned	Leased

MAILING PREFERENCES

19.	Send all other mail and license to (check only one):	Owner address	Business address	Alternate address (provide below)
	Alternate address (if needed): (street) __________________________________________________________________________________________________________
	(city/town) __________________________________________________________________ (state) ________			(zip + 4) __________________________
20.	Send annual renewal bills to (check only one):	Owner address	Business address	Alternate address (provided above)

805-52i (rev. 07/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 4
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

RETAIL LICENSE APPLICATION—PART 1

PERSONAL DATA

Enter primary or first individual’s personal data below. If more than one individual must provide personal data, duplicate this sheet and complete a separate Personal Data Sheet for each individual. Who must provide personal data? Owner if SOLE PROPRIETOR. Each partner if GENERAL PART- NERSHIP. Member/managers and all other members with 10 percent or more interest if LP, LLP or LLC. Officers, directors and all stockholders owning

10 percent or more of corporation's stock if CORPORATION. Officers, directors and trustees if ASSOCIATION or TAX-EXEMPT PRIVATE CLUB.

21.	Trade name of business: ________________________________________________________________________________________________
22.	Full name: (last) ____________________________________________ (first) __________________________							(middle) ____________________________
23.	Social security number: __________________________________			24.	Driver’s license number: ______________________________________________
25.	Date of birth: (MM/DD/YYYY) _____			26.	Place of birth: __________________________________________________
27.	For the purpose of conducting a background check, please indicate your gender:					Male	Female
28.	Are you a U.S. citizen?	Yes	No If No, provide copy of immigration card.
29.	Do you reside in Virginia?	Yes	No If Yes, how long? (years)	______________________________				(months)______________________________
30.	Home phone: (_______)__________________________________			31.	Business phone: (_______) __________________________________

32.Current home address: ____________________________________________________________________________________________________________

33.Previous home address: ________________________________________________________________________________________________

Complete if you have lived at your current address less than one year.

34.Email: ______________________________________________________________________________________________________________

35.What is your relationship to the owner? (Please mark all that apply and provide amount of ownership interest.)

•	Sole proprietorship:	Self
•	Corporation:	Director	Officer (title): _______________________________		Shareholder (shares owned): _______
• LLC, LLP or LP:		Member (member interest): _______%		Member/manager (member interest): _______%
•	General partnership:	Partner (partner interest): _______%
•	Assoc. / tax-exempt private club:	Director	Officer (title): ___________________________________________________________________

36.	Do you currently have financial interest in any business selling alcoholic beverages?	Yes	No
	If Yes, provide:
	(license number) ______________________________ (trade name) __________________________ (location) ____________________________
37.	Have you ever had any type of alcoholic beverage license refused, revoked or suspended?		Yes	No
	If Yes, provide:

(trade name) __________________________________________________________________	(address) ______________________________________________________ (date) ____________________________
38. Have you ever been convicted of any of the following:	•	motor vehicle violation(s) (not including parking tickets)?	Yes	No
	•	driving while intoxicated?	Yes	No
	•	other criminal offense(s)?	Yes	No

If Yes to any of the above, provide the following information (using additional sheets of paper if necessary):
(date)	________________________________	(location)______________________________________________	(offense)	____________________________________________________
(date)	________________________________	(location)______________________________________________	(offense)	____________________________________________________
39. Are you an elected or appointed official of the Commonwealth of Virginia or any political subdivision thereof?					Yes	No
If Yes, provide:
(title)	______________________________________________________		(location) __________________________________________________________

Failure to disclose ownership interest in your business or falsification and/or misrepresentation of information

may result in refusal of your license and/or criminal charges, which may include the Class 5 felony of perjury.

805-52i (rev. 07/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 5
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.

License number (for office use only):

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

RETAIL LICENSE APPLICATION—PART 1

DETAILED BUSINESS INFORMATION

40.Date which you began or will begin operation of business (MM/DD/YYYY): __________________________________________________________

41.Business hours and days of operation: ______________________________________________________________________________________________

42. Is any employee paid a percentage of business proceeds?		Yes	No	If Yes, please explain: ____________________________________
43. Grocery and Convenience Store / Gourmet Shop / Delicatessen
	Month of ____________________________, 20___________	If less than one month, give the number of days: ________________________
	Items of business (complete for your establishment type only)				Sales (less sales tax)*	Inventory (wholesale value)*
	Bulk edible food/grocery items (grocery and convenience stores only)
	(edible items used in the preparation of meals)
	Individual packaged items (for grocery and convenience stores only)
	(snacks, gum, candy, chips, etc.)
	Gourmet items (gourmet shops only)
	Prepared foods (delicatessens only)
	Nonalcoholic beverages (soft drinks, tea, coffee, etc.)
	Total
	*Check here if estimated. Estimated figures are accepted from prospective businesses only; otherwise, actual figures are required.

