PROCEDURES FOR OBTAINING A PEORIA COUNTY LIQUOR LICENSE

1 PROCEDURES FOR OBTAINING A PEORIA COUNTY LIQUOR LICENSE Before completing the application, you must make sure that the building is properly zoned for this purpose. This may be done by going to the Department of Planning & Zoning, Room 301, in the Courthouse. The completed Zoning Report must be submitted to the County Clerk s Office before issuance of the License. For further information on Zoning Reports, call 672-6915. COMPLETION OF THE APPLICATION 1. Everyone must complete the first two pages of the application. 2. Individual Business Owners must complete Schedule I. If the establishment is going to be managed by someone other than the business owner, then the manager must complete Schedule II. 3. If the business is going to be a Partnership, then Schedule III must be completed by all partners. 4. If the business is going to be a Corporation, then Schedule IV must be completed with all appropriate information. 5. If the applicant does not own the property in which the business will be operated, the Property Owner must complete the Request for Site Approval form. 6. Everyone must complete the Statement of Financial Disclosure form. 7. Everyone must submit a floor plan of the building in which the business will be operated. 8. Everyone must have all forms (such as the applicable schedule(s), Request for Site Approval, etc.) properly notarized. NOTICE: Please note that the County collects Social Security Numbers in conjunction with Liquor License Applications in order to carry out its responsibilities under the Illinois Liquor Control Act of 1934 (235 ILCS 5/1-1) and the Peoria County Alcoholic Liquor Ordinance. AFTER COMPLETION OF APPLICATION 1. Submit the completed application to the County Clerk s Office, Room 101, Peoria County Courthouse, with the non-refundable application fee of $300.00. Payment of the application fee must be made by Cashier s Check, Certified Check, Money Order, or Cash. Uncertified personal or business checks will not be accepted. The application fee is in addition to applicable license fees. 2. Complete the AFFIDAVIT OF BENEFICIAL OWNERSHIP OF LICENSED LIQUOR ESTABLISHMENT. This replaces the credit check that was formerly done by the State s Attorney. 3. The applicant must obtain any required Food & Drink license from the Peoria City/County Health Department before a liquor license will be issued or renewed. The Health Department is located at 2116 N. Sheridan Road, Peoria, IL 61604. To learn the correct procedures to obtain a Food & Drink license, call (309) 679-6173.

2 4. All applicants must have a criminal background check. Location: Peoria County Sheriff's Office, Peoria County Courthouse 324 Main Street, Room B-20, Peoria, Illinois Hours: Monday - Friday (Excluding County Holidays) 9:00-11:00 AM and 1:00-4:00 PM Please call the Peoria County Sheriff's Office at (309)672-6040, if you have any questions. ISSUANCE OF THE LICENSE 1. After a complete application and all pertinent documentation have been submitted, the application folder including the liquor license is submitted to the Peoria County Liquor Commissioner. 2. The applicant will be notified upon the approval of the license. All applicable license fees must be paid before any license is issued or renewed. 3. A Peoria County Liquor License in no way relieves the applicant from any requirements imposed by State Law. A State Liquor License must be obtained by the applicant. For more information regarding the State s requirements, contact: Illinois Liquor Control Commission 300 West Monroe Springfield, IL 62706 Ph (217) 782-2136 If you have any additional questions, please call the Peoria County Liquor Commissioner at (309) 672-6056.

3 SCHEDULE LICENSE OF CLASSES & SUBCLASSES CLASSES CLASS A- Tavern Sale & consumption on premises and retail sales $975.00 CLASS B- Restaurant Sale & consumption on premises and retail sales. (At least 50% of gross revenue from sale of food) $975.00 CLASS C- Package Liquors Sale in packages only not for consumption on premises $850.00 CLASS D - Hotel Sale & consumption on premises $975.00 CLASS E- Club Sale & consumption on premises (not-forprofit organizations only) $775.00 CLASS F- Tavern or Restaurant BEER & WINE ONLY. Sale & consumption on premises and retail sales $775.00 CLASS GG -Veterans Veterans Organization Organization Sale & consumption on premises $200.00 CLASS H- Business operating as public accommodation (bottle club) Consumption on premises $975.00 CLASS I - Assembly hall, Sale & consumption on premises stadium or privately Golf course: sale and consumption owned public golf course include exterior grounds $975.00 CLASS J - Golf Course Sale & consumption on premises and exterior grounds BEER & WINE ONLY $775.00 CLASS K- Rental Hall when sold by operator of hall Off premises when food is catered by licensee Sale & consumption on premises $775.00 CLASS L - Catering Sale of alcohol is incidental to food service Sale of alcohol is incidental to food service $775.00

