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STATE OF WEST VIRGINIA

DEPARTMENT OF REVENUE

ALCOHOL BEVERAGE CONTROL ADMINISTRATION

900Pennsylvania Avenue, 4th Floor Charleston, WV 25302

INSTRUCTIONS FOR COMPLETING APPLICATION FOR RETAIL CLASS B LICENSE-OFF PREMISES

PLEASE READ ALL THE INSTRUCTIONS CAREFULLY. ALL QUESTIONS ARE TO BE ANSWERED IN FULL. APPLICANT’S ACCURACY AND THOROUGHNESS IN COMPLETING THE APPLICATION FORM WILL ASSIST THIS OFFICE IN PROCESSING THE APPLICATION AND PREVENT UNNECESSARY DELAYS.

Please find enclosed:

1.) Application for Retail Outlet License, Consumption Off Premises, (ABCA – 192B)

2.) Release of Information & Waiver of Confidentiality of Records (ABCA-Lic. RIWCR.2)

3.) Floor Plan (ABCA-Lic.FP3), give dimensions of licensed premises

4.) Zoning Form (ABCA-Lic.Z.2)

APPLICANTS MUST TYPE OR PRINT, IN INK, ALL ANSWERES ON FORMS

INSTRUCTIONS

All questions and/or descriptions must be answered. The application must be signed and notarized. If any questions/description cannot be completed in the available space on the application, please submit additional pages as needed. Each additional page submitted must include entity name, DBA name, and indicate which question applicant is answering.

Applications must be completed correctly and all necessary paperwork included when mailed to the WVABCA. Failure to do so will result in the application being delayed and/or returned to the applicant for the necessary corrections.

LEASE – Applicants must provide a copy of a valid lease if not the property owner.

LICENSE FEES – License fees must be paid by Certified Check, Cashier’s Check or Money Order. Personal checks, business checks, or cash will not be accepted. Make payable to the WVABCA.

All retail licenses are valid from issue date to June 30th of the current licensing period. If applying for a license to be issued after December 31st, most license fees are semi-annually prorated to half the initial fee.

*An additional $100.00 Operational Fee is to be submitted with your application; and may be included with all fees in your Certified Check, Cashier’s Check or Money Order. This fee is non-prorated and non- refundable.

LIVE SCAN FINGERPRINTING – All applicants must complete a Live Scan Fingerprint in order to obtain a valid license. IdentoGO by Morpho Trust will provide fingerprinting services for all WVABCA license applicants. Contact IdentoGO at 855-766-7746 or online at http://uenroll.identogo.com for information on fingerprinting, locations, scheduling appointments, and fee requirements.

Fingerprint result reports MUST be sent to WVABCA directly from IdentoGO (Morpho Trust).

Please contact the WVABCA Licensing Department at 304-356-5500 to obtain the proper service code for the Live Scan Fingerprinting process.

NO REPORTS WILL BE ACCEPTED DIRECTLY FROM LICENSE APPLICANTS.

WV SECRETARY OF STATE – All Associations, Corporations, Limited Liability, Non-Profit Clubs, and Fraternal Organizations must be duly certified and registered with the WV Secretary of State.

INSTRUCTIONS FOR SIGNING:

a.) If an individual, by the owner

b.) If a partnership, by each member of the partnership (Copy of Partnership Agreement to be submitted to WVABCA)

c.) If an association, by each member of the governing board

d.) If a corporation, by all officers, or by other persons specifically authorized by corporate resolution (copy of resolution must be enclosed)

e.) If a limited liability company, by all members f.) Manager(s) must sign

All applicants must apply for a “Special Occupation Tax (TTB F 5630.5d)” with the Alcohol and Tobacco Tax and Trade Bureau. Form and instructions are available through download at the following website: http://www.ttb.gov/forms/f56305d.pdf or by calling the toll-free number at 1-800-937-8864.

WINE APPLICATIONS – Information pertaining to the requirements for some wine applications and licensure are described below:

Wine Retail ($150.00) – “Wine Retailer” means a person licensed to sell wine at retail to the public at his or her established place of business for off premise consumption.

Wine Specialty Shop ($250.00)-“Wine Specialty Shop” means a retailer who shall deal principally in the sale of table wine, non-fortified dessert wines, wine accessories and food or foodstuffs normally associated with wine and:

(a)who shall maintain representative number of such wines for sale in his/her inventory which are designated by label as varietal wine, vintage, generic and/or according to region of production and the inventory shall contain not less than fifteen percent vintage or vintage-dated wine by actual bottle count: (b) who, any other provisions of this code to the contrary notwithstanding, may maintain an inventory of Port, Sherry, Madeira wines having an alcoholic content not more than twenty-two percent alcohol by volume and which have been matured in wooden barrels or casks.