44.Restaurant: a. Number of seats at counter/bar: ____________________________________________________________________________________________

b.Number of additional dining rooms: ______________________________________________________________________________________________________

c.Number of seats in all dining areas (excluding bar): __________________________________________________________

d. Is there an outside dining area?		Yes	No If Yes, provide the following information:
•	Dimensions of outside dining area: ________________________			•	Number of seats in outside dining area: ____________________
•	Number of tables in outside dining area: __________________			•	Describe physical barrier used to enclose patio:
	____________________________________________________________________________________________________
e. Provide a copy of menu including prices (on-premises privilege only).
Month of ____________________________, 20___________			If less than one month, give the number of days: ________________________
Items of business					Sales (less sales tax)*
Entrees (full meals)
Other prepared food
Nonalcoholic beverages (soft drinks, tea, coffee, etc.)
Prepared food sold to go

Total

*Check here if estimated. Estimated figures are accepted from prospective businesses only; otherwise, actual figures are required.

45. Bed and breakfast / Hotel: Number of bedrooms for overnight guests: ____________________________________________________________________________________________

805-52i (rev. 07/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 6
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.

License number (for office use only):

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

RETAIL LICENSE APPLICATION—PART 1

REQUIRED DOCUMENTS FOR ALL ESTABLISHMENTS

46.Provide official copies of the following required documents. (Note: All documents must be received for agent’s investigation to begin.)

Lease or deed, including all amendments. Must be signed. (Note: Must be in the name of the owner: If general partnership, partners’ names or name of partnership. If LP, LLP, LLC or corporation, name as recorded with State Corporation Commission. If association or tax-exempt private club, name. Only if a sole proprietor, first, middle and last name.)

Name and address of the landlord: ____________________________________________________________________________________

__________________________________________ Telephone number of landlord: (_______) _____________________________________

Health permit and/or agricultural certificate.

Official Department of Motor Vehicles (DMV) transcript for each officer, director and 10-percent-or-more shareholder, member or partner

from each individual's state of residence. (Note: If these individuals have not resided in the Commonwealth of Virginia for at least 12 months, an official driving transcript from the previous state of residence must also be provided.)

Criminal history from the appropriate law enforcement agency in the previous state of residence for each officer, director and 10-percent-

or-more shareholder, member or partner. (Note: Applicable only to individuals who have not resided in the Commonwealth for at least 12 months or to those applicants that do not reside in the Commonwealth of Virginia.)

Valid identification issued by federal, state or foreign government agency or entity, provided it contains a photograph, name, signature, date

of birth and gender. (Note: ABC may require additional identification documents. Also, if the applicant is not a citizen of the United States, a copy of documentation that permits legal residence must also be provided.)

Federal Employer Identification Number (EIN) from the IRS (www.irs.gov / 800-829-4933).

Virginia sales tax certificate (front and back) from the Virginia Department of Taxation (https://www.ireg.tax.virginia.gov / 804-367-8037). Franchise/management agreement (if applicable).

Part 2 of this application (“Posting and Publishing” summary, pp. 9–11).

ADDITIONAL REQUIRED DOCUMENTS

805-52i (rev. 07/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 7
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.

License number (for office use only):

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

RETAIL LICENSE APPLICATION—PART 1

APPLICANT'S SIGNATURE–REQUIRED

I swear or affirm under penalty of law that the information on this application and all attachments are true and accurate. I understand that falsification and/or misrepresentation of information may result in refusal of the license(s) and/or criminal charges.

Signature: __________________________________________________________ Date signed: _______________________

Print name: ___________________________________________________________________________________________

Title: ________________________________________________________________________________________________

805-52i (rev. 10/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 8
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.

License number (for office use only):

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

RETAIL LICENSE APPLICATION—PART 2 (POSTING AND PUBLISHING)

INSTRUCTIONS

•Notice posting and publishing must not be started until Virginia ABC has received Part 1 of the application and application fee(s).

•Notice posting and publishing can be done at the same time.

•The sworn affidavit (below) shall not be signed until these two requirements have been met:

(1)Both newspaper publishings have been completed.

(2)Ten complete and consecutive days have passed since the notice was first posted.

•Airplanes, boats, trains, museums, wine and/or beer shippers, annual banquet, annual mixed beverage banquet, out-of state beer or wine importers and out-of-state delivery permittees do not need to publish or post their intent to apply for a license (VA Code §4.1-230.B).

•Posting Notice: The owner shall fill out the notice (pg. 10) stating that he/she has applied for an ABC license and post the notice for 10 complete and consecutive days on the front of the building, room or place where he/she proposes to conduct business.