4 SUBCLASSES Annual Per Event SUBCLASS 1 - Live Entertainment, DJ's and Karaoke $250.00 N/A SUBCLASS 2 - Outdoor Beer Garden/Café with Live Entertainment, DJ's and Karaoke $250.00 N/A SUBCLASS 3 - Teen Night (1/week Sept-May) $275.00 $45.00 (2/week June-Aug) (Anyone holding ten nights in one license year (benefits excluded), shall be deemed to have paid for an annual license) SUBCLASS 4 - Wine Tasting Events $275.00 $45.00 CLASS C ONLY Maximum 12 wine tasting events per license year (Anyone holding ten wine tasting events in one license year shall be deemed to have paid for an annual license) SUBCLASS 5 - Allows holder of Class A license to permit persons under age of 18 to be present subject to certain restrictions $275.00 NA SUBCLASS 6 - Wine, Distilled Spirits or Beer tasting Events - CLASS C ONLY - t more than three consecutive days NA $45.00 per day SUBCLASS 7 - Retail sale of alcoholic beverages in assembly halls, stadiums or privately public golf courses in temporary locations NA $65.00 per temporary location owned TEMPORARY NA $65.00 per day

5 SEE ORDINANCE FOR QUALIFICATIONS AND RESTRICTIONS Chapter 3, Peoria County Code Instructions for Completing the PEORIA COUNTY LIQUOR LICENSE APPLICATION All applicants must complete: Liquor License Application Site Information Sheet Statement of Financial Disclosure Affidavit of Beneficial Ownership Scale Drawing of the Premises showing: 1) all interior rooms and areas, labeled as to use; 2) all points of ingress and egress, both interior and exterior; and 3) stairs IN ADDITION TO THE ABOVE: Individual applicants must complete: Schedule I Managers, if not the individual applicant, or if the applicant is a corporation, must complete: Schedule II Partnerships must complete: Schedule III Corporations must complete: Schedule II (for manager) Schedule IV If the Applicant Leases the Premises, the applicant must complete: Request for Site Approval If the Application includes a request for a Supplemental Liquor License, the applicant must also complete: A Site Plan Return the completed application to the Office of the County Clerk. A non-refundable fee of $300.00 must accompany the application. personal or business checks will be accepted. Payment must be made by cashier s check, certified check, money order or cash. Your completed application will be given to the Liquor Commissioner after we receive all documentation listed on the "DOCUMENTS REQUIRED" listing (page 21 of this application).

6 LIQUOR LICENSE APPLICATION CLASS: SUBCLASS: 1. Name under which business is to be conducted: 2. Address of the place of business for which application is made: 3. Will this business be conducted by a manager or agent? Yes (If Yes, Schedule II must be completed) 4. Has any manufacturer, importing distributor, or distributor directly or indirectly (a) paid or agreed to pay for this license; (b) advanced to you money or anything else of value or any credit (other than merchandising credit in the ordinary course of business for a period not to exceed 90 days); or (c ) obtained any interest in the ownership, conduct or operation of the place of business? Yes If the answer is yes, give particulars: 5. Are you, or is any other person directly or indirectly interested in the place of business, a law enforcing public official? (Also include all managers, partners if a partnership and if a corporation, all corporate officers, managers and directors and all stockholders owning in the aggregate more than five (5) percent of the stock of the corporation) Yes If yes, describe the office of position held: 6. Has a Federal Gaming Device stamp or Federal Wagering Stamp been issued by the Federal Government for the current tax period to any person or partnership listed in this application or to any officer, manager or director of any corporation listed in this application or to any stockholder owning in the aggregate more than twenty (20) percent of the stock of any corporation listed in this application? Yes 7. Has a Federal Gaming Device stamp or Federal Wagering Stamp been issued by the Federal Government for the current tax period for the premises which is the subject of this application? Yes 8. Do you have a current and valid Food & Drink License as provided by the Peoria City/County Health Department? Yes Give number of such license: of Applicant Social Security Number Phone Number

