(3180) Liquor Delivery Service Licence Renewal Application (2006

Alcohol and Gaming Commission of Ontario
Manufacturer & Special Licensing
Advertising and Promotions
90 Sheppard Avenue E., Suite 200
Toronto ON M2N 0A4
Tel: 416 326-8700
Toll free in Ontario: 1 800 522-2876
Fax: 416 326-5555
Website: www.agco.on.ca
Liquor Delivery Service
Licence Renewal
Application
Instructions
Attachments
The checklist enclosed indicates the documents
that must be submitted for your application to be
processed by the AGCO.
Where the space provided is insufficient to
complete your response, use a separate sheet of
paper and mark the question number at the top
of the page.
Incomplete applications will be returned to the
applicant with a list of the incomplete and/or
outstanding documents.
Warning
Do not fax application forms or personal history
reports. Do not mail photocopies of these
documents. Original, ink signatures are required.
Do not misrepresent or omit any material fact(s).
Each statement made in this application is subject
to verification.
If the AGCO requires more information, you will
be contacted.
It is a serious offence to knowingly provide false
information on the forms and on any attachments.
Responses
Complete all questions on all applicable forms. If
a question does not apply to you, respond by
marking “N/A”.
All application forms must be completed in ink.
Do not use pencil.
Contact Information
Contact the AGCO's Manufacturer & Special
Licensing, Advertising & Promotions department
at 1 800 522-2876 or 416 326-0400 if you have
any questions.
Application forms and guides are available from
our website at: www.agco.on.ca
The provision of false, incomplete, or misleading
information or the omission of information on the
forms or in the documents submitted with your
application, or the failure to notify the Alcohol and
Gaming Commission of Ontario of any material
changes to this information which occur after this
application is filed, may also result in the refusal,
suspension or revocation of your liquor licence.
Mail or deliver your complete application
to:
ALCOHOL & GAMING COMMISSION OF
ONTARIO
MANUFACTURER & SPECIAL LICENSING
ADVERTISING AND PROMOTIONS
90 SHEPPARD AVENUE E, SUITE 200
TORONTO ON M2N 0A4
INCOMPLETE APPLICATIONS WILL BE RETURNED TO THE APPLICANT.
3180E (2006/05)
HECKLIST for Liquor Delivery Service Licence Renewal
C
Application
You must submit all of the required forms, documents and fees, or your application will be returned
to you.
The following items must be submitted for your application to be processed:
❑
Application Fee
●
●
❑
Application Form
●
●
❑
all questions must be answered; if a question does not apply, print "N/A"
must be signed and dated by the applicant(s)
Corporate Structure Form
●
❑
attach cheque or money order payable to the "Minister of Finance"
pay by Visa, Mastercard, or American Express (complete the enclosed Credit Card Payment form)
to be completed by all corporations (holding companies) which hold more than 10% of equity shares
of the corporate applicant.
Personal History Reports completed by all of the following persons:
●
●
●
●
owner (if the applicant is a sole proprietor)
all officers, directors, and persons holding more than 10% of equity shares (if the applicant is
a corporation)
all officers, directors, and persons holding more than 10% of equity shares of any holding
companies
all partners (if the applicant is a partnership)
INCOMPLETE APPLICATIONS WILL BE RETURNED TO THE APPLICANT.
3180E (2006/05)
IMPOR
TANT INFORMA
TION
IMPORT
INFORMATION
FOR
LIQUOR DELIVERY SERVICE LICENCE RENEWAL APPLICATIONS
Companies Branch (Ministry of Consumer & Business Services)
Telephone 1-800-361-3223
●
a review of Companies Branch records is conducted as part of the assessment of
your renewal application to ensure that your business name and company information
(i.e., officers and directors) are properly registered. If they are not, you will be required
to provide written proof that any required registration with Companies Branch has
been completed.
Change of Ownership
●
Your licence renewal application may not be accepted if there has been a change
of ownership that has not been previously reported to the AGCO.
●
If there has been a change of ownership, you may be required to submit a Liquor
Delivery Service transfer or new application to the AGCO.
Expiry Date
●
Your licence renewal application and renewal fee must be received by the AGCO
on or before the expiry date on your licence.
●
If the licence is not renewed before its expiry, your licence will be cancelled and
you can no longer operate your business.
Expired licences cannot be renewed.
