Form Cpltp 01 – Fill Out and Use This PDF

CPLTP-01 Rev 10/ 07

For Official Use Only

Special Club

Charitable

Noncommercial

Noncommercial

Nonprofit

Available to club or golf

Organization

Organization

Organization

Corporation

country club liquor permit

Alcoholic Beverages

Beer Only

Retail Sale of Wine at Auction

holders for outdoor picnics

including Beer

$25.00 per day

$25.00 per day

$25.00 per day

$15.00 per day

$25.00 per day

TIME & PLACE

1. Name of Event

2. Date of Event

3. Rain Date

4. Proposed time of event

of EVENT

5. Street Address of Event

City/Town

State

Zip Code

6.

Will event be held indoors or outdoors? (If indoors, complete item 27).

7. Attach an 8 ½” x

11” sketch showing the exact locations

INDOORS

OUTDOORS

BOTH

within

the event area where alcoholic beverages will be

dispensed and specify the manner by which service of such

beverages to minors will be controlled.

PERMITTEE

8.

Name of Applicant (Last, First, Middle)

9. Date of Birth

10. Telephone Number

APPLICANT

of EVENT

11. Home Street Address

City/Town

State

Zip Code

12.

Have you ever been convicted of a felony crime?

YES

NO

If yes, please attach a statement including the date(s)

of the conviction(s), the court(s) where the case(s) were disposed of and a description of the circumstances involved.

13.

Have you previously been a liquor permittee?

If yes, please specify the liquor permit type(s) and permit number(s)

YES

NO

14.

Are you a minor or a person who holds a position that would prohibit you from obtaining a liquor permit?

YES

NO

*(See item #3(a) in instructions for listing of persons who are prohibited from acting as permittee or backer on a liquor permit)

15. If applying on behalf of a noncommercial organization – will all of the profits derived from the sale of alcoholic beverages be

retained by the organization?

YES

NO

If no, briefly explain the distribution of profits:

16. As the applicant, I assume responsibility as manager and principal representative of the backer for the event to be held on

the premises described in this application. I certify that all information contained in this application is true.

Signature of Applicant x _____________________________________________________

Date ______________________

BACKER

17. Name of club/organization that is acting as backer

18 Business address of club/organization (Street, City, Zip)

ORGANIZATION

SPONSORING

19. Enter State sales tax number of organization

20. If the organization is a charity, enter the Federal tax

EVENT

identification number of the charitable organization: (Or attach a copy

of tax identification letter)

21. In boxes below provide names(s) of the officer(s) of club/organization that is sponsoring event:

Officer #1. Name: (Last, First)

Officer #1 address: (Street, City, Zip)

Officer #2. Name: (Last, First)

Officer #2 address: (Street, City, Zip)

22. Has the club/organization/officer previously been a backer or

If yes, please specify the liquor permit type(s) & number(s)

owner of an entity with a liquor permit?

YES

NO

23.

Has the organization appeared as backer on other

If yes, please specify the number of permits obtained:

temporary permit(s) in this calendar year?

YES

NO

24. I appoint the applicant named in item #8 above, as my principal representative to be in charge of the premises and the event

described in this application. Signature of authorized backer’s representative or officer of club/organization.

x _____________________________________________________________

Date __________________

CITY/TOWN

25. Name of City/Town:

CERTIFICATION

(To be completed by

26. I certify that I am aware of the city ordinances and there is no ordinance prohibiting the dates and times of sale of alcoholic

the city/town clerk

liquor as requested in this application.

where event

is to be held)

Signature of City/Tow n Clerk

Date signed

x __________________________________________________________

LOCAL FIRE

27. This certifies that the premises described in this application complies with the required

Date signed

MARSHAL’S

fire code. Signature of local Fire Marshal (or attach a signed certification to this application)

CERTIFICATION

Rank/Title of Fire Control Official

(If event is held

x ___________________________________________________________

indoors or in a tent)

CITY/TOWN

28. Name of City/Town:

ZONING

(To be completed by

29. I certify that the location in Item #5 of this application is located in the town or city where stated; that I am acquainted with

the zoning official

the zoning ordinances and bylaws of said town or city; and that, at this location said town or city does not prohibit the sale of

where event

alcoholic liquor under the type of permit here applied for.

is to be held)

Signature of Zoning Official

Date signed

x ___________________________________________________________

PRINCIPAL

Where there is no local police department, this section must be signed by State Police.

POLICE

30. Do you approve of the issuance of this permit?

YES

NO If no, please explain.

AUTHORITY

APPROVAL

(Town in which

Signature of Police Authority

Rank/Title of Police Authority

Date signed

event is to be held)

x ______________________________________

PERMITTEE

31. Has the applicant whose name appears in item #8 of this application been convicted of a felony crime?

YES

NO

APPLICANT’S

If yes, please attach a statement including the date(s) of the conviction(s), the court(s) where the case(s) were disposed of

SUITABILITY

and a description of the circumstances involved.

32. Do you believe the applicant named in item #8 of this application is suitable to be a liquor permittee?

YES

NO

(To be completed by

If no, please attach a statement supporting your reasons for this decision

police authority in

city/town where

Signature of Police Authority

Rank/Title of Police Authority

Date signed

applicant resides)

x _____________________________________________________