HomeMy WebLinkAboutForm - Application for Special License Class 10 packet (2026) FillableC.Kimo Alameda, Ph.D.Mayor
William V. Brilhante, Jr.Managing Director
Merrick NishimotoDeputy Managing Director County of Hawai'i
Department of Liquor Control
Hilo Lagoon Centre, 101 Aupuni Street, Unit 230, Hilo, Hawai'i 96720-4261
(808)961-8218 • Fax (808) 961-8684 E-Mail: cohdlc@hawaiicounty.gov
Stacie T. Waltjen Director
PROCEDURES TO BE FOLLOWED BY AN APPLICANT FOR A SPECIAL LICENSE
A special license allows the licensee to sell liquor on a daily basis, from one to a maximum of three consecutive days, for an event open to the public. The special licensee is under the
same duty and obligation as a permanent licensee to observe and enforce the liquor laws. An event that is more than three consecutive days will require an additional application.
Applicants are required to be: (a) a non-profit organization (tax-exempt); (b) political candidate or: (c) a political party.
1 . The application shall be filed by an authorized signatory of the non-profit
organization; or the political candidate, or his or her authorized signatory of the campaign committee, or an authorized signatory of a political party.
2.Submit:
A.Application.
B.Assumption of Responsibility (Form attached).
C.List of the names of the officers, office held, and address.
D.TO AUCTION WINE: Copy of Articles of Organization or By-Laws to verify that
the entity is an educational or charitable organization.
E.A floor plan of the premises with details as to the locations of the bar(s),entrances, exits, restroom facilities, stage or other entertainment areas, and
barricades when applicable.
F.Letter of consent from the landlord for the sale, service, and consumption ofliquors, including an acknowledgement that the premises is subject to inspection.
G.If State or County facility, permit from appropriate state or county agency.
H.State Tax Clearance certificate (Form A-6 attached), or Certificate of VendorCompliance. (www.ehawaii.gov).
I.IRS non-profit determination letter.
Hawai'i County is an Equal Opportunity Provider and Employer
J. Name of person in active charge of the premises who shall ensure compliance to
the liquor laws.
K. List of servers.
3. Submit closing report on form prescribed by the commission within 30 days of the
termination of liquor license.
4. You may purchase liquor from a liquor wholesaler or a Class 4 Retail Dealer license.
Purchase of liquors from military posts for resale is illegal.
C.Kimo Alameda, Ph.D.Mayor
William V. Brilhante, Jr.Managing Director
Merrick NishimotoDeputy Managing Director County of Hawai'i
Department of Liquor Control
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
Stacie T. Waltjen Director
ASSUMPTION OF RESPONSIBILITY UNDER A SPECIAL LICENSE
I, the undersigned, have been instructed and am fully aware and will be responsible for the
exercise of the liquor license issued to
as governed by Hawai'i County Rules and
Regulations and State Statutes. I shall also instruct all members of the association of the rules and
regulations pertaining to the sale of liquor under the special license.
(signature)
(date)
Hawai'i County is an Equal Opportunity Provider and Employer
DEPARTMENT OF LIQUOR CONTROL COUNTY OF HAWAl'I Hilo Lagoon Centre, 101 Aupuni St., Unit 230, Hilo, Hawai'i 96720 * Phone: (808)961-8218 * Fax: (808)961-8684E-Mail: cohdlc@hawaiicounty.gov
APPLICATION FOR CLASS 10. SPECIAL LICENSE
Pursuant to Rule 3-1-K, of the Rules and Regulations of the Liquor Commission of the County of Hawai'i, application is hereby made for a special license as follows:
APPLICANT:
ADDRESS:
PHONE: FAX: ________ EMAIL: _________ _
EVENT DATE(S): _______ _ EVENT TIME: START ______ END ____ _
KIND OF ENTERTAINMENT: (strip tease/lap dancing/exotic entertainment prohibited) -------------
EVENT ADDRESS:
APPLICANT IS NON-PROFIT (Tax-Exempt): □Corporation □Unincorporated Association□Political Party □Educational Organization □Political Candidate□Charitable Organization
KIND OF LICENSE: □Beer □Beer and Wine □General (Distilled Spirits, Beer & Wine)
AUCTION OF WINE: (Limited to educational or charitable organizations only; attach By-Laws) □No.D Yes, limited to three cases of wines, with each case containing not more than 9 liters.
Number of Cases Brands: __________________ _
SUBMIT: •Rental agreement and consent from landlord for the sale, service and consumption of liquors, including acknowledgement that the premises issubject to investigation; or •If State or County facility, permit from appropriate County or State agency.•Attach list: Name of officers, office held, and address.•Assumption of Responsibility (Form attached).•State tax clearance certificate (Form A-6 attached), or Certificate of Vendor Compliance. www.ehawaii.gov •IRS non-profit determination letter•Sketch of the premises indicating consumption area, bar locations, entrances, exits, and restrooms.•Attach list of servers.•Name of person in active charge of the premises who shall ensure compliance to the liquor laws:
* Attach Copy of By-Laws of Organization
The undersigned shall assume responsibility to ensure that the sale, service, and consumption of intoxicating liquors shall be in compliance to the liquor laws.
