1993-022 Alcohol Beverage License' RESOLUTION NO. 22-93
A RESOLUTION OF THE VILLAGE OF NORTH
PALM BEACH, FLORIDA, AUTHORIZING AND
DIRRCTING THE VILLAGE MANAGF,R TO
EXECUTE AN APPLICATION FOR ALCOHOLIC
BEVERAGE LICENSE WITH THF. DIVISION
OF ALCOHOLIC BEVERAGES AND TOBACCO,
DEPARTMENT OF BUSINESS REGULATION,
STATF. OF FLORIDA, FOR USE AT THF
NORTH PALM BEACH COUNTRY C1~UB, WHICH
APPLICATION IS ATTACHED AS EXHIBIT
"A"; PROVIDING INDEMNIFICATION TO
THE VILLAGE MANAGER FOR THE
EXECUTION AND SUBMISSION OF THE
APPI,ICATTON FOR ALCOHOLIC. BEVERAGE
LICENSE; AND, PROVIDING FOR AN
F,FFECTIVE DATE.
BE IT RESOLVED BY THE VIL,L~AGF. COUNCIL OF NORTH PALM
BEACH, FLORIDA:
' Section 1. The Village Council of the Village of North
Palm Beach, Florida, does hereby authorize and direct the Village
Manager to execute and submit an application for alcoholic beverage
]i.cense with the Divi.sior, of Alcohol i. r, Beverages and Tobacco,
Department of. Business Regulation, State of Florida, fo, use at tt,e
North Palm Beach Country Club, which application i.s attached as
Exhibit "A".
Section 2. The Village Cow~ci] of. the Village of North
Palm Bear.h, Florida, does hereby indemnify and save and hold the
Village Manager harmless from loss or damage incurred by reason of
the execution and submission of. the appli.cat.i.on fvr alcoholic
beverage lir.ense.
' Section 3. This Resolution shall. take effect i-mmediately
upon its adoption.
1
PASSED AND ADOPTED THIS 22nd DAY OF APr91 1993.
--'
(Village Seal)
MAYOR
ATTEST: ~e~Qa~~~G_¢-~
VILLAGE CLERK
EXHIBIT "A'
D81t 42-008
Rev. 2/91
Name
Dennis Wayne Kelly
PERSONAL QUESTIONNAIRE
01/8/4? ~ 46
PLACE OF BIRTH: COLOR COLOR RACE: SEX: HEIGHT: WEIGHT:
HAIR EYES
Enid, OK Brown Brown Cau Male ~ 6''0" 185
912 Northlake Ct., #5 HOME PHONE NUMBER: 40?/845-917.1
North Palm Beach, FL 33408 BUSINESS PHONE: 4 476
Are you a citizen of the United States) Yes If the answer is no, complete the following:
Are you legally in this country? Alien Registration Number
From To Jnh Tit1n
rM,.i~..e,.~~ u~me e.,.t e.~.t.-e~~ ...t«~, ot., r,,,~„
389 presen Village Mana er Noef~ig~alm Beach
Have you ever been in this state, any other state, by the United States, or by
any foreign country: YES NO
1. Arrested or charged with any violation of the law excluding
minor traffic violations? .. .................................... .......
~
...
:
•
If yes, were you convicted) ............................. ................
2. Have you in the past or presently, individually or as an
officer of a corporation:
a. Held, or had an interest in a beverage license or cigarette permit?........
b. IIeen denied a beverage license or cigarette permit?. ........................ X
c. 1lad a beverage license or cigarette permit revoked? ...................~..... X
d. Held stock or had any interest in, affiliated or. connected with, directly
or indirectly, any business which manufactures, distributes, imports,
exports or sells at retail any alcoholic beveragesl ........................ X
3. Are you an official with state police powers granted by the Florida
Legislature or designated as a law enforcement officer by 33-4.001,
Florida Administrative Code? .......:....................................... X
If the answer to any of these questions is YES, list full particulars which in clude
char ges, date and place of arrests, arresting agencies, whether convicted and give
busi ness names, cities, states and dates. (Attach extra sheets if necessary.)