Wine Specialty Shop Curbside Wine Delivery ($250) – This license allows a licensed wine specialty shop in good standing, with a grocery store with $100,000 of fresh produce, saleable food and food products to deliver wine to vehicles in its parking lot. Please see additional requirements below:

•Orders must be made in advance of pickup by a person 21 years of age or older, via a mobile application (app) or web-based software program.

•Must be picked up at the licensed establishment while the vehicle is parked within a WVABCA approved designated parking area that is within 500 feet of the licensed Class B location.

•The curbside delivery area must be designated by signs stating that the area is used solely for curbside delivery pickup.

•The person picking up wine must be verified to be 21 years of age or older.

Wine Specialty Shop Tasting ($400.00) – This license is a combination of the Wine Specialty Tasting ($150.00) and the Wine Specialty Shop ($250.00) licenses. This license allows a wine specialty shop to serve complimentary samples of wine in moderate quantities for tastings. Such wine specialty shop shall organize a wine taster’s club, which has at least fifty duly elected members or approved dues-paying members in good standing. Such club shall meet on the wine specialty shop’s premises not more than one time per week and shall either meet at a time when the premises are closed to the general public or shall meet in a separate segregated facility on the premises to which

the general public is not admitted. Must have a Wine Specialty Shop license to obtain a Wine Specialty Shop Tasting License.

Wine Specialty Shop Sampling ($150.00) – This license allows a wine specialty shop to conduct special wine sampling events at a licensed wine specialty shop location during regular hours of business. The wine specialty shop may serve up to three complementary samples of wine, consisting of no more than one ounce each, to any one consumer in one day. Must have a Wine Specialty Shop license to obtain a Wine Specialty Shop Sampling License. Note: A Wine Specialty Shop ($250.00) may add Wine Specialty Shop Tasting ($150.00) = $400.00, or add the Wine Specialty Shop Sampling ($150.00) = $400.00, or add both for a combined total of $550.00.

Wine Specialty Shop (wine with gift basket) Delivery ($250) – This license allows a licensed wine specialty shop in good standing to deliver wine with a gift basket. Please see additional requirements below:

•Wine must be delivered within the county where the licensed premises are located.

•License may not be located within a “dry county” or “dry area”. Deliveries may not be made to a “dry area”. (See www.abca.wv.gov for a list of the dry counties and areas).

•May not deliver to a private club, private wine restaurant, wine retailer, private wine bed and breakfast or private wine spa or any other locations where wine is offered for resale.

•The person receiving wine must be twenty-one (21) years of age or older and must sign for delivery and must use wine for personal use and not for resale. No deliveries may be left without a signature.

•Purchase at wine specialty shop must be made in-person (face-to-face) transaction. Note: Orders may not be made by telephone, electronic or web-based ordering.

•The order must be delivered by an officer or employee of the wine specialty shop. No third-party deliveries may be made.

•Each vehicle used by a Licensee must obtain a WVABCA transportation permit (see www.wvabca.wv.gov for this form) in order to transport wine.

•Wine must be sealed and the delivery package must be labeled “Contains Alcohol: Signature of Person 21 or Older Required for Delivery”.

Wine Tasting “Farm Winery” ($150.00) – This License allows a farm winery to attend fairs and festivals they have listed on Wine Tasting at a Festival, Fair or Special Event (ABC-Lic.w.1) form, that has been submitted to and approved by the WVABCA Commissioner. The license allows the approved farm winery to provide samples served in moderate quantities, which serving size will not exceed two ounces and bottles of wine sold for off- premises consumption. All wines, Port, Sherry, or Madeira offered or sold at the fair or festival must be offered or sold by the farm winery which produced the product.

BEER APPLICATIONS – Information pertaining to the requirements for some beer (nonintoxicating beer Class B Retailer) applications and licensure are described below:

Beer (nonintoxicating beer) Curbside Delivery ($250) – This license allows a Class B beer (nonintoxicating beer) retailer in good standing, with a grocery store with $100,000 of fresh produce, saleable food and food products to deliver beer to vehicles in its parking lot. Please see additional requirements below:

•Orders must be made in advance of pickup by a person 21 years of age or older, via a mobile application or web-based software program.

•Must be picked up at the licensed establishment while the vehicle is parked within a WVABCA approved designated parking area that is within 500 feet of the licensed Class B location.

•The curbside delivery area must be designated by signs stating that the area is used solely for curbside delivery pickup.

