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ORD NO 24-2026 CITY OF VAN BUREN,ARKANSAS . ORDINANCE NO., -2026 BE IT ENACTED BY THE CITY COUNCIL, FOR THE CITY OF VAN BUREN, ARKANSAS, AN ORDINANCE TO BE ENTITLED: AN ORDINANCE AUTHORIZING CONSUELO SOCORRO POSADA TO FILE AN APPLICATION FOR A PRIVATE CLUB PERMIT,PURSUANT TO A.C.A.3-9-222 WITH THE ALCOHOLIC BEVERAGE CONTROL DIVISION, AND FOR OTHER PURPOSES. WHEREAS, Consuelo Socorro Posada has presented to the City of Van Buren, Arkansas, for consideration of an application for a Private Club Permit for a business to be known as "Perez Familia and Co., LLC"to dba"Tres Amigos Mexican Grill" and located at 700 Main Street, Van Buren, Arkansas; and WHEREAS, the City Council of the City of Van Buren, Arkansas, believes it is in the best interest of the citizens of the City of Van Buren, Arkansas to authorize Consuelo Socorro Posada to proceed with such petition before the Alcoholic Beverage Control Division. NOW,THEREFORE,BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF VAN BUREN,ARKANSAS, THAT: SECTION 1: The application submitted by Consuelo Socorro Posada for her Private Club Permit is hereby approved to be submitted to the Alcoholic Beverage Control Division. IN WITNESS WHEREOF, the�ty of V�en, Arkansas, by its City Council, did pass, approve, and adopt, by a vote of for and against, the foregoing Ordinance at its regular meeting held on the 26th day of May 2026. G\erk 7-re,,,,, rews 1� City of Van Buren P. Hurst Mayor N ATTESTED: ��ryCounty,Pt�a�w APPROVED AS TO FORM: Shawnna Reynol Jacob Howell City Clerk/Treasurer City Attorney DrA-ALCOHOLIC BEVERAGE CONTROL 101 E. Capitol Ave.,Suite 401 ' State of Arkansas p Department of Finance Little Rock,AR 72201 p Plione: (501)682-1105 :LS - And Administration Fax: (501)682-2221 littps://www.dfa.arkansas.gov/alcoholic-beverage-control Private Club Application (Select a wet or dry county designation based off the county the business is located.) ❑ Wet County ($1,500.00) JZDry County ($3,000.00) Instructions 1. The Private Club Permit authorizes the purchase of controlled beverages from persons holding an off-premises retail liquor,and the dispensing of such beverages for consumption on the premises of the private club. 2. Fully complete this Application. Incomplete Applications will not be processed.The Application must be notarized by a notary public, and all required documentation must be complete and attached to the Application unless otherwise noted. 3. Applicant or named managing agent must be a citizen of the United States,or a permanent resident alien.If a permanent resident,applicant must provide a copy of his/her Green Card.Applicant must also be an Arkansas resident and reside in the county in which the physical business is located or live within 35 miles of the business unless otherwise noted by Arkansas statutes or ABC Rule. 4. Applicant must visit ARKANSAS LIVESCAN(arkansaslivescan.com)and conduct a criminal background investigation prior to submitting the application.Applications CANNOT be processed until the background is received by our office. (5. If Applicant is purchasing an existing private club with existing alcohol permits under a non-profit organization, the Private Club Board of Directors must provide a written request for any changes to be made to the permit by submitting a Replacement Notice which gives written permission authorizing the new management to operate under the previous management permit until the new applicant/manager can obtain a permit. 6. If application is for a NEW private club,the applicant must submit an ordinance from the governing body of the county or municipality in which the private club is or will be located pursuant to Ark.Code Ann,§3-9-222 to show the approval jW of the application by the corporation,partnership,individual,or limited liability company from the body or municipality. 7. Application must also include each person who(1)holds more than 5%of the stock of the corporation or(2)is a member of the LLC/LLP(these individuals do not have to be Arkansas Residents)see pages 8 and 9 of this application to provide this information.Additionally,please submit the following information: a. A FILE-MARKED copy of the Articles of Incorporation/Articles of Organization(All pages) must be submitted. b. If trade name is different from legal name a FILE-MARKED copy of Fictitious Name Registration(All Pages)must also be submitted. / c. The Business Federal Employee Identification Number(EIN)can be disclosed for all corporations/LLCs. ( 8. Applicant must provide at minimum three(3)different photos of the business location.These photos should show the front,side and back view of the exterior of the building. a. Please attach physical copies of the photos to this application upon submission. 