By _________________ _
Print Name _____________ _
Title _______________ _
Date ________________ _
FOR DEPARTMENT USE The application for a special license has been approved and is issued subject to the following conditions: 1.Time of event shall be between 8:00 a.m. to 12:00 midnight.
2.The license shall be posted at the site.3.Conditions imposed by the Liquor Commission: _______________________ _
By ______________ _ Director Date ________________ _ APPLICATION NO: ____ _
Revised: 1/19/2024 Ratified by the Liquor Commission on: ____ _
Hawai'i County is an Equal Opportunity Provider and Employer
FORM A-6
(REV. 2022)
STATE OF HAWAII -DEPARTMENT OF TAXATION TAX CLEARANCE APPLICATION
Form A-6 can be filed electronically OR for all state, city, or county government contracts, may be obtained through Hawaii Compliance Express. See Instructions. (NOTE: References to "married" and "spouse" are also references to "in a civil union" and "civil union partner," respectively.)
1. APPLICANT INFORMATION: (PLEASE TYPE OR PRINT CLEARLY)
Applicant's Name
Address
City/State/Postal/Zip Code
OBA/Trade Name
2. TAX IDENTIFICATION NUMBER:
HAWAII TAX 1.0. #
FEDERAL EMPLOYER I.D. # (FEIN) _ _ _ ______ _
SOCIAL SECURITY# (SSN) _ _ _ _ _ _ ___ _
3. APPLICANT IS A/AN: (Check only ONE box)
0 CORPORATION
0 INDIVIDUAL
0 S CORPORATION
0 PARTNERSHIP
0 TAX EXEMPT ORGANIZATION
0 ESTATE O TRUST
0 LIMITED LIABILITY COMPANY 0 LIMITED LIABILITY PARTNERSHIP
D Single Member LLC disregarded as separate from owner; enter owner's FEINISSN --------□Subsidiary Corporation; enter parent corporation's name and FEIN _____________ _
4. THE TAX CLEARANCE IS REQUIRED FOR: (MUST check at least ONE box)
0 CITY, COUNTY, OR STATE GOVERNMENT CONTRACT IN HAWAII *
0 REAL ESTATE LICENSE O CONTRACTOR LICENSE
0 LIQUOR LICENSE
0 FINANCIAL CLOSING
FOR OFFICE USE ONLY
BUSINESS START DATE IN HAWAII
IF APPLICABLE I I
HAWAII RETURNS FILED
IF APPLICABLE
20 ___ 20 __ 20 __
STATE APPROVAL STAMP (State Approval QR Code)
vo1,1 may i;can the QR code to authenticate this tax clearance
IRS APPROVAL STAMP
(City, County, or State Government Contract)
0 PROGRESS PAYMENT
0 FEDERAL CONTRACT
0 OTHER
0 PERSONAL
0 SUBCONTRACT
0 HAWAII STATE RESIDENCY
0 LOAN ------------------------*IRS APPROVAL STAMP IS ONLY REQUIRED FOR PURPOSES INDICATED BY AN ASTERISK.
A6_1 2022A 01 V!D01
5. DECLARATION -I declare that I am either the taxpayer whose name is shown on line 1, or a person authorized under section 23·1-15.6 or 231-15.7, HRS, to sign on
behalf of the taxpayer. If the request applies to a joint return. at least one spouse must sign. I declare to the best of my knowledge and belief, that this is a true, correct,
and complete form, made in good faith pursuant to Title 14 of the HRS, and the rules issued thereunder
SIGNATURE DATE TELEPHONE FAX
PRINT NAME PRINT TITLE: Corporate Officer, General Partner or Member, Individual {Sole Proprietor), Trustee, Executor
POWER OF ATTORNEY. If submitted by someone other than a Corporate Officer, General Partner or Member, Individual (Sole Proprietor), Trustee, or Executor, a power of attorney (State of Hawaii, Department of Taxation, Form N-848) must be submitted with this application. If a Tax Clearance is required from the Internal Revenue Service, IRS Form 8821, or IRS Form 2848 is also required. Applications submitted without proper authorization will be sent to the address of record with the taxing authority. UNSIGNED APPLICATIONS WILL NOT BE PROCESSED. PLEASE TYPE OR PRINT CLEARLY -THE FRONT PAGE OF THIS APPLICATION BECOMES THE CERTIFICATE UPON APPROVAL. SEE PAGE 2 ON REVERSE & SEPARATE INSTRUCTIONS. Failure to provide required information on page 2 of this application or as required in the separate instructions to this application will result in a denial of the Tax Clearance request.
(Page 1 of 2) ID NO 01
FORM A-6
(REV. 2022)
APPLICANT'S NAME FROM PAGE 1 _____________ _
6. CITY, COUNTY, OR STATE GOVERNMENT CONTRACT: □ Bid/Entering Into D Ongoing Contract [] Completion/Final Payment
For completion/final payment of contract, provide the name, agency, and telephone number of the contact person at the State or County Agency.
