Application for Liquor License Application for City of Geneseo, Illinois Liquor License Application for City of Geneseo, Illinois Liquor License Date Applicant - Corporate Information FEIN ILLINOIS BUSINESS TAX NUMBER ILLINOIS LIQUOR LICENSE NUMBER Contact Information Name Address Phone Email Status of Buisness Checkboxes 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 AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country SSN DOB Title Position Percentage Owned Add Another Owner Yes No Ownership Information Full Name Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country SSN DOB Title Position Percentage Owned Add Another Owner 2 Yes No Ownership Information Full Name Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country SSN DOB Title Position Percentage Owned TOTAL PERCENTAGE OF ALL STOCK HELD BY ALL PERSONS WITH LESS THAN 5% Percentage Business Premises Information Enter 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 file size: 157.29MB Diagram of Premise Drop a file here or click to upload Choose File Maximum file size: 157.29MB Attach 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 Address Fee 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 A $750 City of Geneseo Liquor License B $750 City of Geneseo Liquor License C $750 City of Geneseo Liquor License D $750 City of Geneseo Liquor License E $750 City of Geneseo Liquor License G$1000 City of Geneseo Supplemental All Class's $250 Other Fees First Time Applicants Administrative Fee ($750.00) Background/Fingerprinting (36.50) Public Hearing Processing Fee ($200.00) TOTAL AMOUNT SUBMITTED Payment Options: Online Payment or Check made out to City of Geneseo (Payment must be received before Application is processed) Eligibility Questions These 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 No BEEN CONVICTED OF A GAMBLING OFFENSE? Yes No EVER APPLIED FOR AND BEEN DENIED A LIQUOR LICENSE? Yes No EVER HAD ANY PREVIOUS LIQUOR LICENSE OF WHICH HE/SHE WAS A PART OF THE APPLICATION REVOKED? Yes No BEEN 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 BEEN 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 No Resident 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 file size: 157.29MB HAVE YOU EVER BEEN CONVICTED OF A FELONY? Yes No HAVE YOU EVER BEEN CONVICTED OF A GAMBLING OFFENSE? Yes No HAVE YOU EVER APPLIED FOR AND BEEN DENIED A LIQUOR LICENSE? Yes No HAVE YOU EVER HAD ANY PREVIOUS LIQUOR LICENSE OF WHICH YOU WERE A PART OF THE APPLICATION REVOKED? Yes No ARE 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 No ARE 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 Signature BASSETT 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 file size: 157.29MB Certificate of Liability Insurance Drop a file here or click to upload Choose File Maximum file size: 157.29MB If you are human, leave this field blank. Submit
