City of Denham Springs
S T O R E / R E S T A U R A N T - A L C O H O L P E R M I T C H E C K L I S T
Attn: Business License Office
P O Box 1629 ~ Denham Springs, LA 70727
Phone: 225-667-8310
Applicant Office
□ □ Completed & Notarized Application
□ □ Schedule A completed for each Partner /Stockholder(s)
□ □ Copy of Driver’s License or ID – Partners/ShareHolders
***
Managers and employees will need D.S. Seller/Server License
□ □ Corporation: Officers- Name, Address, Ph #, DOB, POB,
DL # / State & SS #
□ □ Run Ad in Newspaper 2 Consecutive Times
Phone #665-5176
□ □ Sales Tax ID# & Clearance Letter from L P School Board
Phone # 686-3043
□ □ Fee of either $60.00 Pkg Low $75.00 Rest. Low $500.00 High
□ □ Restaurant or Store Occupational License $50.00 before July 1
st
& $25.00 after July 1
st
□ □ Chain Store License, if needed
□ □ Copy of Lease, if needed
□ □ Measurement’s, if needed
□ □ Attend Council Meeting on 6:00pm
(Business License Dept will schedule meeting ) 2
nd
Tues / 4
th
Mon
□ □ Apply with State Office of ATC Phone # 925-4041
Please ensure that the owner’s name, trade name, mailing address, and location address match exactly on all paperwork
submitted with this application.
Legal names required, no nicknames.
**RETURN WITH COMPLETED AND NOTARIZED APPLICATION.
Please Intitial: Please Intitial:
Applicant Office
APPLICATION FOR RETAIL ALCOHOL PERMIT
Page 1
City of Denham Springs Permit to be issued for the
Attn: Business License Office Calendar Year Ending
P O Box 1629 December 31,
Denham Springs, LA 70727-1629
Permit to be
Issued to:
(Owner-Name of Individual, Name of Partners, or Corporation)
Trade Name (If Any)
Mailing Address
Location Address
1. Application is for an alcohol permit as a
□ Class “A-R” Retail Alcohol Restaurant Outlet (1/2% or more alcoholic beverages by volume) (High-500 or Low-75)
City Ordinance Sec. 10-94. Requirements for issuance of “A-R” permits.
A restaurant establishment shall be defined as an establishment:
a.
Which operates a place of business whose purpose and primary function is to take orders for and serve food items;
b. Which serves alcoholic beverages in conjunction with meals;
c. Which serves food on all days of operation;
d. Which grosses sixty percent of its average monthly revenue from the sale of food, food items, and non-alcoholic beverages;
(For new restaurant establishments without prior business experience on which to determine the gross revenue from the sale
of food, food items, and non-alcoholic beverages the Business License Office will issue a Temporary License, which shall
be valid for sixty days to allow the establishment to make such determination.)
e. Which maintains separate sales figures for alcoholic beverages; and
f. Which operates a fully equipped kitchen, which includes but is not limited to a range, an oven and refrigerated
storage appliances used for the preparation of uncooked foods for service and consumption of such foods on the
premises.
□ Class “A-G” General Bar (6% or less alcoholic beverages by volume) (Low-75)
□ Class “B” Retail Package Outlet (1/2% or more alcoholic beverages by volume) (High-500 or Low-60)
2. Kind of ownership, i.e. Individual, Partnership, or a Corporation?
3. Does Applicant hold Local Alcohol Permit for current year at other location?_____________Kind
4. Has the applicant ever been denied a State or Local Alcohol Permit?
5. Has applicant applied for, or, holds any other Alcohol Permit? ___________ Kind
6. a. Is applicant the owner of the premises to be occupied? Yes or No
b. If no, does applicant hold a bona fide written lease? Yes or No
c. If premises leased, give name and address of lessor:
d. Describe part of building to be occupied by business:
7. Date started, or to start at this address
8. a. Is the business to be wholly or partly conducted by
one or more managers, agents or other representative
b. If answer “yes”, list names below and furnish Schedule “A” on each.
9. If partnership or corporation, list below names, address, and percentage of business owned by each partner or stockholder.
Schedule “A” must be attached for each partner, or, for each stockholder owning more than 5% of the stock. Also, any
Financial backers of the business must be listed and Schedule “A” submitted.