9. This Application must include a floorpian (can be hand drawn or computer generated and should be 8 Y2 x 11 inches). The floor plan must show the full boundaries of the business,including any outdoor patio or porch that will be used for 1 ABC-PC(02-2026) `)1�` � �kx� �' X C _ customers. The plans must be fully labeled, indicating customer areas, dining areas (if applicable), employee areas, bathrooms, kitchens (if applicable), alcohol sales areas,alcohol storage areas, cash registers/check-out stands and all entrance/exit doors. Floor plans MUST be legible and easily show the full scope of the business's premises. 10. For On-Premises permits a full and detailed list of activities at the business must be provided (cafe/restaurant/food service, pool hall, dancing, live bands, dancers, etc.)! Using the space provided below please list of all the on-site activities your business will offer.If more space is needed,you may attach a separate sheet of paper.Please be advised that under 3 CAR§ 1-304 any permit issued by ABC is only valid for the uses described in the original application.Any material changes in the outlet's operations or entertainment other than originally listed,without prior approval of the ABC director,shall be grounds for revocation of the permit or other administrative penalties. 11. The business shall own or lease, be the holder of a buy-sell agreement or offer and acceptance,or have an option to lease a building,property,or space for the reasonable comfort and accommodation of its members and the families and guests of its members.A copy of the lease,deed or agreement must be submitted with this application. �J 2. n addition to this application your business must also apply for and receive a retailer's/sales tax permit from the Arkansas Sales and Use Tax section.You will be required to provide our office with a copy of your Sales and Use Tax certificate (preferably submitted with this application) and your account with SaleS—aDd•-Use—Tax UST be in good standing. For any questions regarding this process please c n�ct Sales and Use Tax at 501-682-7104. 13. At time of submission of this application the applicant must also provide payment of th $3,OOO.00)dry counties) or $1,500.00(wet counties)application fee with either a check or certified funds(money order or cash ei rs check).WE DO NOT ACCEPT CASH! .1- a. Submit half of the amount listed above when making application after December 11'and before May 1s1. b. All private club's annual renewal fees are$1,500.00. c. NOTE:To the extent an applicant needs any other Alcohol Permit(s)for their business,those applications must be submitted independently of this permit application. Definitions■ Applicant.Means the person(sole proprietor/single owner)or business entity applying for an alcohol permit. ■ Manager.The person named by the Applicant or Private Club Board who agrees to live within 35 miles of the physical location of the business and be responsible for the ABC permits at the business. This person will be considered the manager of the permit and will have the legal authority to sign and accept and submit legal documents as pertaining to these permits on the Private Club behalf. ■ On-premises consumption. Means the sale of alcoholic beverages by the drink or in broken or unsealed containers for consumption on the premises where sold or within the boundaries of a designated entertainment district under ACA§14-54- 2523 that is contiguous with the premises. ■ Private Club. Means a nonprofit corporation, sole-proprietorship, corporation, partnership, or limited liability company organized and existing or authorized to do business under the laws of this state. ■ Restaurant. Means any public or private place that is primarily engaged in the business of serving a meal for consumption on the premises to a guest and has a suitable kitchen facility to serve the entire menu approved by the Alcoholic Beverage Control Division.The menu shall contain a selection of food and shall not be limited to sandwiches or salads.The kitchen shall: have adequate refrigeration to preserve the food on the menu, be kept in a sanity condition, and comply with the rules of the Department of Health. Food from the menu shall be available from opening time until two(2)hours before closing time. ■ Meal.Means the usual assortment of food commonly ordered at various hours of the day. 2 ABC-PC(02-2026) Generill information—Applicant MUST answer�ach question' 7 1. Do you,Applicant, understand and agree to follow, stay current on, and comply with all local, federal,and