7 SITE INFORMATION To be completed by Applicant 1. Mailing address to which information concerning license should be mailed: 2. Do you own or lease the premises of the place of business for which you are applying? Own Lease 3. If you lease the premises, when does the lease expire? note: A current and signed valid copy of the lease must be on file with the County Clerk. If such a copy is not on file, it must accompany this application. The Request for Site Approval must also be completed. 4. Does the premises have two separate and private lavatories, one for men and one for women? Yes 5. Are the premises within 100 of any church, school, hospital, home for the aged or indigent persons, nursing home or home for veterans, their wives or children or any military or naval station? Yes 6. If the answer to #5 is yes, specify whether the business is (a) a hotel offering restaurant services, (b) a regularly organized club, (c) a restaurant or (d) a food shop or other place where sale of alcoholic liquor is not the principal business: Give exact date when business was established: 7. If you are also applying for a supplemental liquor license: a. State the current and proposed use of the property (e.g. tavern, or tavern and restaurant, or tavern with living quarters on the second floor, etc ) b. List all other food or liquor licenses held for the subject property: c. List the hours of operation, specifically the hours during which a beer garden will be open to patrons or live entertainment will be provided: d. State whether the property is served by public water or a well and whether it is served by public sewer or a septic system: e. Attach a site plan which shows: i. Layout of all existing and proposed buildings and structures onsite; ii. The traffic circulation pattern; and iii. The parking and loading areas. Continued on next page

8 SITE INFORMATION CONTINUED f. Are you planning to build any additional improvements (building, beer gardens, decks, accessories, etc.) upon the property? Yes. If yes, describe such improvements:

9 REQUEST FOR SITE APPROVAL (To be used if the Applicant is leasing the premises) 1. Name and address of Property Owner (not Applicant): 2. Street address of property requested for approval: 3. Legal description of property (Attach legal description if necessary): 4. Do you intend to lease this property to another party to be used for the sale of alcoholic liquor? Yes. If yes, state name and address of the intended lessee (should be same as person completing page one of the Liquor License Application): 5. Are there any improvements such as buildings, beer gardens, decks, accessories etc., presently on the property? Yes. If yes, describe such improvements: 6. Are you planning to build any additional improvements such as buildings, beer gardens, decks, accessories, etc., upon the property? Yes. If yes, describe such improvements: 7. What type of sale of alcoholic beverages will be conducted on the premises? (i.e., tavern, package liquors, club, etc): 8. Is the property located in a residential section? Yes 9. Read and sign affidavit below. I (we) swear/affirm that I (we) am (are) the owner (s) of the property described in this application and that the statements contained herein are true and correct. of Property Owner of Property Owner of Property Owner of Property Owner Subscribed and sworn to before me this day of, 20. tary Public

10 SCHEDULE I INDIVIDUAL 1. Name (including maiden name or any alias used): 2. Residence address: 3. How long have you resided in Peoria County? List all addresses at which you resided in the past five years: 4. of Birth: Place of Birth: 5. Are you a citizen of the United States? Yes 6. Give character of business to be conducted at place to be licensed: 7. How long have you been engaged in business of this character? (On a separate sheet, include a list of locations and inclusive dates during which you have been in said business.) 8. Have you made application for a license to sell alcoholic liquor at retail on premises other than described in this application to Peoria County or to any other state or political subdivision thereof? Yes If yes, please give date, location, and disposition of each such application: 9. Has any liquor license held by you been revoked or suspended? Yes. If yes, state reasons for the revocation or suspension: 10. Have you ever been convicted of: A felony? Yes Being a keeper of a house of ill fame? Yes Prostitution? Yes Pandering? Yes Gambling offense? Yes Other crime opposed to decency and morality? Yes If you answered yes to any of the above convictions, please give the dates, locations, and dispositions of any such convictions: 11. Have you ever been convicted of a violation of any federal or state law concerning the manufacture, possession or sale of alcoholic liquor? Yes Have you ever forfeited your bond to appear in court to answer charges for any such violation? Yes If you answered yes to either question, please give the dates, locations and dispositions of any such convictions or forfeitures: Continued on next page