Name of Person
Partner, Stockholder or Financial Backer
Kind of Interest
% Owned
FEE
PENALTY
TOTAL
Page 2
RENEWAL APPLICATION MUST BE ENTIRELY COMPLETE & WITH PROPER FEE ATTACHED
10. Does applicant owe any excise tax (sales, occupational license,
income, franchise, etc) to the state or any parish or municipality?
11. Is this application by a new owner to take over a going business that has
been selling beer regularly and continuously to the present time?
Show (1) name of immediate prior owner, (2) trade name, and (3) permit number.
To Be Answered by Owner, Partner, Manager, Agent, or Official Signing This Application.
Schedule A
a. Name: Drivers License #:
b. Sex Race Social Security #:
c. Residence Address:
d. Date of Birth: Place of Birth:
e. Are you a citizen of the United States? The State of Louisiana? Over 18 years of Age?
f. How did you become a citizen?
g. Have you resided in the State of Louisiana continuously for a period of not less than two (2) years next preceding the
date of filing this application?
h. Have you ever been convicted of a felony under the laws of the United States, the State of Louisiana or any other state?
If “yes”, a proof of pardon and restoration of citizenship must be submitted with this application.
i. Have you ever been convicted in this state or in any other state or by the United States of soliciting for prostitution,
pandering, letting premises for prostitution, contributing to the delinquency of juveniles, keeping a disorderly place,
letting a disorderly place, or dealing in narcotics?
j. Have you had a license or permit to sell or deal in alcoholic beverages issued by the United States or any other state
revoked within five (5) years prior to this application?
k. Have you been convicted or had judgment against you involving alcoholic beverages by the state or any other state or
the United States within (5) years prior to the date of this application?
l. Have you ever been convicted for violating any of the provisions of the Beer or Liquor Laws of this State?
m. Are you married? If “yes”, is spouse eligible for permit?
n. Do you or your spouse hold interest in any establishment holding an alcohol permit other than the type applied for
herein? If “yes”, list the following:
Permit # Trade Name Address Kind of Interest % Equity
o. Have you ever used any other name than the one given herein? If yes, give details below:
Name Used Place Used Date
- - - - - - - - - - - - - - -
AFFIDAVIT
This affidavit must be signed by owner if individual ownership, authorized partner if a partnership, or authorized official if
corporate ownership. It is understood that any misstatement or suppression of fact in an application or Schedule “A” affidavit is
a ground for denial or a permit.
I swear (or affirm) that I have read each of the questions in this application and that the answers, which I have given, are true
and correct to the best of my knowledge, that I meet the qualifications and conditions set out in La. R. S. 26:279.
Subscribed and sworn to before this Signed:
Day of ,
Title:
Notary Public or Revenue Deputy Phone #:
Failure to file application before beginning business, or, for renewal permit not later than December 10 of each year will incur penalties, to include 25% of permit fee
Schedule A
To Be Answered by Owner, Partner, Manager, Agent, or Official Signing This Application.
a. Name: Driver’s License or I D #:
b. Sex Race Social Security #:
o. Residence Address:
p. Date of Birth: Place of Birth:
q. Are you a citizen of the United States? The State of Louisiana? Over 18 years of Age?
r. How did you become a citizen?
s. Have you resided in the State of Louisiana continuously for a period of not less than two (2) years next preceding the
date of filing this application?
t. Have you ever been convicted of a felony under the laws of the United States, the State of Louisiana or any other state?
If “yes”, a proof of pardon and restoration of citizenship must be submitted with this application.
u. Have you ever been convicted in this state or in any other state or by the United States of soliciting for prostitution,
pandering, letting premises for prostitution, contributing to the delinquency of juveniles, keeping a disorderly place,
letting a disorderly place, or dealing in narcotics?
v. Have you had a license or permit to sell or deal in alcoholic beverages issued by the United States or any other state
revoked within five (5) years prior to this application?
w. Have you been convicted or had judgment against you involving alcoholic beverages by the state or any other state or
the United States within (5) years prior to the date of this application?
x. Have you ever been convicted for violating any of the provisions of the Beer or Liquor Laws of this State?
y. Are you married? If “yes”, is spouse eligible for permit?
z. Do you or your spouse hold interest in any establishment holding an alcohol permit other than the type applied for
herein? If “yes”, list the following:
Permit # Trade Name Address Kind of Interest % Equity
o. Have you ever used any other name than the one given herein? If yes, give details below:
Name Used Place Used Date
- - - - - - - - - - - - - - -
AFFIDAVIT
This affidavit must be signed by owner if individual ownership, authorized partner if a partnership, or authorized official if
corporate ownership. It is understood that any misstatement or suppression of fact in an application or Schedule “A” affidavit is
a ground for denial or a permit.