state laws, pertaining to Alcoholic Beverages. YES❑ NO A full list of rules&regulations can be found on the ABC website: https://www,dfa.arkansas.gov/office/alcohol-beverage-control/ 2. Do you,Applicant, understand that it is illegal in the State of Arkansas to give,barter or sell to anyone under the age of twenty-one(21)alcohol in any form? YES❑ NO 3. Has Applicant or any person who owns or operates the business been denied a permit,license, or other authorization to engage in any business by any government agency(federal,state,local or foreign)or had such permit,license or other authorization revoked,suspended or otherwise terminated? YES NO • If yes,please attach to this application the details of each occurrence, 4. Has Applicant or any person who owns,operates,or manages the business ever been convicted of or found in violation of any Arkansas alcohol statute,rule,or regulation? ❑YES NO • If yes,please attach to this application the details of each occurrence. s. Are you,Applicant, purchasing an existing ABC permitted retail location? YES❑ NO • If yes,please provide a Replacement Notice Form (obtained from ABC) which authorizes you to operate using the current ABC permits while your application is processing. 6. Does Applicant verify and agree that it will not operate out of a residential address and that it / will be in compliance with all applicable local, state & federal ordinances, including but not ©YES❑NO limited to zoning,building,&health ordinances? 7. Do you, Applicant, understand and agree to provide written notice to the Arkansas Alcoholic Beverage Control Director when the business changes physical locations? YES❑ NO • An ABC permit holder must receive ABC approval prior to making any sales at a new location by submitting a Transfer of Location Application provided by the ABC office. 8. Do you Applicant, understand that if your business is a private club the business MUST exist for some other reason than the consumption of alcoholic beverages. YES❑ NO • Please be detailed and specific in your list of activities at the business as outlined on the instruction page of this application and in 3 CAR§1-304 of ABC rule.If you are in doubt about whether to list 3 ABC-PC(02-2026) and Item,you are urged to include it.Please attach a separate sheet of paper to this application if the space provided is not adequate to list all activities. 9. Do you, Applicant, understand and agree to submit a change of manager notice to the ABC Board within thirty(30) days of a change in (i)the managing partner, limited liability company managing member, or president or chief executive officer of a corporation, partnership, or ZYES❑ NO limited liability company; or (ii) the stockholders affecting more than five percent (5%) of the total voting shares of a non-publicly traded corporation? 10. Do you, Applicant, understand and agree to maintain a copy of the signed server awareness forms for each employee who engages in the sale of any alcohol products, which you must YES❑ NO provide immediately upon demand by ABC and its authorized Agents? 11. Do you,Applicant, understand and agree to display in a conspicuous place a sign indicating that the sale,purchase or possession of alcoholic products by a minor is prohibited by law? YES❑ NO 12. Do you,Applicant,understand and agree to display in a conspicuous place a sign indicating that the consumption of alcoholic products while pregnant is harmful to the health of an unborn YES❑ NO child? 13. Does Applicant understand an ABC permit cannot be issued until the Arkansas Sales Tax office deems the business to have a clear account? YES❑ NO • If your account is not clear,you must satisfy any debtor clear your account before ABC can approve your permit. Please attach a copy of sales and use tax certificate to this application. Should you have any questions please contact Sales Tax Compliance at 501-683-5560, 14. Do you, Applicant, understand if you are a new location or are changing/amending previous permit types at the location you will be required to post a public notice poster in a conspicuous YES❑ NO location at the business(typically on or above the main entry doors)for a minimum of 30 days, to notify the public of Alcohol Sales and provide the public the opportunity to dispute the opening of your business? • The poster will be given to you along with formal posting Instructions at the time the application is submitted to the ABC office. 