11 Schedule I continued 12. Have you received treatment for alcoholism or any drinking problem? Yes Have you been involved in any incident involving the police, including traffic, in which you were intoxicated? Yes If you answered yes to either question, please give the date, location, and result of any such treatment or incident: 13. Have you ever been involved in any battery, assault, fight, or public disorder? Yes If you answered yes, please give the date, location and disposition of any such incident: 14. Read and Sign the Affidavit below. AFFIDAVIT OF INDIVIDUAL I certify that I am the sole owner of the business described in this application, and that the premises specified in this application comply in all respects with the requirements of the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of the County of Peoria. I am qualified to obtain a license under the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of the County of Peoria. I swear that I am fully informed as to the provisions of the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of Peoria County, and that I will not violate any of the laws of the State of Illinois or any of the ordinances of Peoria County in the conduct of the place of business described herein and that the statements contained in this application and any schedules and other attachments made a part of this application are true and correct. of Applicant of Applicant Social Security Number: Drivers License Number: Social Security Number: Drivers License Number: Subscribed and sworn to before me this day of 20. tary Public

12 SCHEDULE II - MANAGER (If Manager is a person other than the applicant, or if the applicant is a Corporation). 1. Name (including maiden name or any alias used): 2. Residence address: 3. How long have you resided in Peoria County? List all addresses at which you resided in the past five years: 4. of Birth: Place of Birth: 5. Are you a citizen of the United States? Yes 6. Give character of business to be conducted at place to be licensed: 7. How long have you been engaged in business of this character? (On a separate sheet, include a list of locations and inclusive dates during which you have in been said business.) 8. Have you made application for a license to sell alcoholic liquor at retail on premises other than described in this application to Peoria County or any other state or political subdivision thereof? Yes If yes, please give the date, location, and disposition of each such application: 9. Has any liquor license held by you been revoked or suspended? Yes If yes, please state the reasons for the revocation or suspension: 10. Have you ever been convicted of: A felony? Yes Being a keeper of a house of ill fame? Yes Prostitution? Yes Pandering? Yes Gambling offense? Yes Other crime opposed to decency and morality? Yes If you answered yes to any of the above convictions, please give the dates, locations, and dispositions of any such convictions: 11. Have you ever been convicted of a violation of any federal or state law concerning the manufacture, possession or sale of alcoholic liquor? Yes Have you ever forfeited your bond to appear in court to answer charges for any such violation? Yes Continued on next page

13 Schedule II continued If you answered yes to either question, please give the dates, locations and dispositions of any of such convictions or forfeitures: 12. Have you received treatment for alcoholism or any drinking problem? Yes Have you been involved in any incident involving the police, including traffic, in which you were intoxicated? Yes If you answered yes to either question, please give the date, location, and result of any such treatment or incident: 13. Have you been involved in any battery, assault, fight, or public disorder? Yes If you answered yes, please give the date, location and disposition of any such incident: 14. Read and Sign the Affidavit below. AFFIDAVIT OF MANAGER/AGENT I certify that I am the manager/agent of the business described in this application, and that the premises specified in this application comply in all respects with the requirements of the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of the County of Peoria. I am qualified to obtain a license under the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of the County of Peoria. I swear that I am fully informed as to the provisions of the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of Peoria County, and that I will not violate any of the laws of the State of Illinois or any of the ordinances of Peoria County in the conduct of the place of business described herein and that the statements contained in this application and any schedules and other attachments made a part of this application are true and correct. of Manager of Manager Social Security Number: Social Security Number: Drivers License Number: Drivers License Number: Subscribed and sworn to before me this day of 20. tary Public