STATE OF FLORIDA
Department of Dusiness Regulation
Division of Alcoholic Beverages and Tobacco
F F I D A V I T
In compliance with Florida Beverage Laws and Regulations, I hereby certify that
Dennis Wayne Kelly
(Name of Person to be licensed)
of Village of North Palm Beach, 501 U.S. #1, N. Palm Beaeh. FL 33908
(Complete Address)
was fingerprinted by me for the Florida State Division of Beverage and that
the attached fingerprints are his/hers.
(Signature ~~ Officer)
Public Safety Department
(Department)
Village of North Palm Beach, FL
(Address)
Sworn to and subscribed before me
this day of
19
(Notary Public)
My Commission Expires:
PLEASE PRINT
NAP1E K 1
LAST FIRST MI DLE
ADDRESS 412 Northlake Ct. #5, North Palm ReAeh, Ft, 33408
CITY STATE ZIP
U.S. CITIZEN YES X NO - OTHER COUNTRY
SEX M RACE W HGT 6'0" WGT 185 EYES Br HAIR Br
DATE OF BIRTH 01/08/47 CITY Enid STATE - OK
SOCIAL SECURITY NUMBER 267-?0-6143
NAME AND ADDRESS OF BUSINESS TO BE LICENSED Village of North Palm RPanh
aka North Palm Beach Country Club
Restaurant. 501 U.S. Hie~hwav #1. North_Palm_BQach__Fi. 43408
PHONE NUMBER WHERE YOU CAN BE CONTACTED (407) '848-3476
oaN.~-oo;6 '
n,.. oleo STATE OF FLORIDA - .
Dopanmonl of Buslnou Ropulapon
Divlslon of Alcoholic Bovorapoc and Tobacco
ELCCTIQN OF SURCHARGE PAYMENT METHOD ": ~.
• AND CERTIFIED INVENTORY REPORT
This applicollon Is for a:#)NEw LICENSC, ()TRANSFER OF LICL-NSE or a ()t-Day, ()2-Day, ()9-Day PERMIj~PERMIT EXPIRES •:__1_/._ .
APPLICANT'S NAME: N Po lm Ro_nnh C_nLnt ry C.1 ub ~'Ihorobypormanonlly olocl to payluluro.aurcharpor
ReS tauCant basod on purchatoa.
DvslNESSNAME: Village of North Palm-Beach
No, f do not pormanondy okct to peyNluro •
MAILING ADDRESS: 5 O 1 U . S . Highway # 1 s . NPB ~__ ruroharpos basod on purehpros, 7horoloro, l wit!
FL 33408 paybarod on reloa.: '
LOCATION ADDRESS: 9 O 1 U . S . Highway. # 1 ~ ucENSEM - '• ' '
cITY: North Palm Beach ,FL. COUNTY: Palm Beach • zIP:33408
NAME OF CONTACT PERSON: ShaUkat Khfln PHONER (407) 848-3474 ~ ~ •
Finance Director
II person preparing monthly reports is dillerenl Irom abovo, plsaso Ilsl namo and phono number below:
NAME; Alan Sayer PHONEa (4b7) 628'-4345 •'
• ~ ~ .o rntr~ 1 ib'MLrr. ,9 19 93
Applicuro •.Tlllo Dato
FOR:LICGNSE TRANSFERS ONLY
NOT APPLICABJ~E
FORMER DUSINC-SS NAME;
LICENSE NUMDER:
SERIES:
This Ic to conily that as loimor ownor of lhlc Ilconca or avlhoflzod roprownlalivo of Ihb Iiconsoo, I uwd lho
-PURCHASES _ SALES molhod to dolonnlno lho amount of bovoropo suroharpos duo pnd that paymon] of
lhoso SURCHARGES is current ac of
Sipnaturo of Formor Owner
or Authorized Roproeonlalivo
Dato
INVENTORY TO BE TRANSFERRED FOR CONSUMPTION ON PREMISES
Gallons Dralt Door Gallons Packapod Door
Gallonc COOlow Gallons Wlno
Gallon: Liquor
WE CC-RTIFY THAT THIS INVENTORY IS TRUE AND CORRECT 70 THE BEST OF OUR KNOWLEDGE AND BELIEF.