•The person picking up the beer order must be verified to be 21 years of age or older.

BUSINESS CLOSURE

The license may not be abandoned, rented, leased, given, loaned, or sold to another. Upon sale or closure of the applicant’s business, the license must be returned to the WVABCA Licensing Division. Please include reason for closure, date business closed, and signature on back of license.

MAIL COMPLETED APPLICATION, FEES, AND REQUIRED ACCOMPANYING FORMS TO:

West Virginia Alcohol Beverage Control Administration

ATTN: Licensing Division

900 Pennsylvania Avenue, 4th Floor

Charleston, WV 25302

IF YOU HAVE ANY QUESTIONS OR NEED ASSISTANCE PLEASE CALL THE ADMINISTRATION AT 1- 800-642-8208 OR (304) 356-5500 AND ASK FOR THE LICENSING DIVISION.

CHECKLIST OF FORMS/PAPERS TO RETURN TO THE WVABCA, LICENSING DIVISION:

฀Application Form

฀Release of Information & Waiver of Confidentiality of Records

฀Copy of Valid Lease (if not owner)

฀License Fee(s)

฀Floor Plan

฀Zoning Form completed by applicant & municipality if within city limits or, Zoning Form completed by applicant & letter from County Commission if outside city limits

฀Copy of TTB form

฀Naturalization Papers (if applicable)

WEST VIRGINIA ALCOHOL BEVERAGE CONTROL ADMINISTRATION

ABCA – 192A

APPLICATION FOR RETAIL LICENSE

CONSUMPTION “OFF PREMISES”

Revised 05/19

CLASS B

FOR FISCAL YEAR ____________ TO _____________

COUNTY:

PLEASE CHECK ALL APPROPRIATE BOXES BELOW. BE SURE TO CHECK THE BOX(ES) BESIDE EACH (ALL) OF THE LICENSES FOR WHICH YOU ARE APPLYING.

A. WINE APPLICATION

B. BEER APPLICATION

C. APPLYING AS:

฀

Wine Retail

$150

฀ Carry-

(CHECK ONE)

฀

Wine Specialty

$250

out…………………………...$150

฀

Individual

฀

Wine Specialty/ Tasting

$400

฀ Beer Curb Side Service……….

฀

Partnership

฀

Wine Specialty Gift Basket

………………………………$250

฀

Limited Partnership

Delivery*…………………$250

*Beer Curbside Service (must have at least

฀

Corporation

฀

$100,000 in groceries)

Wine Sampling*

$150

฀

Association

฀ Wine Tasting “Farm Winery”

$150

Operational Fee

฀

Limited Liability Corporation

฀

Wine Specialty Curbside

Operational Fee……………….. $100

Service……………………………...…………… $250

* Wine sampling only available to Wine Specialty license holders.

*This is a non-refundable and non-

prorated fee to be paid with the filing of

*Wine with a gift basket Specialty Delivery (must also obtain

the application.

transportation permit).

*Wine Curbside Service (must have at least $100,000 in groceries)

Email (Required):

Fax Number:

WV TAX I.D./FEIN:

1.)

Applicant/Entity Name:

2.)

Doing Business As (DBA) Name:

3.)

Business Address:

(STREET)

(CITY)

(STATE)

(ZIP CODE)

(TELEPHONE)

4.)

Mailing Address (required):

(STREET)

(CITY)

(STATE)

(ZIP CODE)

(TELEPHONE)

5.) SUPPLY THE FOLLOWING INFORMATION ABOUT OWNER(S) AND/OR OFFICER(S) AND MANAGER(S).

US Citizen**

Title

Name

Residence Address, City, State and Zip code

% Ownership

Y/N

Date of Birth

Social Security Number

Telephone Number

YRS Resident of WV

Title

Name

Residence Address, City, State and Zip Code

% Ownership

Y/N

Date of Birth

Social Security Number

Telephone Number

YRS Resident of WV

Title

Name

Residence Address, City, State and Zip Code

% Ownership

Y/N

Date of Birth

Social Security Number

Telephone Number

YRS Resident of WV

Title

Name

Residence Address, City, State and Zip Code

% Ownership

Y/N

Date of Birth

Social Security Number

Telephone Number

YRS Resident of WV

Title

Name

Residence Address, City, State and Zip Code

% Ownership

Y/N

Date of Birth

Social Security Number

Telephone Number

YRS Resident of WV

**IF NATURALIZED US CITIZEN, MUST SUBMIT COPY OF NATURALIZATION DOCUMENTS. NON-CITIZENS MAY BE LISTED AS SHAREHOLDER, OWNER, OR DIRECTOR OF CORPORATION ONLY.