14 SCHEDULE III PARTNERSHIP Each member of a partnership must answer each question. 1. Name of Partnership: 2. Names of all persons who have an interest in the partnership or who are entitled to share in the profits of such partnership (include maiden name or any alias used): (a) (b) (c) (d) 3. Residence addresses of above persons: (a) (b) (c) (d) 4. Birth dates and places of birth for above persons: (a) (b) (c) (d) 5. How long has each person listed above resided in Peoria County? (a) (b) (c) (d) 6. List all addresses at which each person has resided in the past 5 years: (a) (b) (c) (d) 7. Are the above listed persons citizens of the United States? (a) Yes (b) Yes (c) Yes (d) Yes 8. Give character of business to be conducted at place to be licensed: 9. How long has each person listed above been engaged in business of this character? (a) (b) (c) (d) Continued on next page

15 Schedule III continued (On a separate sheet, include a list of locations and inclusive dates during which each person has been in said business). 10. Have any of the persons listed above previously made application for a license to sell alcoholic liquor at retail (on premises other than those presently applying) to Peoria County, or any other state of political subdivision? Yes If the answer is yes, please give the date, location and disposition of each such application: 11. Has any liquor license held by any of the above persons listed above been revoked or suspended? Yes If yes, please state the reasons for the revocation or suspension: 12. Have any of the persons listed above been convicted of: A felony? Yes Being a keeper of a house of ill fame? Yes Prostitution? Yes Pandering? Yes Gambling offense? Yes Other Crime opposed to decency and morality? Yes If you answered yes to any of the above convictions, please give the dates, locations, and dispositions of any such convictions: 13. Have any of the persons listed above received treatment for alcoholism or any drinking problem? Yes Have any of the persons listed above been involved in any incident involving the police, including traffic, in which they were intoxicated? Yes If you answered yes to either question, please give the date, location and result of any such treatment or incident: 14. Have any of the persons listed above ever been convicted of a violation of any federal or state law concerning the manufacture, possession or sale of alcoholic liquor? Yes. Have any of the persons listed above ever forfeited their bond to appear in court to answer charges for any such violation? Yes If you answered yes to either question, please give the dates, locations, and dispositions of any such convictions or forfeitures: 15. Have any of the persons listed above been involved in any battery, assault, fight or public disorder? Yes If you answered yes, please give the date, location and disposition of any such incident: 16. Read and Sign the Affidavit on next page. Continued on next page

16 Schedule III continued AFFIDAVIT OF MEMBERS OF PARTNERSHIP We certify that we are the persons listed in this schedule for the business described in this application, that the premises specified in the application comply in all respects with the requirements of the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of Peoria County, and that we are qualified to obtain a license under the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of Peoria County. We certify that we are fully informed as to the provisions of the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of Peoria County and that we will not violate any of the laws of the State of Illinois or the ordinances of Peoria County in the conduct of the place of business described herein. We certify that the statements contained in this application and any schedules and other attachments made a part of this application are true and correct. of Partner of Partner Social Security Number: Social Security Number: Drivers License Number: Drivers License Number: of Partner of Partner Social Security Number: Social Security Number: Drivers License Number: Drivers License Number: Subscribed and sworn to before me this day of 20. tary Public Continued on next page

17 Schedule III continued AFFIDAVIT OF CRIMINAL BACKGROUND IN LIEU OF FINGERPRINTING FOR MEMBERS OF A PARTNERSHIP I certify that I am one of the persons listed in this schedule for the business described in this application. I further certify that the statements made concerning me and contained in paragraphs 12, 13, 14 and 15 in this application and statements made about me in any schedules and other attachments made a part of this application with regard to convictions are true and correct. Print Name: Print Name: Print Name: Print Name: Subscribed and sworn to before me this Print Name: Print Name: Print Name: Print Name: day of 20. tary Public