15. Do you,Applicant,understand if you are a new location or are changing/amending previous permit types at the location the business must also advertise to the public that a license is being requested and provide our office with proof of publication?Publication runs either 2 or YES❑ NO 4 times depending on the permit type. A verification of posting must be submitted and shall be posted for no less than 30 days. • Posting instructions will be provided to you at the time the application is submitted to the ABC office. 4 ABC-PC(02-2026) 16. Do you,Applicant, understand that under NO CIRCUMSTANCES should any alcoholic products be given away for free? ZYES❑ NO 17. Do you, Applicant, understand that as part of this application process you MUST attend an Educational Seminar class hosted by ABC Administration? YES❑ NO • Please check the ABC website for dates of upcoming seminar classes and locations. https://www.dfa.arkansas.gov/office/alcohol-beverage-control/ 18. Do you,Applicant,understand that as part of this application process you MUST successfully complete and pass an inspection by an ABC agent to ensure that all requirements are met,all codes and ordinances are being followed,and the facility is truly ready to operate and serve YES Q NO Alcoholic Beverage Products? • This inspection will be scheduled by you at a time that is convenient for both parties. PLEASE ENSURE your business is truly ready for an inspection. Any issues or deficiencies found at the inspection will delay your permit approval time and require further inspections to show corrective actions have been taken to come into compliance. 19. Do you,Applicant,understand that ABC applications will not be finalized until they are approved by the ABC Board? YES❑ NO • The ABC board only meets one time each month.It is your responsibility to ensure your application packet is completely and accurately filled out so that it may be submitted to the board for approval. 20. Do you,Applicant,understand that there is no set timeframe for our office to process and issue you an ABC permit?The timing is completely dependent on the completeness and accuracy of your application packet as well as the time it takes to clear your accounts with other state agencies, receive your completed background checks, perform your final inspections, and get YES Q NO approval from the ABC board.Our office will typically have permits ready for pick up within 60 days of submission,however this timeframe cannot be guaranteed. • Permits cleared for release will be available for pick up or wili be mailed on the day following the board meeting in which your application was approved.Permits CANNOT be printed early or until fully approved. 21. Do you,applicant,agree to and understand that if you are a Non-Profit you must have,at time of application and continually maintain, a list of members for the private club? This list of YES❑ NO members must be available at the business location. Application continues next page! s ABC-PC(02-2026) BusiHess Inforination Permit Fee type:$3,000.00 Private Club(Dry County)$1,500.00 Private Club(wet County)NO CASH Legal Business/Company Name: Try Business Designation: ❑Sole Proprietorship(Single Owner) LLC❑INC❑Partnership ❑Corporation❑Other If Corporation:Publicly traded?❑YesVNo C Corp.❑S Corp. ❑Other Type Name of Business if different from Legal Name: (Any fictitious name or`Doing Business As"(DBA)name must be filed with the Secretary of State's Office) Sales Tax Number: FEIN: (if applicable) Physical Business/911 Address: I Suite/Unit#: r (Must be numeric address plus street name(example: 152 Smithy AStt);CANNOT be a P.O.Box or location description�)-7 _ City: V County: Nr u�t Zip Code: 1 Township: (applicant must verify and disclose the legal township where the business is located) Business Mailing Address(if different): Suite/Unit#: (This is the address where you want to receive any and all mail communication from ABC;CAN include P.O.Box) City: / County: Zip Code: Is the business inside city limits?®YES ONO Is the beer to be sold in connection with another business?DYES NO If yes,please list name and type of business: Store Phone Number: U_ - Secondary line if applicable: Has another business,to your knowledge,held a beer or any other ABC permit at this location? ®YES ONO 2� q0 _f) Previous ABC Permits)(if applicable): Business Email: gyres 1 0 ry)cW . Note:Alcoholic Beverage Control primbrily uses e-ynaiAb cominimicate with ermit holders.Please provide the most up-to-date email for your business that is reviewed frequently.Ifyour email address changes for any reason,please notify us immediately. Facility in ormation: ❑I own the property /rent this property ❑other (A copy of lease or option to purchase must be attached if applicable.)