TITLE REFERS TO CORPORATE OFFICERS, PRESIDENT, VICE PRESIDENT, SECRETARY TREASURER, OR

MEMBER

6.) CRIMINAL HISTORY- THE FOLLOWING IS A RECORD OF ALL CONVICTED ARRESTS OF THE OWNERS, PARTNERS, OFFICERS, DIRECTORS, MEMBERS AND/OR MANAGERS. ATTACH ADDITIONAL PAGES IF NECESSARY. IF THERE HAVE BEEN NO ARRESTS

INSERT THE WORD “NONE”

NAME____ DATE OF ARREST__ CHARGE ___ DISPOSITION OF ARREST LOCATION OF COURT (COUNTY & STATE)

7.) STATE NAME AND ADDRESS OF ALL PERSONS HAVING TWENTY PERCENT (20%) OR MORE INTEREST IN THE APPLICANTS’ CORPORATION, ASSOCIATION, PARTNERSHIP, LIMITED PARTNERSHIP, AND/OR LIMITED LIABILITY COMPANY. STATE THE EXACT PERCENTAGE OF OWNERSHIP INTEREST FOR EACH PERSON LISTED. A TRUST

CANNOT HOLD A PERCENTAGE OF OWNERSHIP.

NAME

ADDRESS

__________

SOC. SEC. #

%OWNERSHIP

8.) HAS ANY OFFICER, MANAGER, OR 20% STOCK HOLDER EVER HELD OR CURRENTLY HOLD A WVABCA LICENSE?

YES NO IF YES, WHO? _____________________________________________________

DBA NAME? _________________________________________________________

WAS THE LICENSE: REVOKED	_______	DATE _______
SUSPENDED	_______	DATE _______
SANCTIONED _______		DATE _______

9.) OWNER OF PREMISES TO BE LICENSED (PROPERTY OWNER’S NAME) _______________

IF NOT PROPERTY OWNER, APPLICANT MUST HOLD A VALID LEASE (ATTACH COPY OF THE LEASE)

10.)DOES THIS LOCATION CURRENTLY HAVE A WVABCA LICENSE? YES NO IF YES, NAME OF LICENSED ESTABLISHMENT: _____________________________________

LICENSE #: __________________________________________

11.) ARE THE APPLICANT’S PREMISES LOCATED:

A. WITHIN AN INCORPORATED MUNICIPALITY OR WITHIN ONE MILE OF THE

CORPORATE LIMITS OF ANY MUNICIPALITY:

YES

B.WITHIN ONE MILE OF THE CORPORATE LIMITS OF TWO OR MORE

MUNICIPALITIES:

YES NO

IF YES, NAME THE MUNICIPALITIES:

(1)

(2)

(3)

13.) WILL TOBACCO PRODUCTS BE SOLD AT THIS ESTABLISHMENT? YES

14.) IS THE APPLICANT’S LOCATION READY FOR AN INITIAL INSPECTION? YES NO

IF NO, WHAT IS THE PROJECTED DATE FOR THE INITIAL INSPECTION? ______________

15.) ESTIMATED RETAIL SALES PER MONTH OF FOOD AND FOOD PRODUCTS (FOR THE TABLE): ______________________________________________

ESTIMATE BASED ON: ____________________________________________

16.) ON WHAT DAY (DATE) WAS THE “SPECIAL TAX REGISTRATION AND RETURN APPLICATION”

(TTB FORM) SUBMITTED TO THE ALCOHOL AND TRADE BUREAU? _________________

The undersigned agree, if a license is issued as herein applied for, to comply at all times and observe all the provisions of West Virginia

§§Chapter 11, Article 16 et seq., and Chapter 60, Articles 1 through 8 et seq., and all Federal and State Statutes and all other laws of this State and the rules and regulations promulgated by the Alcohol Beverage Control Administration. I or we certify under penalty of law and disqualification of licensure that all statements are true and complete. I or we release the State of West Virginia and any agent acting on its behalf from any and all liability due to the request for such information.

The undersigned hereby verify that we are all officers and all member of the board of directors on the application and that the statements and answers made in the foregoing application are true and the said writing is the act and deed of said Corporation, Limited Liability Company, Association, Individual, Partnership, Limited Partnership. OFFICERS, INDIVIDUAL, OR MEMBER(S) SIGNATURES MUST BE NOTARIZED! MUST

MATCH OFFICERS LISTED WITH THE SECRETARY OF STATE. MANAGERS MUST ALSO SIGN.

