HomeMy WebLinkAboutForm - Application for Liquor License - Renewal (fillable)DEPARTMENT OF LIQUOR CONTROL, COUNTY OF HAWAI‘I HILO LAGOON CENTRE, 101 AUPUNI STREET, UNIT 230, HILO, HAWAI‘I 96720-4261 PHONE: (808) 961-8218 FAX: (808) 961-8684 E-MAIL: cohdlc@hawaiicounty.gov
APPLICATION FOR RENEWAL OF LIQUOR LICENSE
TO THE LIQUOR COMMISSION OF THE COUNTY OF HAWAI‘I:
THE UNDERSIGNED hereby makes application for renewal of Liquor License No. :
CLASS: CATEGORY: KIND: (Wholesale, Retail, Dispenser, Club, etc.) (A, B, C, D) (General, Beer and Wine, Beer, Etc.)
as defined by law and, and as a basis for the renewal of such license, makes the following statements.
1.That applicant’s full name is:
2.That applicant will do business under the name of:
3.That applicant is a (an):
(Individual, Partnership, Corporation, Limited Liability Corporation, Limited Liability Partnership, Unincorporated Association)
4.That applicant’s mailing address is:
PHONE: FAX: E-MAIL:
5.That the following are all the officers and directors of the applicant corporation:
OFFICERS AND TITLES DIRECTORS
STOCKHOLDERS / MEMBERS (Owning shares of 25% or more)
Name Percent Name Percent
6.That the following are all the members of the applicant partnership, LLC, LLP, or Unincorporated Association:
NAMES AND TITLES AGE (YRS) ADDRESS
_
_
7.That no person other than the applicant named herein shall have any interest in the business affected by this application without prior approval of such interest by the Liquor Commission.
8.That no liquor license shall be issued to an applicant who has had any liquor license revoked less than two years previous to the date of this application or has any outstanding or overdue payments to the Department of Liquor Control.
9.That applicant is familiar with the provisions of Chapter 281, Hawai‘i Revised Statutes, and the Rules and Regulations of the Liquor Commission.
10.That prior to issuance of the license, applicant will submit a certificate from the State Director of Taxation that the applicant does not owe any delinquent taxes or an installment plan approved by the Department of Taxation, and proof of liquor liability insurance of not less than one million dollars.
11.That all persons named herein are not less than twenty-one years of age and are not persons who have been convicted of a felony and not pardoned.
Hawai‘i County is an Equal Opportunity Provider and Employer
12. I attest, under penalty of law, that the information provided is true and correct.
DATE:
To be signed by individual, officer, partner, or member.
Name of Applicant:
Trade Name (dba):
By (print name):
Signature (type name if submitting electronically):
Title: