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Alcohol License Application Unincorporated Utah County Community Development 51 South University Ave., Suite 117, Provo, Utah, 84601 Phone (801)851-8353 Fax (801)851-8359 Applicant’ s Section I It is the applicant’ s responsibility to complete all “ Applicant” sections and to receive approval from the Health department and Sheriff’ s office before submitting this application to our office for approval. The applicant must also attach (1) a photocopy of their valid drivers license and (2) a photocopy of their current alcohol server s car d. Alcohol license fees are in addition to any regular business license fee. It is also the applicant’ s responsibility to contact the Alcoholic Beverage Compliance Division for State approval. TO THE BOARD OF COUNTY COM M ISSIONERS OF UTAH COUNTY, UTAH: Pursuant to Laws of the State of Utah and the Ordinances of Utah County, the undersigned hereby makes application for a New Application Renewal Application Class A Retail Beer License Class B Retail Beer License Single Event Beer License (Off-premise consumption) (On-premise consumption) to sell beer in Utah County outside the limits of incorporated cities and towns and herewith submits the following information which is hereby certified to be true: Person or Entity Requesting License Description of business or activity from which beer will be dispensed: Name of Business Home Address City Phone ( Business Address State ) Z ip ( ) M ailing Address City Phone ( State ) Z ip ( ) List management and ownership information: (If partnership list all partners, if corporation list all shareholders owning 10% or more of the outstanding shares, all officers and all directors; if any other legal entity list all officers, members, managers, partners, directors and all owners holding 10% or more ownership interest in such legal entity. Each listed person must also complete a separate Applicant’ s Section II. Attach additional sheets if necessary). M anager/Operator Birth Date Name/Title SS# Home Address Home Phone Birth Date SS# Home Address Driver' s License # Home Phone Driver' s License # Business Phone Business Phone Name/Title Birth Date SS# Home Address Home Phone Name/Title Birth Date Driver' s License # Home Address Home Phone Business Phone SS# Driver' s License # Business Phone For Office Use Alcohol License # Fee $ Receipt # Date Received Dates Covered by Single Event License Page 1 of 4 Alcohol License Application Unincorporated Utah County Community Development 51 South University Ave., Suite 117, Provo, Utah, 84601 Phone (801)851-8353 Fax (801)851-8359 Applicant’ s Section II Under penalty of perjury, the undersigned personally certifies, represents, and warrants as follows: That I am a citizen of the United States and over the age of 21 years. That I am of good moral character and have never been convicted of, pleaded guilty to, pleaded no contest to, nor forfeited bail on any of the following: any felony, any violation of any law or ordinance relating to the sale or use of alcoholic beverages, intoxicating liquors, drunken driving, driving under the influence, or driving while intoxicated, or of keeping a gambling or disorderly house. That I am not a member of any partnership, corporation, or legal entity, of which any partner, member, director, manager or officer lacks any such qualifications. I have complied with the requirements, and possess the qualifications specified in U tah C ounty C ode C hapter 3 and the U tah Alcoholic Beverage Control Act, including Section 32A-10-203. I agree that if a license is issued that it shall be subject to revocation as provided in the above ordinances. Respectfully Submitted, COUNTY OF UTAH) § STATE OF UTAH) being first duly sworn on oath, deposes and says: That he/she is the applicant above named, that he/she has read the foregoing application for Class A Beer Retail License Class B Beer Retail License Single Event Beer License to sell beer; that he/she knows the contents thereof; and that the statements contained therein are true. Subscribed and sworn to before me this day of A. D. , 20 Notary Public M y Commission Expires: Residing at: Page 2 of 4 . Alcohol License Application Unincorporated Utah County Community Development 51 South University Ave., Suite 117, Provo, Utah, 84601 Phone (801)851-8353 Fax (801)851-8359 UTAH COUNTY HEALTH DEPARTMENT SECTION (Applicant’ s Responsibility to Obtain Approval Signatures from Health and Sheriff) Approved This is to certify that I have personally inspected the premises described in the above and foregoing application, and find them to be in sanitary condition, and that the equipment used in storage, distribution and sale of beer complies with all the health regulations of Utah County and the State of Utah, and to be fit and proper for the uses permitted under the license applied for. UTAH COUNTY BOARD OF HEALTH By Date _________ Inspector Disapproved This is to certify that I have personally inspected the premises described in the above and foregoing Application for a license to sell Beer, and disapprove for the following reasons: UTAH COUNTY BOARD OF HEALTH By Date _________ Inspector UTAH COUNTY SHERIFF DEPARTMENT SECTION Approved This is to certify that I have personally examined the above and forgoing Application for license to sell Beer, and I believe the statements therein contained to be true; and I know of no reason why the License applied for should not be granted. Date __________ Sheriff of Utah County By Deputy Sheriff Disapproved This is to certify that I have personally examined the above and foregoing Application for license to sell Beer, and disapprove for the following reasons: Date __________ Sheriff of Utah County By Deputy Sheriff Page 3 of 4 Alcohol License Application Unincorporated Utah County Community Development 51 South University Ave., Suite 117, Provo, Utah, 84601 Phone (801)851-8353 Fax (801)851-8359 UTAH COUNTY COMMISSION SECTION ACTION ON APPLIC ATION FOR LIC ENSE TO SELL BEER:: Comments/Conditions/Reasons for Approval or Disapproval: Approved Disapproved By: Utah County Commission Date: UTAH COUNTY COMMUNITY DEVELOPMENT SECTION ACTION ON APPLIC ATION FOR LIC ENSE TO SELL BEER: Comments/Conditions/Reasons for Approval or Disapproval: Approved Disapproved By: Business License Official Date: Page 4 of 4