•Newspaper Publishing Notice: The owner shall publish notice (pg. 11) in English at least two times in a newspaper having general circulation in the county, city or town where the owner proposes to conduct business. The two publishings must occur in consecutive weeks. The second pub- lishing must occur at least seven days after the first publishing, but not later than Saturday of the second week. Hint: The easiest way to meet this requirement is to publish on the same day in both weeks (e.g., on two consecutive Mondays).

POSTING AND PUBLISHING SUMMARY

1. Owner's name: ______________________________________________________________________________________________________

If general partnership, enter partners’ names or name of partnership. If LP, LLP, LLC or corporation, enter name as recorded with the State Corporation Commission. If association or tax-exempt private club, enter name. Only if a sole proprietor, enter first, middle and last name.

2.Trade name of business: ________________________________________________________________________________________________

3.Type(s) of license(s) applied for: __________________________________________________________________________________________

4.Location where business will trade: (street) ________________________________________________________________________________

	(city/town) ____________________________________________ (county) ________________________________________ (state) Virginia
5.	Date notice posted at establishment (MM/DD/YYYY):____________________________________________________________________________________
6.	Date first notice published (MM/DD/YYYY): _______________________	Name of newspaper: ______________________________________________
7.	Date second notice published (MM/DD/YYYY): ____________________	Name of newspaper: ______________________________________________

APPLICANT'S SIGNATURE–REQUIRED

I swear or affirm under penalty of law that the information on this posting and publishing summary is true and accurate. I understand that falsification and/or misrepresentation of information may result in refusal of the license(s) and/or criminal charges.

Signature: __________________________________________________________ Date signed: _______________________

Print name: ___________________________________________________________________________________________

Title: ________________________________________________________________________________________________

805-52i (rev. 12/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 9
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

The applicant shown below is applying to the

Virginia Alcoholic Beverage Control Authority.

TYPE(S) OF LICENSE(S):	____________________________________________________________
FULL NAME(S) OF OWNER(S):	____________________________________________________________
	If general partnership, enter partners’ names or name of partnership. If LP, LLP, LLC or corporation, enter name as
	recorded with the State Corporation Commission. If association or tax-exempt private club, enter name. Only if a
	sole proprietor, enter first, middle and last name.
TRADE NAME:	____________________________________________________________
EXACT LOCATION WHERE
BUSINESS WILL TRADE:	____________________________________________________________
	(street address)
	____________________________________________________________
	(city/town)
		Virginia
	____________________________________________________________
	(county)	(state)	(zip + 4)
PARTNERS / CORPORATE OFFICERS
HAVING INTEREST IN THE BUSINESS:	____________________________________________________________
	(name)	(title / nature of interest)
	____________________________________________________________
	(name)	(title / nature of interest)
	____________________________________________________________
	(name)	(title / nature of interest)
DATE OF FIRST NEWSPAPER
PUBLISHING:	____ / ____ / ________	_______________________________________
	(date of first newspaper publishing)		(signature/title)

Objections to the issuance of this license must be submitted to ABC no later than 30 days from above date, the publishing date of the first of two required newspaper legal notices.

Objections should be registered within 30 days at www.abc.virginia.gov or 800-552-3200.

805-52i (rev. 07/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 10
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.

Virginia Alcoholic Beverage Control Authority • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800) 552-3200

RETAIL LICENSE APPLICATION—PART 2 (POSTING AND PUBLISHING)

PUBLISHING NOTICE

Please publish the following item in the legal notice section of your newspaper. Please refer to the instructions provided on page 9.

[Full name(s) of owner(s):] ________________________________________________________________

If general partnership, enter partners’ names or name of partnership. If LP, LLP, LLC or corporation, enter name as recorded with the State Corporation Commission. If association or tax-exempt private club, enter name. Only if a sole proprietor, enter first, middle and last name.

Trading as: ____________________________________________________________________________

(trade name)

____________________________________________________________________________________

(exact street address where business will trade)

____________________________________________________________________________________

(city/town)

______________________________________________________	Virginia	____________
(county)	(state)	(zip + 4)

The above establishment is applying to the VIRGINIA ALCOHOLIC BEVERAGE CONTROL (ABC) AUTHORITY

for a ___________________________________________________________________________________________________ ______________________________________________________________________________________ license

(type[s] of license[s] applied for)

to sell or manufacture alcoholic beverages.

____________________________________________________________________________________

(name and title of owner/partner/officer authorizing advertisement)

NOTE: Objections to the issuance of this license must be submitted to ABC no later than 30 days from the publishing

date of the first of two required newspaper legal notices. Objections should be registered at www.abc.virginia.gov

or 800-552-3200.

805-52i (rev. 07/2018). This is an official state document. All information contained or submitted therein is public information. Please	Retail License Application, page 11
refer to privacy statement (pg. 3) regarding personal/tax information. Reference instructions (provided separately) with questions.