Application for Liquor LicenseApplication for City of Geneseo, Illinois Liquor LicenseApplication for City of Geneseo, Illinois Liquor License If you are human, leave this field blank. Date Applicant - Corporate Information FEIN ILLINOIS BUSINESS TAX NUMBER ILLINOIS LIQUOR LICENSE NUMBER Contact Information Name Address Phone Email Status of BuisnessCheckboxes Partnership Illinois Corporation Foreign Corporation Date of Formation Date of Incorporation IL Date of Incorporation Foreign State of Incorporation Date Qualified to Do Buisness in Illinois Navigate to the website below to pay online: Ownership Information Paragraph (A) For each owner, partner, corporate officer or director (whether or not they own any stock), and/or shareholder owning in the aggregate equal to or more than 5% of the stock, provide full name, home address, city, state, zip code, social security number, date of birth, sex, title/position, home telephone number, and percentage ownership. Percentage ownership should equal 100%. If there are a number of shareholders owning less than 5%, indicate the aggregate total of ownership. If additional space is needed, provide information on a separate sheet in the same format. No License shall be issued to a person that has not submitted to a City background check to determine compliance with eligibility requirements of Section 110.17 prior to the initial issuance of any license to an applicant, A new background check will only be required if the owners, sole proprietor or resident manager changes. The applicant shall, in addition to the license fee thereinafter set forth, reimburse the City for the actual cost of the background check. Notwithstanding the foregoing, background checks will not be required for applicants for Class F and Class H licenses. Full Name Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country SSN DOB Title Position Percentage Owned Add Another Owner Yes NoOwnership Information Full Name Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country SSN DOB Title Position Percentage Owned Add Another Owner 2 Yes NoOwnership Information Full Name Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country SSN DOB Title Position Percentage Owned TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% PercentageBusiness Premises InformationEnter the name of the business. NOTE: THIS NAME WILL APPEAR ON YOUR LIQUOR LICENSE AND MUST BE CONSISTENT WITH THE NAME PRINTED ON YOUR ILLINOIS DEPARTMENT OF REVENUE SALES TAX CERTIFICATE. If operating under an assumed name, attach written proof that the Illinois Assumed Business Name Act has been satisfied. NAME / DOING BUSINESS AS (D/B/A) Phone Address Buisness Type Bar/Tavern Restaurant Hotel/Motel Liquor Store Grocery Store Convenience Store Convenience Store/Gas Station Fraternal/Veterans's Organization Recreational Facility Brew Pub OtherOther Owned Premises Enter the 14-digit Henry County Property Tax Identification Number. Attach a copy of the deed of ownership.Upload Deed Drop a file here or click to upload Choose File Maximum upload size: 104.86MBDiagram of Premise Drop a file here or click to upload Choose File Maximum upload size: 104.86MBAttach an accurate diagram of the business premises SHOWING ALL EXITS AND LOCATIONS WHERE LIQUOR WILL BE STORED, DISPENSED, SOLD, OR CONSUMED. Leased Premises Landlords Name Address Landlords AddressFee Section Paragraph FEE SCHEDULE LICENSE CLASSIFICATION FEE Class A - General $750.00 Supplemental Liquor License - Class A Only $250.00 Class B - Package Store $750.00 Supplemental Liquor License – Class B Only $250.00 Class C - Restaurant, Beer and Wine On Premises Only $750.00 Supplemental Liquor License – Class C Only $250.00 Class D - Restaurant, Alcoholic Liquor On Premises Only $750.00 Class E - Other Business, Beer and Wine Off Premises Only $750.00 Class G – Brew Pub $1,000.00 Fee Submittted With Application - Liquor License Fee City of Geneseo Liquor License Option – ½ Year Liquor License Payment (2nd half due by October 30) Entertainment License - Annual ($250.00) Entertainment License – One Time ($50.00) Juke Box License ($25.00) Amusement License - $35 per machine Tobacco License ($50.00)Other Fees First Time Applicants Administrative Fee ($750.00) Background/Fingerprinting (36.50) Public Hearing Processing Fee ($200.00) Bassett Training for Servers – Submit Proof of Training Per