Sipnaturo of Formor Ownor
or Authorized Roprocontaliv
Sipnaturo of Applicant
" NOTICE TO ALL COP APPLICANTS" -.
ALCOFfOLIC OEVERAGE SURCHARGET/UCESAREDUf OYTHE lSTNOf fACHMONTH. ITISTHE VENDORS RESPONSIQILITYTO
CONTACT THE PLANTAT/ON AUDITING OFFfCE AT(905J y97-a499, fO 00TAlN.THEREOUIRED FORMSdINSTRUCTIONS.
ACCO/IOC/CGEVERAGE SURCHARGETAXL'S FOR ONC-,TWO, OR TFfREE DAYPERMITSAREDUf200AYS AFTER THE EVENL.
FAILURE TO FIL E S PAY SURCHARGE TAXES WICL RESULT IN PENACTIESOF ! 9G PER DAYOR SL00 PER DAY, WHICHEVER IS GREATER,
ANO MAY RESULTIN THE FIEVOCATIONOf YOUR LICENSE, ~•!'~~ "."~ i '
r..i' ;).
• ' ti,,;•
UEYARTMENT OF BUSINESS REGULATIONS ~:; `
U1VISION OF ALgOHOLIC BEVERAGES AND TOBACCO
. i,:
LICENSE/PERMIT APPLICATION WAIVER .
,.s;
['r. .
,:.
Chapters 120 and SG1 of the Florida Statutes require your application be `
processed within ( ) 7U days ( ) 180 days. The Division of Alcoholic
beverages and 1'obaccu is unable. to meet the time requirements in your case.
Therefore, the Mvis.l.ou requests you waive the time •requirements for
processing your ul~l~li.cation. Your application will be processed as
expeditiously as possible.
If you wish to waa.vc the above limitations, please complete the following:
business Name:_ North Palm Beach Country Club 'Restaurant
Applicant's Name: Village of North Palm Beach 1
Business Address: 5.0.1 U.S. Highway #1
Street Number
North Palm Eeach Palm Beach, FL 33408
Cl.ty County Zip
Phone No.: Area code (40?) 848-3476
I do hereby waive :i'L1 time restrictions surrounding the processing of the
above referenced application. I do so knowingly and voluntarily.
` }
~"!~ ~ i .
,.., .,
04/19/93 ~ - ',
Date Signature o "Applicant
DBR 42-001
Rev. 7/91
aF T1IE
~~ ', ,
~!, M1. Ci
STATE OF FLORIDA
Department of Business Regulation
Division of Alcoholic Beverages and Tobacco
APPLICATION FOR•ALCOHOLIC BEVERAGE LICENSE
AND CIGARETTE PERMIT
SECTION I BUSINESS TELEPHONE i4 407/848-476
TYPE OF LICENSE/PERMIT DESIRED: Check Appropriate Boxes
(){) Alcoholic Beverage License
(X) New ( ) Change of Location
( ) New - Temporary .. Temporary
( ) Transfer ( ) Change in Series
( ) Transfer - Temporary ( ) Decrease in Series
( ) Change of Location ( ) Increase in Series
TYPE OF APPLICATION: Check Appropriate Boxes
( ) Cigarette Permit
( ) Change of Business Name
( ) Change of Officers/Stockholders
( ) Correction
( ) Other
TYPE OF APPLICANT: Check Appropriate Bo% and List CharteC Number, If Applicable
( ) Individual ( ) Partnership •
(}{) Corporation ( ) Limited Partnership ( ) Chartec Number
(MuniciQality)
1. Applicant's Full Name: Nnrth Palm Beach COUntCV C1Ub RestauCant
2. Business Name: Villa of Nor h Palm Beach
3. Location Address: 901 U.S. #1. North Palm Beach FL 33408
Street City State Zip
9. Mailing Address:
Street
FL
ate z
If application is for a NEW license/permit, questions 5-6 are not applicable.