18 SCHEDULE IV CORPORATION 1. Name of Corporation: 2. and State of Incorporation: 3. If state of incorporation is not Illinois, please give date on which the corporation was qualified under the Illinois Business Corporation Act to transact business in Illinois: 4. Corporation organized for what purpose? 5. Give character of business to be conducted at place to be licensed: 6. How long has corporation been engaged in business of this character? (On a separate sheet, include a list of locations and inclusive dates during which the corporation has been in business of this character). 7. Provide the following (including maiden names and any aliases used) for each director, officer or manager (excluding establishment manager), or any stockholder owning in the aggregate more than 5% of the corporation. Use additional sheets if necessary. Name: Title: Board of Directors Corporate Officer Stockholder Address: City: State: Zip Code: of Birth: / / Place of Birth: U.S. Citizen: Yes Law Enforcing Official: Yes Peoria County Board Member: Yes Social Security #: Driver's License #: Previous addresses in the past 5 years Address: City: State: Zip Code: When: Address: City: State: Zip Code: When: Name: Title: Board of Directors Corporate Officer Stockholder Address: City: State: Zip Code: of Birth: / / Place of Birth: U.S. Citizen: Yes Law Enforcing Official: Yes Peoria County Board Member: Yes Social Security #: Driver's License #: Previous addresses in the past 5 years Address: City: State: Zip Code: When: Address: City: State: Zip Code: When: Continued on next page

19 Schedule IV continued Name: Title: Board of Directors Corporate Officer Stockholder Address: City: State: Zip Code: of Birth: / / Place of Birth: U.S. Citizen: Yes Law Enforcing Official: Yes Peoria County Board Member: Yes Social Security #: Driver's License #: Previous addresses in the past 5 years Address: City: State: Zip Code: When: Address: City: State: Zip Code: When: 8. Have any of the individuals listed above or the corporation made application for a license to sell alcoholic liquor at retail on premises other than described in this application to Peoria County or any other state or political subdivision thereof? Yes If the answer is yes, please give the date, location, and disposition of each such application: 9. Has any liquor license held by the above listed individuals or the corporation ever been revoked or suspended? Yes If the answer is yes, please state the reasons for the revocation or suspension: 10. Have any of the individuals listed above or the corporation been convicted of: A felony? Yes Prostitution? Yes Being a keeper of a house of ill fame? Yes Pandering? Yes Gambling offense? Yes Other crime opposed to decency and morality? Yes If the answer is yes to any, please provide dates, locations, and dispositions of such convictions: 11. Have any of the individuals listed above been treated for alcoholism or any drinking problem? Yes Been involved in any incident involving the police, including traffic, in which they were intoxicated? Yes If the answer is yes to either question, please give the date, location and result of any such treatment or incident: Continued on next page

20 Schedule IV continued 12. Have any of the individuals listed above been involved in any battery, assault, fight or public disorder? Yes If the answer is yes, please give the date, location and disposition of any such incident: 13. Have any of the individuals listed above or the corporation ever been convicted of a violation of any federal or state law concerning the manufacture, possession or sale of alcoholic liquor? Yes Have any ever forfeited their bond to appear in court to answer charges for any such violation? Yes If the answer is yes to either question, please give the dates, locations, and dispositions of any such convictions or forfeitures: 14. Are you a not-for-profit corporation? Yes 15. Read and sign the Affidavit below. AFFIDAVIT ON BEHALF OF CORPORATION The undersigned certify that the premises specified in this application comply in all respects with the requirements of the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of Peoria County, and that the applicant corporation and its manager or agent are qualified to obtain a license under the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of Peoria County. We certify that the applicant will not violate any of the laws of the State of Illinois or the ordinances of Peoria County in the conduct of the place of business described herein. We certify that we are fully informed as to the provisions of the Illinois Liquor Control Act and the Alcoholic Liquor Ordinance of Peoria County. We certify that the statements contained in this application and any schedules and other attachments made a part of this application are true and correct. of President of Secretary Subscribed and sworn to before me this day of, 20. tary Public Continued on next page

