SELECT*

NEW

RENEWAL

SELECT*

PROPRIETORSHIP PARTNERSHIP

CORPORATION

MISSOURI SALES TAX #*

MISSOURI CORPORATION REG. #*

CURRENT CITY OF BLACK JACK OCCUPANCY PERMIT

YES

NO

CURRENT CITY OF BLACK JACK BUSINESS LICENSE

YES

NO

BUSINESS NAME:*

BARBER/BEAUTY/NAIL SALON*

YES

NO

BUSINESS ADDRESS*

BLACK JACK, MO 63033

BUSINESS OWNER NAME*

PHONE #*

BUSINESS OWNER ADDRESS*

ARE YOU A REGISTERED VOTER IN THE STATE OF MISSOURI

YES

NO

IS THE BUSINESS FOR WHICH YOU ARE APPLYING FOR A LIQUOR LICENSE A RESTAURANT/BAR?

YES

NO

IS FOOD AND LIQUOR SOLD

YES

NO

IF YES

FOOD PERCENTAGE

LIQUOR PERCENTAGE

IF APPLICABLE PLEASE COMPLETE A VERIFICATION OF FOOD AND ALCOHOL SALES/SCHEDULE OF GROSS RECEIPTS. HIS FORM CAN BE OBTAINED FROM THE MISSOURI DEPARTMENT OF PUBLIC SAFETY-DIVISION OF ALCOHOL AND TOBACCO CONTROL.

PROPERTY OWNERS NAME*

PHONE #

PROPERTY OWNER ADDRESS

MANAGER'S NAME*

ADDRESS*

PHONE #*

THE UNDERSIGNED HEREBY MAKES APPLICATION FOR THE LIQUOR LICENSE(S) ISSUED TO THE BUSINESS NAMED IN THIS APPLICATION AS PROVIDED FOR IN THE CODE OF ORDINANCES OF THE CITY OF BLACK JACK, MISSOURI, AS AMENDED:*

FULL LIQUOR INCLUDING PACKAGE (1)$450.00 BEER & WINE INCLUDING PACKAGE (2)$75.00 PACKAGE LIQUOR ONLY (3)$150.00 BEER ONLY, EXCLUDING PACKAGE (4)$75 3.2 BEER ONLY, INCLUDING PACKAGE (5)$22.50 TEMPORARY (BY THE DRINK/CENTAIN ORG) $25

SUNDAY FULL LIQUOR (6i)$300.00 SUNDAY BEER & WINE (6ii)$150.00 SUNDAY BEER ONLY (6iii)$50.00 SUNDAY PACKAGE LIQUOR (7)$300.00 SUNDAY ENTERTAINMENT (7)$300.00 WINE TASTING (8)$100.00

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

AND IN SUPPORT OF SAID APPLICATION DOES SUBMIT THE ABOVE INFORMATION.

SIGNATURE OF APPLICANT*

DATE*

LIQUOR LICENSE CHECKLIST: COMPLETED APPLICATION, APPLICATION FEE, RECORD CHECK FROM ST. LOUIS COUNTY, A COPY OF CURRENT DEED OR LEASE. ANY REQUIRED DOCUMENTS CAN BE EMAILED TO CITYCLERK@CITYOFBLACKJACK.COM

_____________________________________________________________________________________________________________________________________

FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS AREA

AMOUNT PAID ____________DATE PAID____________PAYMENT METHOD ____________INITIAL_____

LIQUOR LICENSE COMMITTEE MEETING DATE ____________

APPROVAL _____YES _____NO

DATE ____________ INITIAL _____

CITY COUNCIL

APPROVAL _____YES _____NO

DATE ____________ INITIAL _____