LIQUOR LICENSE APPLICATION

TO BE COMPTETED BY VITTAGE:

Date:

License Year

License Class:

Fee:

VIL!.AGE OF BURR RIDGE

7660

County

Line Road

Burr

Ridge,

60527

(630)

65/r-8181

LIQUOR LICENSE APPLICATION

Liquor Licenses are not transferable.

Attach a separate sheet if needed to

provide

all required information.

A. Basic Information

r. Business:

(Name

of Business)

(Describe

principal

nature ofbusiness and alcohol senice, e.g. spa, hotel, restaurant)

2. Business TlTre:

(lnaia.t"

o,orn" of *tlty

tia"oa" ,a

iraued

to and

whetier

corporation, LLC,

partnership,

association or individually owned

must complete and attach

general

information

using

supplemental Village form(s) for

your

form ofownership)

Liquor

Service

(Describe

t1pe

-spirits,

beer and wine only, wine only, etc. & days and hours

of service)

Licensed

Premises:' address

Phone and Email:

Website:

Applicant

for License

(Must

be completed by an

Olmer

Or,mer

representative)

Namez

Home Address:

Cell/Work Phone :

Relation to Business:

Date of Birth:

361117_1

Atizenship

Status:

ace

of Birth:

6. Sole

Proprietor/Manager(s): Any sole

proprietor

or manager(s) employed or contracted for

during the term of this license must also complete

FORM

fOwner/Manager

Application-

available from Villagel. Each sole

proprietor/manager

must be fingerprinted by Burr fudge

Police Departrnent. Appointments for fingerprinting

are

required

and must be at least

hours

advance. The cost of the fingerprinting is borne by the Applicant.

Questions:

List Name/Address/Phone & lncal Liquor License Numbers issuing entity, issuance

date/expiration

for Businesses

Owned

Operated

w/in Iast

Years Requiring

Liquor

License:

Has Owner,

Applicant

or any of

its managers ever had a liquor license

denied, suspended or

revoked?

If the answer is"Yes", explain:

Other

than when making an initial application for a license, has the Applicant

or any

predecessor

to or

subsidiary or corporate

parent

entity of the Applicant ever been

subject to charges, hearing

investigation

by any

jurisdiction

with respect to a liquor license?

If so,

please

state:

a) the

licensor; b) the licensee(s) by names and addresses;

c) the address ofthe licensed

premises;

and d) the names ofthe licensed establishment and the

date or dates of such revocation

nr sllsnpnslnn'

Has the Applicant or any

person

listed in this Application

or any of

your

managers ever been

found

guilty

of a

felony

or a

misdemeanor, including

but not limited to

any

gambling

offense,

concerning the sale or use of illegal drugs or any alcohol related

trafEc offense?

If so,

explain the charge, the date, the city and state where the charge was

brought, and the disposition.

This must include all findings of

guilty,

whether subsequently vacated

not

and shall specifically

include any orders of court supervision,

whetler

satisfactorily completed

not. Provide name,

charge(s) and disposition, date and

jurisdiction

involved.

Illinois Business Tax Number

6. Is the

Applicant delinquent in the

payment

ofthe Retailer's

Occupational

Tax

(sales

tax)?

If the answer

'Yes'',

explain:

361117 1

.).

Federal Employe r Identification Number

Is the Premises

be licensed within roo feet of any church or educational

program

(nearest

part

of the building) or within roo feet of any school, hospital, home for the elderly, indigents or

veterans, their spouses of children: Explain:

Provide

the name of the

person/persons

who will manage

the business, club or association

operating under this

license

(each

person

must complete Form

"Manager

Application Form")

Documentation Required:

Provide

certificate of dram

shop

policy providing

liquor license liability insurance.

Provide copy

of current

lease of

premises

[if

not ou,ned].

file

Provide copy of current

State

of Illinois Liquor License

(if

currently

hold

one, or

promptly

after

obtained).

Provide

written

explanation of any incident involving

police

intervention for

any business

you

have owned or operated in the

past

that was licensed to serve alcohol.

Must complete

and attach

general

information using

the

following

supplemental Village form(s)

for

your

form of

ownership:

FORM A

Corporation,

LLC,

Club

or Association

FORM B

Partnership or Sole Proprietorship

FORM

Manager

(s)

and

Owner Serving as

Manager

361117_1

Corporate Seal

Place Here

(lf

applicable)

AFFIDAVIT

The undersigned, as duly authorized owner

agent

for this

business/entity and

property

owner or

lessee

hereby affirms under oath that s/he is the Applicant for this

license

and that the

information

provided

this application

true and correct. I have read and

understand all applicable laws, including,

without

limitation, the requirements of the Illinois Liquor

Control

Act

(235

ILCS

5/r-r,

et seq. and the

Code

provisions

of the Burr Ridge Municipal

Code

that

govern

the sale and delivery

alcoholic

beverages. I have read and affirm

each

the statements

required at Sections 25.28 and 25.38 of the

Burr

Ridge

Municipal

Code. We agree not to violate any of

the laws of the

State

of Illinois, the

United

States of America or any of the ordinances of the Village of

Burr Ridge in the conduct of this

place

ofbusiness or its activities.