�n 1 J If rent/lease,Landlord name: j Gr�v n Phone Number: 0 z(o -Li el-7^ 'i 13Y Contact Address: 3 O O 1 0—i AA—_ C t>V F--OP--T -`��t l,tr`1'1'1 A fl--, -121 0,2 Does the business serve food(restaurant,cafe,etc.):DYES ONO IF YESPLEASEATTACHA COPY OF YOUR MENU If yes,do you have an Arkansas Health Department certificate for on-site food preparation and sales: OYES ONO If yes,please list your Health Department Certification Number: (Please note the Health Department certificate must be presented to the agent during fi►tal inspection for verification) 6 ABC-PC(02-2026) Additional Pellinit(s) Request—WET COUNTIES ONLY For businesses in a WET county the following permits can be added to a Private Club Permit.Each permit has its own fee amount that must be paid in addition to the price for the Private Club Permit Fee.These permits will allow the business to purchase beer or wine from a distributor which is otherwise prohibited with the private club permit. Choose the option for Retail Beer and any subsequent Wine options that best fits your business needs: Non-Restaurant Options(these options are for businesses not classified as a restaurant.) On Premises Wine(allows on premises consumption without food)$500.00 Retail Beer On Premises(allows on&off premises consumption without food)$350.00 Restaurant Options(only allows on premises consumption) Caf6/Restaurant/Wine(allows on premises consumption with food)$300.00 Combo Beer&Wine(allows on premises consumption with food)$350.00 Total Payment: $ (Please ensure you have totaled all applicable permit fees for each permit you are requesting.) (Example:$1500.00+$500.00+$350.00=$2,350.00 Type of Application(Please choose one): New Business(an existing business holding an ABC permit is NOT involved.) Replacement Application(An existing business holding an ABC permit IS involved.) "Must submit replacement Notice. Application continues next page! ABC-PC(02-2026) Entertaininent/Activity Information FOR ON-PREMSIS CONSUPTION PERMITS ONLY-Using the space provided please list all activities and/or forms of entertainment that will be offered at the business as outlined in 3 CAR§ 1-304.(please attach a separate sheet of paper if needed) '�h -� i 1 0 t S m Infx� r(A I�1 � s � n e l n Wmh MA bin iwvi WN(AMb Val- Y W _ QK Wry) Dtlun . ri I ' U Si ru r� fi r _ 60 '(W5I Y Sa Y is 0 MIN WAInA Y6 . VIV MIN C(AS.WoLl nfflf Ut (A Uib MySU/ / tt� 0 cawn mn.111A US uhf/Vle I Pf(jujV-d holA S 0 (97 0 () ore nIMM 40 0 - t -O - It r Y I ° D rim 01 - U If the business is a Dance Hall/Club with on premises patron dancing, please provide the size of the dance floor: x *Please note that pei foi-niance dancing or entertainer dancing has specific requirements that must be followed as outlined in 3 CAR§3-401 8 ABC-PC(02-2026) / i Owncr/PresidentlCEO Demographicj Information: II NOTE:hJormation must be for the legal head ofthe company. �J/� Owner/President/CEO Name: �S y l��) nn�UI�b Date of Birth:�l�I G�"t"l Home Address: 0 2,4 OLd N!10,d MAY SuiteMnit#: n' r`' t be a numeric address plus street n me; j�jT�b�e6PP�.O.Brix or location description) 1295 ^� 7 _ City: � ((}Vpyp L tr n County:�.`, "I�/-1��—►�aA. Zip Code:17 5 lY E-mail Address: Qjpk-l.NMI,,10li��W1 Phone Number: �-�— Driver's License/ID Number: State of Issuance: Alien Registration No.: SSN:Q2J I C1 Percentage of Ownership in business: % Gender: Do you live within 35 miles of the business or within the same county? gpYES ONO *If no yott iW11 need to declare a manager who does live within 35 miles of the location to be the printa►y contact petsotr/perntitee for the business. Manager/Prrimarr�y�Cnontact Inf ormation: /� Must live within 35 miles of business. Name: �,U�1alo Date of Birth:V /OZ- /—NO Gender: Home Address; LW 2�` V ' OV6 WM Suite/Unit#: (Must be a numeric address plus street name; CANNOT&(a�P..O.Box or location description) city: von �u a ty:l�l W 6 rd p r f,0 SIP Ci //���nf+Conn Zip Code: l� /,, E-mail Address:C)C 1JV%ez-l� ��ll f N I. Phone Number: '( ?q ) 1�- _ 3_ U0 Driver'sLicense/ID Number CI� q,) `"1' I It State of Issuance: Alien Registration No.: SSN:0�--�4 -52— - 2- 1 -! How many miles from the location does the person live? J Does the manager understand that they might be called at any time day or night to appear onsite at the business to respond to activities or provide information needed by ABC in process of an inspection or investigation? YES ONO Does the manager understand and agree that they will be held responsible for all employees in the establishment and can face prosecution under the full extent of the law for any violations of Arkansas Alcoholic Beverage Laws,Rules,or Statutes?)6YES ONO Does the Manager understand that in the absence of the owner of the business they will be considered the primary responsible party and will be expected to present all