|
<br />
<br />DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
<br />Division of Hotels and Restaurants
<br />www,hospitalityeducation,org
<br />
<br />
<br />APPLICA TION FOR LICEN$E
<br />
<br />Required for licensure es e public food service or lodging esteblishment plKSuant /0 s, 509,241 FS _.. 61C-1_002 FAC
<br />
<br />TYPE OF APPLICATION
<br />c=J New Establishment
<br />(PLEASE PRINT OR TYPE)
<br />I Opening ITII
<br />Date ~
<br />MOnh Day Year
<br />
<br />c=I Change of Ownership
<br />
<br />.S~~~~~D - D -I
<br />
<br />Check if exempt
<br />
<br />I Owner
<br />Name
<br />
<br />(Corporation or Individual: For applications from individuals, please place name in the following order: LAST NAME, FIRST NAME, MIDDLE INITIAL)
<br />
<br />President Name I
<br />
<br />
<br />LAST NAME
<br />
<br />Telephone: Business
<br />
<br />(Z) Seating - # of seats
<br />(Z) mmmt~~~~~sarkFoodCart':
<br />
<br />(G) Vending
<br />---~--~-------~-_._^--~-_.
<br />(G) No Seats
<br />------~_.__.__.-
<br />(G) Catering
<br />(0) Mobile Food Dispensing Vehicle"
<br />(P) Temporary
<br />
<br />(1) Non-Transient Apar1ment
<br />(2) Hotel
<br />................................................. ..................-.............................-.....
<br />(3) Motel
<br />(5) Transient Rooming House
<br />(6) Individual Condominium
<br />
<br />(6) Individual Resort Dwelling
<br />(7) Transient Apartment
<br />(8) Group Condominium
<br />(8) Group Resort Dwelling
<br />(9) Collective Condominium
<br /> ----
<br />(9) Collective Resort Dwelling
<br />
<br />. Provide Vehicle Identification Number as
<br />applicable in the space below, Use separate
<br />sheet if necessary for group licensing of theme
<br />park food carts,
<br />
<br />(10) Ncn- Tla1Sient Roormg House
<br />
<br />
<br />(11) Bed and Breakfast
<br />',NUMBER OF UNITS'
<br />
<br />I-D-O
<br />
<br />Sole Proprietor
<br />Partnership
<br />Corporation
<br />Other
<br />
<br />FIRST NAME
<br />. -
<br />
<br />.
<br />
<br />MIDDLE INITIAL
<br />
<br />Under the Federal Privacy Act, disclosure of social security
<br />numbers is voluntary unless specifically required by federal statute,
<br />In this instance, disclosure of social security numbers is mandatory
<br />pursuant to Title 42 United States Code, sections 653 and 654; and
<br />sections 409,2577,409.2598, and 559.79, Florida Statutes, Social
<br />security numbers are used to allow efficient screening of applicants
<br />and licensees by a Title IV-D child support agency to assure
<br />compliance with child support obligations. Social security numbers
<br />must also be recorded on all occupational license applications and
<br />are used for licensee identification purposes pursuant to the
<br />Personal Responsibility and Work Opportunity Reconciliation Act of
<br />1996 (Welfare Reform Act), 104 Pub,L.193, Sec, 317.
<br />
<br />
<br />lications from individuals, ease ace name in the foliO win order: FIRST NAME, MIDDLE INITIAL, LAST NAME
<br />
<br />
<br />FOR ESTABLISHMENTS OWNED OR OPERATED BY PARTNERSHIPS, CORPORATIONS OR COOPERATIVES, please attach a separate sheet or sheets listing the name, address,
<br />and social security number of each person who owns 10% or more of the outstanding stocks or equity interest in the licensed activity and the name, address, and social security numbers of
<br />each officer, director, chief executive, or other person who, in accordance wnh the rules of the issuing agency, is determined to be able directly or indirectly to control the Operation of the
<br />business of the licensed entity,
<br />
<br />Has any person interested in the operation of this establishment, whether owner, operator, agent, lessee or manager, been adjudicated guilty, or forfened
<br />a bond when charged wnh solicning for prostnution, letting premises for prostnution, keeping a diSOrderly place, illegally dealing in narcotics, gambling, or
<br />any other crime reflecting on professional character wnhin the last fIVe (5) years in this state, or any other jurisdiction of the Unned States?
<br />
<br />DYes
<br />
<br />DNO
<br />D No
<br />
<br />Has any person interested in the operation of this establishment, whether owner, operator, agent, lessee or manager, had a license for an Adu~
<br />Congregate Living Facilny at this establishment denied, suspended or revoked pursuant to s, 400,414, F,S" wnhin the last fIVe(S) years?
<br />
<br />DYes
<br />
<br />THIS APPLICATION MUST BE SIGNED UNDER OATH OR AFFIRMATION BY THE APPLICANT OR OWNER OR CHIEF EXECUTIVE OF THE ESTABLISHMENT, WITHOUT THE NEED FOR
<br />WITNESSES, IF A CORPORATION IS IN THE HANDS OF A RECEIVER OR TRUSTEE, THIS APPLICATION SHALL BE EXECUTEO ON BEHALF OF THE CORPORATION BY THE HANOS OF A
<br />RECEIVER OR TRUSTEE,
<br />
<br />I certify that I am empowered to execute this application as required by Section 559,79, F.S. J understand that my signature on this application has the same legal effect
<br />as if made under oath, To the best of my knowledge, all information contained on this application is true and correct. I understand that falsification of any information on
<br />this application ma result in administrative action, includin fines u to $1,000, suspension or revocation of the license,
<br />
<br />Applicant Name and Title (please print or type)
<br />DBPR Form HR 5021-020 Revised 2000 February 10
<br />
<br />Applicant SIgnature Date
<br />NOTE: PLEASE KEEP ALL INFORMATION CURRENT REGARDING THE LICENSED PREMISES.
<br />
|