IJNDERSTAND

THAT ANY \TOII.TION

THE ABOVE

CAN

RESULT IN PENALTTES

DENIAL,

SUSPENSION, OR

REVOCATION

ANY LOCAI UQUOR LICENSE, INCLUDING THOSE

PENALTIES

CONTAINED

IN THE UQUOR

CODE OF

THE VILII.GE OF BURR RIDGE

(CFIAPTER

Zs)

I further

give

full authority and

permission

to the Village of Burr

fudge

or any agency of the Village to

conduct such

background search and credit check on the Applicant, and where

applicable, t}te officers,

shareholders,

partners,

or members of our business or entity, as the local liquor control commissioner

may

deem

appropriate, and by executing this application, Applicant agrees

to assist the local liquor

control commissioner

conducting such

background search

and credit check and agrees to cooperate

fully with such investigations. Applicant agrees to

provide

any

further

information

may

be required by

the Burr Ridge Municipal Code, as amended, or as may be lardully requested

by the

local Liquor

Commissioner

[or

Commissioner's designee], from time to time.

APPLICANT

(Authorized

Signatories)

Corporation/LLC/Association

I ndividual/Partnership/Other

President or

Manager

Owner/Authorized Representative

Secretary

Ovmer/Authorized

Representative

Subscibed and Sworn to before me this

daa of

2o1-

----Seal----

NOTARY

PUBLIC

APPLICATION APPROVED:

Local Liquor Control Commissioner

Date:

361117 1

LOCAL

LIQUOR LICENSE APPLICATION

SUPPLEMENTAL

FORMS

SPECIFY

BUSINESS ENTITY OR ORGANIZATION

General

Information Forms

(Proper

form to be completed and included

with liquor

license application dependent on tlpe ofbusiness or organization

required

Application Section

Applicant-ususrce!0pl9l9-and-attaeh

general

information using the following

supplemental

Village form(s) for

your

form of

ownership:

FORM A --

SUPPLEMENTAL

INFORMATION FORM

FOR

CORPORATION, CLUB OR

ASSOCIATION

FORM B --

SUPPLEMENTAL

INFORMATION FORM

FOR PARTNERSHIP OR

SOLE

PROPRIETORSHIP

FORM

SOLE

PROPRJETOR/

MANAGER APPLICATION FORM

362203

VILI-AGE OF

BURR. RIDGE

7660 County

Line Road

Burr

Ridge, IL

60527

(530)

6s4-8181

FORMA

SUPPLEMENTAL

INFORMATION

FORM

FOR CORPORATION,

LLC,

CLUB OR

ASSOCIATION

This

section

to be completed if the

licensee

applicant

is a corporation, LLC

(or

LLP) a club or

association.

Local Contact and Operations

Information

Association/Club Name

Corporation,

LLC,

(LLP)

Registered Company

Name

-oR--

Date of Incorporation/Organization

Date of formation

State

of Incorporation

(ifnot

Illinois

date authorized to transact business

Illinois)

Headquarters/Main

Office

Registered Address Street/Local

Address

Business Mailing

Address Association/Club Mailing Address

Phone Phone

Name/Title of

local

Contact

Name/Title of Local

Contact

Local Licensee Address l,ocal Licensee Address

Phone

A1l officers

(if

corp.);

all members

(if

LLC)

AII directors

All

persons

owning more than 25% of t}te ag$egate stock of the Corporation or ownership

interest in the Company

The

business

manager

362203

If a corporation or

lirnited liability company, complete information below for the following:

Name:

Place of birth:

Home

Address:

Work Address:

Home

Phone:

Business Email:

Driver's License

Relationship to business

percentage

of ownership:

Name:

Place of birth:

Home Address:

Work

Address:

Home Phone:

Business Email:

Driver's License

Relationship to

business

percentage

of olrrrership:

Name:

Place of birth:

Home Address:

Home Phone:

Driver's License #:

Relationship to business

percentage

of ownership:

DlolB:

Citizenship:

City/Z1p:

City

/Zip:

Work Phone:

Fax:

Position:

DlolB:

Citizenship:

City/Zip:

City

/Zip:

Work

Phone:

Position:

D/O/B:

Citizenship:

City/Zip:

CiIy

/Zip:

Work Phone:

Fax:

16220t

Position:

Fax:

Work Address:

Business Email:

1 Provide the address of the

principal

office ofthe corporation,

LLC, association or club.

Provide

a copy ofthe

certified copy of the articles of incorporation

(new

licensees,

appiicable),

certificate of organization and/or charter

Has the corporation

ever been dissolved, either

voluntarily or involuntarily?-

Explain:

Is the business a subsidiary of a

parent

corporation or organization?

If so,

state

the name, address and telephone

number

ofthe

parent

entiLy.

(The

Local Liquor

Commissioner

has the right to

require that

the

porent

entitA complete and submit thts Application.)