21 Schedule IV continued AFFIDAVIT OF CRIMINAL BACKGROUND IN LIEU OF FINGERPRINTING FOR CORPORATION OFFICERS, MANAGERS, DIRECTORS AND STOCKHOLDERS OWNING IN THE AGGREGATE MORE THAN 5% OF THE STOCK OF THE CORPORATION I certify that I am one of the persons listed in this schedule for the business described in this application. I further certify that the statements made concerning me and contained in paragraphs 10, 12, 13 and 14 in this application and statements made about me in any schedules and other attachments made a part of this application with regard to convictions are true and correct. Print Name: Print Name: Print Name: Subscribed and sworn to before me this Print Name: Print Name: Print Name: day of 20. tary Public

22 STATEMENT OF FINANCIAL DISCLOSURE ALL APPLICANTS must answer Questions 1 2 1. List below the names and addresses of all creditors who have any right to control the use or disposition of the business or any asset thereof: 2. Please list below a description of all agreements or obligations which purport to bind any successor to you to continue to purchase, rent, or accept any goods, wares, or services from a specified supplier thereof: 3. If you are a corporation, attach a copy of the corporation's latest annual report required to be filed pursuant to Section 14.05 of the Business Corporation Act of Illinois (805 ILCS 5/14.05). 4. The Liquor Commissioner, at this discretion, may request further information at a later date. This may include a detailed statement of assets and liabilities of the business. Information supplied by: (Please Sign) ()

23 DOCUMENTATION REQUIRED TO OBTAIN A LIQUOR LICENSE IN PEORIA COUNTY Completed application including scale drawing Zoning Report (Planning & Zoning Room 301) Liquor Bond issued to the County of Peoria (Insurance Company) Liability Insurance Coverage naming the County of Peoria as a certificate holder (2017 minimum coverage: $67,356.23 each person; $82,324.28 loss of support/society) Affidavit of Beneficial Ownership Police Report Corporation Papers requested, including latest Annual Report (if applicable) Lease Agreement (if applicable) Deed Copy (if applicable) Previous Owner s License Food and Drink. (Health Department) Site Plan (if applicable)

24 AFFIDAVIT OF BENEFICIAL OWNERSHIP OF LICENSED LIQUOR ESTABLISHMENT STATE OF ILLINOIS COUNTY OF PEORIA ) ) ) The Alcoholic Liquor Ordinance as contained in Chapter 3 of the Code of Peoria County, requires that the owner, whether individual, partnership or corporate, demonstrate a beneficial interest as owner of the business to be operated under a Peoria County liquor license. (Code of Peoria County, Section 226(19)). ON OATH AFFIANT STATES AS FOLLOWS: 1. The beneficial owner of the proposed licensed establishment and business is as an individual/partnership/corporation. (circle one) 2. Funding for the purchase/lease of the licensed premises was obtained from:. 3. The personal property of the establishment was purchased/leased using funds of:. 4. The sales inventory, including alcoholic liquor, other beverages and foodstuffs was/is to be purchased with funds provided by:. 5. Mortgages/loans have been acquired from the following person(s) or entities to fund the operation of the proposed establishment:. 6. Other:. (Enter any information relevant to the above that more fully explains the business transactions involved in relation to the funding provided.) I fully understand that any false or other intentional misrepresentation of the sources of funding for the operation and beneficial ownership of this proposed licensed liquor establishment may result in the revocation of the license applied for and be a further bar to the issuance of a future license to any individual, partnership or corporation involved. AFFIANT DATE Subscribed and sworn before me this NOTARY PUBLIC day of, 20.

25 TO BE COMPLETED FOR ALL SUPPLEMENTAL LICENSES SITE PLAN Size of site: acres or dimensions: x Complete the site plan using blue or black ink. Include the following information on this site plan above or attach a reproducible site plan with the same information: LEGEND Property line = All existing and/or proposed buildings and structures and the dimensions of each Existing structure = Topographical information such as roads, trees, ponds, hills gullies, streams, etc. Proposed structure = Label all structures (e.g. house, shed, garage, etc.) Fence = Label requests pertinent to this petition Tree =