Server N/C TOTAL AMOUNT SUBMITTED Payment Options: Online Payment or Check made out to City of Geneseo (Payment must be received before Application is processed) Eligibility QuestionsThese questions apply to any person listed under question 3. These questions must be answered or the application will be rejected. If any question is checked YES, a detailed, written explanation is required and must be attached to this application. BEEN CONVICTED OF A FELONY? Yes NoBEEN CONVICTED OF A GAMBLING OFFENSE? Yes NoEVER APPLIED FOR AND BEEN DENIED A LIQUOR LICENSE? Yes NoEVER HAD ANY PREVIOUS LIQUOR LICENSE OF WHICH HE/SHE WAS A PART OF THE APPLICATION REVOKED? Yes NoBEEN CONVICTED OF A VIOLATION OF ANY FEDERAL OR STATE LAW CONCERNING THE MANUFACTURE, POSSESSION, OR SALE OF ALCOHOLIC LIQUOR OR FORFEITED A BOND TO APPEAR IN COURT TO ANSWER CHARGES FOR ANY SUCH VIOLATION? Yes NoBEEN CONVICTED OF A VIOLATION OF ANY FEDERAL OR STATE LAW CONCERNING THE MANUFACTURE, POSSESSION, OR SALE OF ALCOHOLIC LIQUOR OR FORFEITED A BOND TO APPEAR IN COURT TO ANSWER CHARGES FOR ANY SUCH VIOLATION? Yes No CURRENTLY SERVING IN AN ELECTED POSITION OR AS A LAW ENFORCEMENT OFFICIAL IN ANY GOVERNMENTAL ENTITY? Yes No IF YES, PLEASE LIST TITLE AND TYPE OF GOVERNMENTAL ENTITY. NOT A CITIZEN OF THE UNITED STATES OF AMERICA? Yes No ARE YOU OR YOUR PARTNER(S) CURRENTLY NOT CITIZENS OF THE UNITED STATES OR RESIDENT ALIENS WITH LEGAL STATUS? Yes NoResident Manager or Sole Proprietor Information Full Name Phone Number SSN DOB Home Address How long have you resided at this address Drivers License Number Drivers License Exp Attach a copy of Drivers License Drop a file here or click to upload Choose File Maximum upload size: 104.86MBHAVE YOU EVER BEEN CONVICTED OF A FELONY? Yes NoHAVE YOU EVER BEEN CONVICTED OF A GAMBLING OFFENSE? Yes NoHAVE YOU EVER APPLIED FOR AND BEEN DENIED A LIQUOR LICENSE? Yes NoHAVE YOU EVER HAD ANY PREVIOUS LIQUOR LICENSE OF WHICH YOU WERE A PART OF THE APPLICATION REVOKED? Yes NoARE YOU CURRENTLY SERVING IN AN ELECTED POSITION OR AS A LAW ENFORCEMENT OFFICIAL IN ANY GOVERNMENTAL ENTITY? Yes No IF YES, PLEASE LIST TITLE AND TYPE OF GOVERNMENTAL ENTITY. WERE YOU BORN OUTSIDE OF THE UNITED STATES OF AMERICA? Yes NoARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA? Yes No IF A NATURALIZED CITIZEN, PROVIDE THE FOLLOWING INFORMATION: Date of Naturalization City and State I, THE UNDERSIGNED, UNDER PENALTIES OF PERJURY, SWEAR OR AFFIRM THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. SHOULD ANY OF THE ABOVE INFORMATION CHANGE, I AGREE TO NOTIFY THE LIQUOR COMMISSIONER WITHIN SEVEN DAYS OF THE CHANGE. Printed Name and Dated is your Electronic SignatureBASSETT TRAINING LIST Per City of Geneseo Liquor Ordinance Section 110.17Q Paragraph (Q) An applicant for any liquor license who has not provided evidence of the following: evidence to the Commissioner that all employees who will be engaged in mixing, preparing or delivering alcoholic liquor to to customers, guests, or patrons, have successfully completed a Beverage Alcohol Sellers and Services Education and Training (“BASSETT”) Program conducted by an agency licensed by the Illinois Department of Alcohol and Substance Abuse or training provided by the insurance company providing coverage to a license holder. Each new Such employee hired by the licensee after issuance of the license shall complete a BASSETT program at the next Available training session or within sixty (60) days of actually beginning work, whichever comes first. A copy of the certificate of completion of such BASSETT program for each such employee shall be filed with the Commissioner. Each certification shall be renewed every three (3) years from the date of issue. Organizations that are issued a Class F, Special Event License shall not be required to have their servers trained as set forth above. Organizers of a Class F Special Event shall meet with designated City Officials to go over standard protocol for serving alcoholic beverages prior to the event. LIST OF ALL EMPLOYEES WHO WILL BE ENGAGED IN MIXING, PREPARING, OR DELIVERING ALCOHOLIC LIQUOR TO CUSTOMERS, GUESTS, OR PATRONS Bassett Training Certificates Drop a file here or click to upload Choose File Maximum upload size: 104.86MBCertificate of Liability Insurance Drop a file here or click to upload Choose File Maximum upload size: 104.86MB Submit