362203

FORM

SUPPLEMENTAL

INFORMATION FORM

FOR PARTNERSHIP OR SOLE

PROPRIETORSHIP

individual or

partnership,

complete information below

for the following:

AII owners

Any

general

partner(s),

if a limited

partnership,

any

limited

partner(s)

owning

more than

25% of the total

limited

partnership

interest

The business

manager

D/o/B:

Place

of birth:

Citizenship:

Home Address:

Work

Address:

Home Phone:

Business Email:

Driver's License #

Name:

Home Address:

Work Address:

Home Phone:

Business Email:

Driver's License #:

Relationship to business

percentage

ofownership:

City

State

/Zip:

City

/State/zip:

Work

Phone:

Fax:

Position:

DlolB:

Citizenship:

City/State/Zip:

City

/State/Zip:

Work Phone:

Fax:

362203 t

Name:

Relationshiptobusiness/percentageofownership:-

Place of birth:

Position:

Name:

D/o/B:

Place ofbirth: Citizenship:

Home Address:

Work

Address:

Home Phone:

CiW/StatelZipl

City

/State/Zip:

Work Phone:

Business Email: Fax

Driver's License

#: Position:

Relationship to business

percentage

of ownership:

1 Provide the address of the

principal

or main office of the

partnership

or owner.

2 Has the

business

ever been dissolved or bankrupt, either

voluntarily

or involuntarily?

362203 I

FORM C

MANAGER APPLICATION

FORM

(Includes

Ovuner(s) serving

in managerial capacity)

Pursuant to Section

25.o3 of the Burr Ridge Municipal Code,

provide

the following:

r. Basic

Identffication.

Ciry

lState/Zi

C. Home

Phone No.: Cell:

Work Phone

No.:_Pager

Email:

Home Address:

Emolover:

Male:

FemaLe: Date of Birth

Place of Birth:-Citizenship Status:-

If naturalized citizen, time and

place

of naturalization:-

Driver's

License Number:

Vehicles

owned

by registration numbers

L. Otlrer home addresses

within

the

last

years:

Please use additional sheets i.f needed

Address

City

State/Zip

(Dates)

From/To

Address

City

362203-t

State/Zip

(Dates)

From/To

Businesses owned or operated

within the last

years

that required a liquor license:

Please use additional

sheets ifneeded.

Address City/State/Zip Phone Number

Dates Ouned/Managed

From to

Municipality

issuing liquor license:

Address City/State/Zip

Phone Number

Describeanyliquorlicenseincidentrequiringpoliceintervention:-

General

Information

Have

you

ever been convicted of

either a misdemeanor or a felony and/or are

you

disqualified to

receive a license by reason of any matter or thing contained

this

Burr

Ridge Liquor

Control

chapter of t}re Burr

Ridge Municipal

Code, the

laws

of this

state, or

other ordinances of the

Village?

Ifso, exp

B I understand and agree

that I am required to and shall require all agents and employees

to testify

(subject

to constitutional limitations) at any hearing that may be called by the

Village or any of its committees, commissions, boards, or agencies, or the

local Liquor

Control Commissioner,

relating,

directly or

indirectly,

to any events or occurrences of

which

they may have

knowledge

arising out of their

position

as officer, agent or

employee.

addition, a

statement

acknowledging such

requirement

and indicating that

the manager has informed all

agents and

employees,

and

has

made the same a condition

of empioyrnent for all employees.

362203 1

Business Name

AFFIDAVTT

The undersigned, as manager/owner

manager for hereby

affirms under oath that the

information

provided

in this Application is true

and

correct. I have read

and

understand all applicable laws, including,

without

limitation, the

requirements

of the

Illinois

Liquor Control

Act

(zgS

ILCS

5/t-r,

et seq. and the Code

provisions

of the Burr Ridge Municipal Code

that

govem

the sale and delivery of alcoholic beverages. I have

read

and affirm each of the statements

required at

Sections

25.28 and 25.38 of the

Burr Ridge Municipal

Code.

agree

not

violate any of

the laws of the State of

Illinois, the

United States

of America or any of the ordinances of the Village of

Burr Ridge

the conduct

this

place

ofbusiness or its actMties.

I UNDERSTAND

THAT ANY \TIOLATION OF THE ABOVE CAN RESULT IN PENALTIES OF DENIAL,

SUSPENSION, OR

REVOCATION

ANY LOCAI LIQUOR LICENSE, INCLUDING THOSE

PENALTIES CONTAINED

IN THE LIQUOR CODE OF THE \'ILIAGE OF BURR

RIDGE

(CHAPTER

2s)

I further

give

fuIl authority and

permission

to the Village of Burr Ridge or any agency of the

Village to

conduct such

background search and credit check on

as the

local liquor

control

commissioner may

deem appropriate, and by executing

this application, I agree to assist the

local liquor

control

commissioner

in conducting such background search and credit

check and agree to cooperate fully

with

such

investigations. I agree to

provide

any

further information as may be required by the Burr Ridge

Municipal

Code,

as amended, or as

may

larr{ully requested by the tocal Liquor Commissioner

[or

Commissioner's

designee], from time to time.

MANAGER/O\4NER

MANAGER

Subscibed

and stDorn to before me this daa

201

Seal

NOTARYPUBLIC

362203 I