documents,invoices,sales t nsactions,or any other material deemed necessary in the course of an Inspection or Investigation at the establishment? YES ONO Date: Signature of Manager Date: Signature of Owner 9 ABC-PC(02-2026) Use the following pages/sections to (1)list any other person(s) considered owners(Example: Wife/Husband, Brother/Sister, Son/Daughter, etc.) OR (2) to list any other business partners,LLC members, company officers, stockholders, etc. Please note it is also recommended that the person(s)are also listed on your sales and use tax permit. USE ADDITIONAL PAGES AS NECESSARY i Officer/Partner/Stocltlrol(ler Information: If dii f"erentfivan orvne)/Presideut/CEO/Manager Name: Date of Birth: Horne Address: Suite/Unit#: (Must be a numeric address plus street name;CANNOT be a P.O.Box or location description) City: County: Zip Code: E-mail Address: Phone Number: (� - I am a: US Citizen_Permanent Resident Alien Percentage of Ownership in business: % Driver's License/ID Number: State of Issuance: SSN: - - or Alien Registration/Green Card No.: Have you ever pled guilty,pled no contest,or been convicted of a Felony? OYES ❑NO Have you been convicted or any violation of any laws related to alcoholic beverages within the last 5 years?❑YES ONO Have you ever previously or currently been involved or held stock in a ABC permitted location? ❑YES ❑NO Officer/Partner Information: Name: Date of Birth: Home Address: Suite/Unit#: (Must be a numeric address plus street name;CANNOT be a P.O.Box or location description) City: County: Zip Code: E-mail Address: Phone Number: I am a: US Citizen_Permanent Resident Alien Percentage of Ownership in business: % Driver's License/ID Number: State of Issuance: SSN: - - or Alien Registration/Green Card No.: Have you ever pled guilty,pled no contest,or been convicted of a Felony? ❑YES ❑NO Have you been convicted or any violation of any laws related to alcoholic beverages within the last 5 years?❑YES ❑NO Have you ever previously or currently been involved or held stock in a ABC permitted location? ❑YES ❑NO 10 ABC-PC(02-2026) Important Information Please note that this application MUST be completed in its entirety. Any application that is submitted that is incomplete will not be accepted and will be returned to the applicant. Please review the application to ensure that you have provided all required information and documentation for application submission. By accepting a permit from Arkansas Alcoholic Beverage Control, the permit holder is agreeing that they, and their business, will follow all lawful requirements and furthermore acknowledge that they understand that Alcoholic Beverage Control Agents, or any other official Law Enforcement Agency will periodically conduct inspections and compliance checks to ensure compliance with the law. I,egal Responsibility-Application Signature Page By dating and signing below,I certify and attest that I am an owner or duly authorized agent,partner, officer,or applicant and hereby declare and sign under penalty of law that the information provided on this application(all pages, 1 through 10) is true and correct to the best of my knowledge and belief. The undersigned applicant also agrees to faithfully comply with all local,state,and federal laws including,but not limited to,all rules promulgated pursuant thereto, and all lawful orders of the Alcoholic Beverage Control Board. Applicant understands and agrees that any intentional false or misleading information,of any nature or relative to any item,will be sufficient grounds for denial or subsequent revocation of the permit for which he/she is applying. Date: Signature of Owner or Authorized Representative—(Please sign in notary's presence) Printed Name of Owner or Authorized Representative Business Title of Owner or Authorized Representative Notary InfoLmation Subscribed and sworn to before me,a Notary Public,by ,to me well known or identified to me by government issued photo identification,on this day of .20 My Commission Expires: Name: Please place Notary Stamp in box For office use only:Date Received II ABC-PC(02-2026) C = li'�i' Ffybo Application for Criminal History Check for Alcoholic Beverage Permit A.C.A 3-2-103 (Sce udwr side for instructions) Pull Name Lank Name First Name Middle Name All other trtntt.:evr.r used (ntzu'ried names, 111aulc1l, Date of Rirth; ..o(D f n `qqq _ St'tW of 13i Ah (n'�lnlh(I)il1 f Y l'ili') Citizenship: _.U _.._ _ _ - . - Rac:c: W _ . .__ -. Sex: . }'r ( c)IC1t': I Mil Color: Height: �l ._ _.. Weight: V V tibcictl Security It: ULb ` 1 ... .