		PRINT CLEARLY/ WRITTEN SIGNATURES REQUIRED
NAME:			TITLE:
	SIGNATURE:		DATE OF SIGNATURE:
NAME:			TITLE:
	SIGNATURE:		DATE OF SIGNATURE:
	SIGNATURE:		DATE OF SIGNATURE:
NAME:			TITLE:
	SIGNATURE:		DATE OF SIGNATURE:
NAME:			TITLE:
	SIGNATURE:		DATE OF SIGNATURE:
	SIGNATURE:		DATE OF SIGNATURE:
NAME:			TITLE:
	SIGNATURE:		DATE OF SIGNATURE:

State of West Virginia,				County, To-Wit:
			, being first duly sworn
according to law, deposes and says that he/she is				of the
		President, Individual or Controlling Member(s)
		, authorized by law to do business in the State of West Virginia, and that the
	Business Entity

statements and answers made in the foregoing application are true and acknowledged the said writing to be the act and deed of said corporation.

STATE OF WEST VIRGINIA,			(Applicant Signature)
STATE OF WEST VIRGINIA,
COUNTY OF	, to wit:
COUNTY OF	, to wit:
Sworn to before me and subscribed in my presence this		day of		,
Sworn to before me and subscribed in my presence this		day of		,

NOTARY PUBLIC

My Commission Expires:

SEAL OF NOTARY

West Virginia Alcohol Beverage Control Administration

Floor Plan

License period:		-

Applicant Entity Name:

Doing Business As (DBA) Name:

County:

Floor plan must include all areas under the control or lease of the applicant where alcohol is to be stored, sold, or consumed. All areas under control or lease of the applicant must be licensed.

SUBMIT (1) COPY TO WVABCA. MUST GIVE DIMENSIONS. KEEP (1) COPY AT LICENSED PREMISES.

*If there are attached drawings please check:

(Additional drawings must include entity & DBA name and must be signed and dated.)

Room or Outside Structure

(Width, Length) (Example: 24’ X 36’)

Located on What Floor

Seating Capacity

Location

(Serving, Kitchen, Storage, Etc...)

I or we hereby certify that the floor plan above and/or attached is the only area where alcoholic beverages will be sold, dispensed, consumed, and/or stored. And, I or we further understand that any violation of this provision will mean immediate revocation or suspension of my license.

Print:	Signature:	Title:	Date:
Print:	Signature:	Title:	Date:
Print:	Signature:	Title:	Date:
Print:	Signature:	Title:	Date:
Print:	Signature:	Title:	Date:

Applicant/Entity Name: ____________________________________

Doing Business As (DBA) Name: ____________________________

WEST VIRGINIA ALCOHOL BEVERAGE CONTROL

ADMINISTRATION

RELEASE OF INFORMATION AND WAIVER OF CONFIDENTIALITY OF RECORDS

I or we, having made application with the West Virginia Alcohol Beverage Control Administration for issuance of a license to sell alcoholic beverages within the State of West Virginia, hereby waive the benefit of any municipal, county, state, or federal statute, rule, ordinance, regulation or other law prescribing the confidentiality of any records or documents, whether formal or informal, pending or closed, maintained by any public or private agency or organization as those records or documents pertain to residency, business location, business activities, education and/or training, employment, criminal history, civil litigation, or law enforcement investigation.

I or we, hereby authorize and request every public or private agency, organization, or person maintaining such records to furnish to the West Virginia Alcohol Beverage Control Administration, or their agents or representatives, any information contained therein and to permit them to inspect and make copies of such records and documents.

I or we, hereby authorize the West Virginia Alcohol Beverage Control Administration to disclose any information pertaining to the licensure to any municipal, county, state, federal or private agency or organization that has any interest in the licensing of said applicant.

I or we, hereby release the West Virginia Alcohol Beverage Control Administration, their agents and representatives, and any agency, organization, or person furnishing information from all liability arising out of any investigation concerning the applicant. I or we further agree that a copy of this Release and Waiver shall function as an original.

I or we, herby acknowledge that it is understood that a background check will be completed by both the West Virginia State Police and the Federal Bureau of Investigation. It is further understood that if I or we, dispute an FBI submission under Title 28, C.F.R., 16.34, I or we have the right to challenge the completeness or accuracy of the criminal history record by contacting the Federal Bureau of Investigation directly.

I or we acknowledge that by affixing a signature(s) below gives this document full force, and upon this date all aforementioned information may be received and shared as prescribed.

Name: Must include owner’s, officer’s, member’s and manager’s printed and written signature(s).

Title

Date

(Addendum B) ABCA-Lic.RIWCR.2

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Form Name	Wv Abca Form
Form Length	13 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 15 sec
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