I swear (or affirm) that I have read each of the questions in this application and that the answers, which I have given, are true
and correct to the best of my knowledge, that I meet the qualifications and conditions set out in La. R. S. 26:279.
Subscribed and sworn to before this
Day of , Signed:
Title:
Notary Public or Revenue Deputy
Phone #:
State of Louisiana Parish of Livingston
I, , am applying to
the Office of Alcohol and
Tobacco Control of the State
of Louisiana for a permit to
sell beverages of High &
Low alcoholic content at
retail in the Parish of
Livingston at the following
address;
Denham Springs, LA 70726
Owners:
Before me, the undersigned authority, personally came and
appeared , who, being duly
sworn, deposes and says: That she is an agent of the
Livingston Parish News, a newspaper published Sunday and
Thursday in Denham Springs, LA
That the hereto attached advertisement for liquor license ,
was published in said newspaper in its issues dated
.
Sworn and subscribed before me in Denham Springs, LA on
this day of .
Notary Public
The
Livingston
Parish
News
Livingston Parish School Board
Sales Tax Division
PO Box 1030
Livingston, LA 70754-1030
Phone (225) 686-3043 Fax (225) 686-0438
SALES AND USE TAX CLEARANCE CERTIFICATE
For Louisiana Office of Alcohol and Tobacco Control
Name of Business:
DBA:
Address:
City:
Louisiana Revised Statutes 26:78, 26:80, and 26:280 provided that the local sales tax collection agency or agencies issue a
clearance for sales tax purposes before a state Alcoholic Beverage permit(s) is issued.
This document certifies that you are current in filing and paying your local sales taxes. This sales tax clearance must be attached
to your Alcoholic Beverage Application and submitted to the Louisiana Office of Alcohol and Tobacco Control.
Livingston Parish School Board
Date Released By: Sales/Use Tax Division
TRADE NAME:
LEGAL NAME:
ACCOUNT NUMBER:
LOCATION ADDRESS:
DENHAM SPRINGS, LA 70726
This is to advise that the above taxpayer is current/delinguent (circle one) in the remittance of
sales/use tax, penalty and/or interest or Occupational License tax due to this office.
If you have any questions, please contact the Revenue Division at (225) 686-3043.
I hereby certify that the above listed taxpayer is current in filing and paying all required sales tax returns and taxes.
Local:
Signature Title Date
RESTAURANT(Only) CLASS A-R ALCOHOL PERMIT
BREAKDOWN OF FIRST SIXTY DAYS GROSS SALES
City of Denham Springs Vendor # .
Attn: Business License Dept Temporary License #
P O Box 1629 Date Temp License Issued
Denham Springs, LA 70727-1629 Date Temp License to Expire
Permit to be
issued to:
(Owner – Name of Individual, Name of Partners, or Corporation)
Trade Name (If Any)
Mailing
Address
Location
Address
Class “A-R” Retail Alcohol (High-Low) Restaurant
Requirements for issuance of “A-R” permits:
A restaurant establishment shall be defined as an establishment:
(a) Which operates a place of business whose purpose and primary function is to take orders for and
serve food items;
(b) Which serves alcoholic beverages in conjunction with meals;
(c) Which serves food on all days of operation;
(d) Which grosses sixty percent of its average monthly revenue from the sale of food, food items, and
non-alcoholic beverages;
(For new restaurant establishments without prior business experience on which to determine the
gross revenue from the sale of food, food items, and non-alcoholic beverages the Tax Office will
issue a Temporary License, which shall be valid for sixty days to allow the establishment to make
such determination.)
(e) Which maintains separate sales figures for alcoholic beverages; and
(f) Which operates a fully equipped kitchen which includes but is not limited to a range, an oven
and refrigerated storage appliances used for the preparation of uncooked foods for service and con-
sumption of such foods on the premises.
(g) Gross Sales from food & Sales from
Sales_________________________ non-alcoholic beverages_____________________ alcoholicbeverages only_______________________
I affirm that the information given on this report in Section (g) is true and correct.
_______________________________________ ____________________________ _______________
Signature of Applicant Title Date