____._ I7rivrt 's Licct�se ;'l: I�} (� �II Starr. ivIn lin), Addi-css: 4ly� l State ZIP Doty Time Phone:1 I (11VC MY CONSENT POIRTHE ARKANSAS 133TKI T,' POLICK 'O CONDUCT A CRIMINAL RECORD SEARCH ON MYSELF AND I?KLEIASL ANY IRE,SUI;I;S '1'0 THE POLLOWING PI*-;RSON AND/Old ENTITY: ?m- 0 ,. ' ( GP + [ +-, 7 Full Name of Person/Isttlitt `' ✓ MttiliitT; Adclt c sti: VC1 t street ._..______--_._--..._._. City State ZIP C Sil,l�atttrc: Date: _ •nr:1/,1-il/i.ast. Nantr) � (Month) )ii�•jYc.u•) _For Official Use Only L] 82005 Civil hecc�rei Che'el< — 80019 li*131 lReee�r'el Cltc.e I< 80006 FBI Record Che cIe__..... NEWSCHAO102 SCIAED1,11.1" A - INDIVIDUAL'S PERSONAL I US-rolly Application filled by Applicant - A, Stock holder/Nt rtner - S I submit anXwers to the following questions under oath: I Name U- SAW. -,--.Sex Date of Birth-ow 2. Home Address Lola Street 0_ ._VV_d __ft. ____. Phone No. y Zip 3, lz6ralr_� ci, r, you a person of good character and reputation in your community? 1. Ale you (CITIZEN PERMANF. ENT ALIEN) Of the United States? CIRCLE ONE Social S6 Green Card No. 5. Are you a resident of the county in which application has been made? If not, do you live within 35 miles of the premises to be G. Have you ever been convicted of a felony? YES_ NOX_ If so, give full Information 7. Have you been convicted of any violation of any law relatitigto alcoholic beverages within the rive (5)years preceeding this application? YES NO If so, give full information_.,. B. Have you had any alcoholic bpverage permit issued to you revoked within the five (5) years preceeding this application? YES NO 2<, If so, give full information 9. Do you presently hold or have you ever held an alcoholic beverage permit($)? If so, give flame, place, and permit number(s) I k- Of ve you applied and been refused a permit at the applied for location within the last 12 moilths? So, give full Information 11, Marital Status: Single Married �) Divorced Separated otlic!f. 12. Furnish complete Information regarding members of Immediate family: R.e.1aL'Q.n5hJP Ek&hlJQMQ Wdr= I�V��(�l'�I_.__��������w�.1�1'`�d.0.___'-����l�I_��vGl�..._ r � I►�� wG�1�� VLAII13nn �ACIP02 1 i I (a) Are any of the above to be connected with the Operation of the outlet? (b) If so, who and in what capacity? � � 13. Give your home address (city or town) and dates at each for the past five (5) years; Z __ 1_ .ktfid1 ��1�t�a_ 1�1t-n-__f L __1.2-q5Ze -. 14. (::overing the past five (5) years, give in detail the following: MM !>lame��sLc�c,��.s...of.�mlalgy,�z P�.��..4.f-F.tJ(II2LQYl11.etlt l k UO�L- "^r^Ly state on oath that I will not violate any law of this State or any regulation of the Alcoholic BeverayL Control Division, nor will any agent or employee be allowed to violate any law or regulation. It Is hereby consented that the licensed premises and its books and records shall be open at all times to all law enforcement Officials without warrant or other legal process. ._...�....�..T_.._._..STATE OF ARKANSAS Applicant's Signature COUNTY of --- - — — , being first duly sworn on oath deposes and says that he/she has read each of the questions to which he/she has made answer, and that his/her said answers in each instance are true and correct. Subscribed and sworn to before me this _ _ day of-___-_____, Notary Public My Commission Expires; AUTHORITY HORITY TO RELEASI" INFORMAI-I0I1 Application filled by Applicant - A, Stockholder/Partner - S ; TO WHOM IT MAY CONCERN: I understand that the Alcoholic Beverage Control Enforcement Division will conduct a thorough investigation before a final decision is made regarding my eligibility to hold an alcoholic beverage permit, This investigation may include inquiries as to my character, reputation, and the location and feasibility of a permit being issued at the applied for location. To facilitate this investigation, I do hereby give my consent and authority for any public utility or police agency to furnish information from their records to the Alcoholic Beverage Control Enforcement Division and the Alcoholic Beverage Control Board. Signature - Full Name Home Address VM City, State ` zip Mailing Address City StateState Zip Contact Phone Business phone E-Mait Address Sworn and subscribed before me this day of Notary Public My Commission Expires: (Revised 3/08) REPRPNC0101 r i REPLACEMENT NOTICE , DATE: (Must be within 90 days of receipt of application) I• Cm '�orss do hereby give permission to operate on my permit(s) until such time as consideration of his/her replacement application is completed by the Alcoholic Beverage Control Division. Type Permit(s) - - �ll1Ct� C VIa C/,, 'Js /q Permit No. (s) j 7 �O ` C? Business Address 7— -72-p`r6_ _ Permittee's Signature Sworn to before me this day of Q Notary blic ~ �.