Name:______________ Agency:_____________ Telephone Number: __________ _
7. LIQUOR LICENSING: D Initial D Renewal D Transfer-Seller D Transfer-Buyer D Special Event
8. CONTRACTOR LICENSING: □Initial □ Renewal
9. STATE RESIDENCY: DATE APPLICANT ARRIVED OR RETURNED TO HAWAII
10.ACCOUNTING PERIOD: □Calendar year □Fiscal year ending (MM/DD)
11. TAX EXEMPT ORGANIZATION:
A)Provide the Internal Revenue Code section that applies to your exemption (e.g., 501 (c)(3)): _______ _
B) Does your organization file federal Form 990-T, Exempt Organization Business Income Tax Return? □YES
C) Is your organization required to file federal Form 990, Return of Organization Exempt From Income Tax, or
federal Form 990-EZ, Short Form Return of Organization Exempt From Income Tax? D YES D NO
If "YES," your organization is required to obtain a general excise tax license. Go to line 13.
If "NO," go to line 110.
D) Does your organization have fundraising income? □ YES □ NO
If "YES," your organization is required to obtain a general excise tax license.
□NO
12.INDIVIDUAL: Spouse's Name _______________________ SSN _____________ _
13. IF YOU QQ..NQI HAVE A GENERAL EXCISE TAX LICENSE AND REQUIRE A TAX CLEARANCE:
A) Description of your firm's business ______________________________________ _
B)Has your firm had any business income in Hawaii?
C) Has your firm had an office, inventory, property, employees, or other representatives in the State of Hawaii?
D) Has your firm provided any services within the State of Hawaii (e.g., servicing computers, training sessions, etc.)?
E)In the current or preceding calendar year has your firm had gross income of $100,000 or more, or entered into
200 or more separate transactions attributable to Hawaii in any of the following, or combination of the following,
activities? a) Tangible property delivered in Hawaii; b) Services used or consumed in Hawaii; or c) Intangible property
used in Hawaii.
Note: If you answer "Yes" to any of the above questions, you are required to apply for a general excise tax license.
FILING THE APPLICATION FOR TAX CLEARANCE
□YES □NO□YES □NO□YES □NO
□YES □NO
The completed application may be mailed, faxed, or submitted in person to the Department of Taxation, Taxpayer Services Branch. Form A-6 may be used to get both a state tax clearance and a federal tax clearance. If you need to get a tax clearance from both agencies, you should submit a separate Form A-6 to each agency.
State Department of Taxation Taxpayer Services Branch P.O. Box 259 Honolulu, HI 96809-0259
Telephone No.: 808-587-4242 Toll Free: 1-800-222-3229 Fax No.: 808-587-1488 or 830 Punchbowl Street Honolulu, HI 96813-5094
Internal Revenue Service W&I Field Assistance 300Ala Moana Blvd., #1-128 Honolulu, HI 96850
(By appointment only. To make an appointment, please call 844-545-5640.)
Automated phone messaging: 808-466-6011 Fax No.: 855-877-0789
Applications are available at Department of Taxation and IRS offices in Hawaii, and may also be requested by calling the Department of Taxation on Oahu at 808-587-4242 or toll-free at 1-800-222-3229. The Tax Clearance Application, Form A-6, can be downloaded from the Department of Taxation's website at tax.hawaii.gov.
(Page 2 of 2)
DEPARTMENT OF LIQUOR CONTROL
COUNTY OF HAWAI'l
INSTRUCTIONS FOR SELLING LIQUOR UNDER A SPECIAL LICENSE
The following rules have been compiled for your information and assistance. While the
list covers most of the important provisions of the liquor laws, it is not a complete
summary of all laws and regulations applicable to a special license. Keep this
information handy during the term of your license and feel free to call the Department at
808) 961-8218 for any assistance you may need.
1. Don't allow other liquor on the premises except that which is covered by your
license.
2. Don't sell or permit the consumption of liquor on the licensed premises before
8:00 a.m. and after 12:00 midnight.
3. Don't allow liquor to be removed from the premises for consumption. Patrons
must drink their liquor on the premises.
4. Don't sell more than two drinks of liquor to the same person at one time.
STACKING" of drinks is not allowed.
5. Don't allow any person under the age of 18 to be connected in any way with the
sale or service of liquor.
6. Don't sell or furnish liquor to any person under the age of 21, even though that
person may be married. Minors cannot consume or even possess liquor.
7. Don't sell or furnish liquor to an intoxicated person.
8. Don't allow patrons to become disorderly or to gamble or engage in other
unlawful activities. The licensee must immediately prevent or suppress any
violent, quarrelsome, disorderly, lewd, immoral, or unlawful conduct of any
person on the premises.
9. Don't allow an intoxicated person or disorderly person to remain on your
premises. Even if you do not furnish said person with liquor, it is against the law
for said person to be or remain on your premises.
10.Don't allow workers/volunteers (i.e. serving, furnishing, providing, preparing
liquor or food) to consume liquor.
11.Don't fail to admit into your premises any liquor control investigator, member of
the Liquor Commission, or police officer who may desire to inspect the premises
in the course of their official duties.
Hawaii County is an Equal Opportunity Provider and Employer
Rev. 3.21.2023