5. Current owner's Name: N/A
6. Current Business Name:
7. Current Location Address: N/A
Street City State Zip
8 Current License/Permit Number: N/A Current Series:
9. Series of Licenses/Permits Desired: ( 4COPSR.X ) AND
10. Complete the following if you are an applicant for a quota, special or club
alcoholic beverage license. The license is issued pursuant to ,
Florida Statutes or Special Acts, and as such we acknowledge the following minimum
requirements must be met and maintained:
(1)
Counirv Club Administrative Board Members
TITLE/POSITION NA M
Chairman M. C. Love
Vice Chairman Chuck Weston
Board Members: Arnold Ness
Leonard Pellegren
Frank shone
Lucia Traugott
Dick Voss
SECTION III
1. snces TAX: Owners Name: Vi11aQe of North Palm Beach
Business Name:North Palm Beach Country Club Restaurant
A. Disclosure Authorization. Section A is to be Completed By Owner Only if Transfer
of Alcoholic Beverage License.
N/A
I hereby authorize the Department of Revenue to release to the aforementioned applicant
and to the Division of Alcoholic Beverages and Tobacco the current status of my account
Sworn to and Subscribed
before me this
day of
19
/'
Owner or uthocized Corpora
Officer Must be Notarized
Notary public My Commission Expires:
B. Disclosure. Section B is to be Completed by Department of Revenue.
1. This is to verify that the current owner as named in
this application has filed all returns and that all
outstanding billings and returns have been paid
through the period ending N/A or the
liability has been acknowledged and agreed to be paid
by the applicant'. This verification does not
constitute a certificate as contained in Section
212.10(1), F.S. (Not applicable if no transfer
involved).
2. Furthermore, the named applicant for an Alcoholic
Beverage License has complied with Florida Statutes
concerning registration for Sales and Use Tax, and
has paid any applicable taxes due.
(Signed)
(Title)
09/19/93
(Date)
(3)
(YES) (NO)
D. Is the proposed premises MOVABLE or ABLE TO BE MOVED?. ............... X
E. is the proposed premises located in a shopping center, mall or
off ice building? .................................................... X
F. Is there any access through the premises to any area over which
you do not have dominion and control? ............................. X
G. is the premises occupied by anyone not listed on this application?.. X
SECTION V
FEDERAL EMPLOYER'S IDENTIFICATION NUMBER
A. Federal Employer's identification Number: 59-6017984
B. Not Required ( )
C. Not Available ( ) I will submit to your agency as soon as possible.
SECTION VI
these questions must be answered about this business for every person or entity listed.
copies of agreements and documentation to support the financial arrangements must be
submitted with this application.
NOT APPLICABLE
YES NO
1. Is there a management contract or service agreement in connection
with this business? .......................................................( ) ( )
2. Are there any agreements which require a payment of a percentage of
gross or net receipts from the business operationl ........................( )' ( )
3. Does anyone hold a mortgage or security agreement for this business?......( ) ( )
4. Nave you or anyone listed on this application borrowed money from or
accepted money, equipment, fixtures, or anything of value from an owner
or representative of a distiller, rectifier, blender, bottler, manu-
facturer, brewer, distributor, exporter, importer or retailer oz
secured a loan from any source connected with the alcoholic beverage-
industry7 .................................................................( ) ( )
5. if purchasing the business, what is the purchase price? ..............~ N/A
6. List the total investment :...........................................~ N/A
A. Total CASH invested .................... ............................~ N/A
B. Total LOANS invested ..............................................~ N/A
(5)
SKETCH OF LICENSED PREMISES
Sketches should be drawn in ink and include all walls, doors, counters, sales area's,
storage areas, reatroome, bar locations and any other specific areas which are part of
the premises sought to be licensed. A multi-story building where the entire building is
to be licensed must show each floor.
Floor Plan Attached
(7)
EAVE BLANK
APPLICANT
412 Northlake Ct., #5
N. Palm Beaeh, FL 33408
Village of N. Palm Bch.
501 U. S. Highway #1
North Pa lm_Bch. . FL 33408
pFATON RNGERPRINTfO
Liquor License application
c/o Village of N. Palm Bch.
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L p. (NUMB ~ ] R. INOfY -
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TYPE OR PRINT ALL INFORMATION IN BLACK
IATf NAMf NAM FIRTI NAMF MIDDIF NAM[
Kelly "Dennis Wayne
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