� My Commission Expires: NOTE: Pursuant to Section 1.20(18) of the ABC Regulations, permission to use tire above listed permits) may not be withdrawn once (lie application is submitted and accepted for processing. WENDY GOMEZ CRAWFORD COUNTY NOTARY PUBLIC-ARKANSAS My Commission Expires SEPT.30,2032 Commission No.12720926 AUTHORIZATION FOR RELEASE OF TAX INFORMATION Excise Tax Administration Room 2420,Ledbetter Building P.O.Box$054 Little Rock,AR 72203-8054 Telephone:(501)682-7200 Fax:(501)682-7900 The information will not be released until the original signed document is received. ' Company Name ca, 6�N des Address _ 700 City Vl�-N . U I�L�-� State Zip 7� FEIN �7�j Social Security Number Do you have employees in Arkansas? F YES Xj / NO Taxable? i_ Corporation C Sub-S (' Partnership f Sole Proprietorship If a subsidiary of a parent corporation filing a consolidated return with Arkansas,give the name of the parent and parent federal employer identification number(F.E.I.N). If the business is a Sole Proprietorship,enter the social security number(S.S.N)of the owner,in addition to the F.E.I.N of the business. AUTHORIZATION FOR RELEASE The taxpayer Indicated above hereby authorizes the Arkansas Department of Finance and Administration to release information to the following individual: _} Name bus- Address q04 _Wja� V City VfAn_�3m-h to zip (� Phone ) L+ _ vice president,secretary/treasurer,or owner. lbad.o_ Rrj& Email Ut Taxpayer name and tide printed as shown above Subscribed and Sworn to before me this day of ._ G�_ _ 20 2(o _, Notary Public WENDY GOMEZ K 030201. CRAWFORD COUNTY Clear Form Print Form rurrn troor NOTARY PUBLIC-ARKANSAS My Commission Expires SEPT.30,2032 Commission No. 12720926 V AN BURE N HISTORIC DIS RIC COMMISSI ON 11 1 12111 Street Van Buren,AR'12956 479-•4/J 5006 APPLICATION FOR ' oll NN uu HH''II q P �r !! y 7 DD ll 11'' aa NN //�� pp �, �,C AA ��,ri�,7�:I��ttri� H`4.A�CIV `��� �nriD�➢�'�a(l�Xp�b1t1'hrri FNF.SS tC��A) I Application Number Fee: $2.0.00 Paid: Y/N Cliecic # PROPERTY OWNER NAME,: 0 jU 4AIle-V Address: t�(_ -t ffk CGvt7 J b 62 `_0?7- 33 y II) BUSINESS OWNER NAME: i( ��OSGlC�01 Address: 2 _!���� �� �L� _1_v l►l_�,N_M—P—d2 COO`T2� III BUILDING DATA Datc of('ollstruction/Bltil(lin T ilistor r t Original Use of Property: `1 &N I --__--_- .- Current Use of Property: CUSS IV) DESCRIPTION OF PROPOSED WORK AND MATERIALS (See below for complete description requirements): Estimated Dates of Proposed Work: Project Arcliitect/Engineer/Contractor: Address _ -_ Telephone V) IDENTIFY THE HISTORIC DISTRICT GUIDELINE SECTION THAT APPLIES: 10.3 Awnings _ 10.5 Banners 10.6 Brick/Masonry 10.8 Color(Fagadc) 10.13 Flags 10.16 Lightin&, Any Other Sections) 10.25 Signagc (Size: Color: Font: ) VI) Submit the following hkfoi-matioii with the application. The Van Buren Historic District Commission cannot review your applicotio„ unfit the „ecessa,•y nttorninflon is submitted. SECTION 10 GUIDELINES FOR EXISTING BUILDINGS: A. Accurate (scaled)sketch,photograph, or drawing of each elevation where changes are proposed, showing existing appearances and proposed changes. B. Description of materials to be used and an overall scheme, including,but not limited to, fowidation, walls, trim,windows,doors,roof' chimneys, and any other exterior surface or detail. SECTION 10.10 DEMOLITION: A. Current photographs of each elevation. 13, Current evaluation by professional architect,engineer. C. Demolition cost estimate. SECTION 10.25 AS[GNAGE OR WINDOW LETURING A. Attaeh a drawing of your proposed sign or window lettering, including,dimensions, font, and size, alone; with historic colors. SECTION 12 GUIDELINES FOR NEI W CONSTRUCTION: A. Accurate (scaled) sketch ofall elevations showing proposed appearance and its relationship to adiacent and nearby buildings. B. Description of materials to be used including all exterior surfaces and details. VII) Application must be iweive(l no later than eight (8) (lays prior to the scheditled meetiog of the V€ u Buren Historic District Commission, Ai) authorize(l rep►•ese►itative of the illll)BUIlt li►ilst attend the I1DC` meeting all([ be present (luring the consideration of the application by the Collllilissioll. Meetings are held at file City of Van Bui-en ( imicipal Complex (1003 Broad1way) on the 2"`1 Thursday of each mouth at 5:30 p.m. Signature of Applicant Date ACTION TAKEN: Approved U Approved with doted coliditiolls Denied Van Buren Historic District Commission Date Main St �j Guest u YX bob ONX xx k x �l ,< xX �{ X Q xx xx xx �x Bar xx � X Sink yam( Racks A L y Mep ra6'e Flat `�\ Grill \ Warmar Kitchen _„y. sleamcr urne ftdye Table ("+ ccl...t Fryer m j ! Cooler/ Freezer Separate address IMenMen Courtyard Gate fL (emer enc exit ��