3180E (2006/05)
Alcohol and Gaming
Commission of Ontario
Manufacturer & Special
Licensing, Advertising and
Promotions
90 SHEPPARD AVE E
SUITE 200
Commission des alcools
et des jeux de l’Ontario
Délivrance des permis aux
fabricants et des permis spéciaux,
publicité et promotion
90 AV SHEPPARD E
BUREAU 200
TORONTO ON M2N 0A4
TORONTO ON M2N 0A4
Tel./Téléphone : 416 326-8700
Fax/Téléc : 416 326-5555
1 800 522-2876 toll free in Ontario/sans frais en Ontario
Website/site Web : www.agco.on.ca
Liquor Delivery Service
Licence Renewal Application
Demande de renouvellement
de permis de service de
livraison d'alcool
1. Business Information / Renseignements sur l’établissement
Business name (as it appears on the licence) / Nom de l’établissement (comme il figure sur le permis)
Licence number
No de permis
Proposed Business name (if different from above) / Nom proposé de l’établissement (si différent de celui indiqué ci-dessus)
Unit Number / No de l'unité
Exact Address of Business (not mailing address) / Emplacement exact de l’établissement (pas l’adresse postale)
City, Town or Village / Ville ou village
Postal Code / Code postal
Telephone No. / No de téléphone
(
)
—
Mailing Address (if different from above) / Adresse postale (si différente de celle indiquée ci-dessus)
City, Town or Village / Ville ou village
Postal Code / Code postal
2. Contact Information (for processing this application) /
Renseignements sur la personne-ressource (aux fins de traitement de la demande)
Name / Nom
Language / Langue
❑ English / Anglais ❑ French / Français
Mailing Address / Adresse postale
City, Town or Village / Ville ou village
E-mail Address / Courriel
Postal Code / Code postal
Telephone No. / No de téléphone
(
3180 (2006/05)
)
—
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3. Applicant Information: select only ONE ownership type (A, B, or C) and complete that ONE section. /
Renseignements sur l’auteur(e) de la demande : cocher UN genre d’entreprise (A, B ou C) et
remplir la section correspondante.
A.
❑
Sole Proprietorship — The business is owned by one person, NOT an incorporated business. A Personal History
Report must be completed by this individual.
Entreprise personnelle —
L’entreprise appartient à une personne et N’EST PAS constituée en personne morale.
La ou le propriétaire doit remplir la formule « Renseignements personnels ».
Owner's Last Name / Nom de famille de la ou du propriétaire
B.
❑
Owner's First Name / Prénom
Corporation — The business is owned by a corporation.
Personne morale — L’entreprise appartient à une personne morale.
Name of Corporation (as per Articles of Incorporation) /
Nom de la personne morale (figurant dans les statuts constitutifs)
Jurisdiction of Incorporation: /
Palier de constitution :
Corporation number /
Numéro matricule
❑ Ontario
❑ Federal / Fédéral
❑ Other (specify) / Autre (préciser)
Note: For any corporation incorporated outside of Canada, provide proof of authorization
under the Extra-Provincial Corporations Act of Ontario.
Nota : Toute société constituée en personne morale à l’extérieur du Canada doit présenter
une preuve d’autorisation aux termes de la Loi sur les personnes morales
extraprovinciales de l’Ontario.
●
●
●
●
Name all officers, directors and shareholders.
(If more space is required, use a separate sheet.)
Indicate the percentage of equity shares held.
Complete a Personal History Report for all officers, directors
and shareholders owning more than 10% of equity shares.
●
Complete a Corporate Structure Form for all corporations
owning more than 10% of equity shares.
●
Name /
Nom
C.
❑
Partnership —
●
●
Are shares offered to the public for sale? /
Des actions sont-elles offertes au public?
Yes / Oui
No / Non
❑
❑
Date of Incorporation / Date de constitution
YY/AA
MM
DD/JJ
Dresser la liste de tous les dirigeants, administrateurs et actionnaires.
(Si l’espace fourni est insuffisant, utiliser une feuille distincte.)
Indiquer le pourcentage d’actions de participation détenues.
Remplir la formule « Renseignements personnels » pour tous les dirigeants,
administrateurs et actionnaires possédant plus de 10 % des actions de
participation.
Remplir la formule « Structure organisationnelle » pour toutes les personnes
morales possédant plus de 10 % des actions de participation.
Officer /
Dirigeant(e)
Yes/No
Oui/Non
Director /
Administrateur(trice)
Yes/No
Oui/Non
Shareholder %
of equity shares /
% d'actions de participation
détenues par actionnaire
The business is owned by two or more partners who carry on business together. A personal history
report must be completed by all individuals listed as partners. A corporate structure form must be
completed for all corporations listed as partners.
Société en nom collectif — L’entreprise appartient à deux associés ou plus qui l’exploitent ensemble. Tous les
particuliers indiqués comme étant associés doivent remplir la formule « Renseignements personnels ». La formule « Structure
organisationnelle » doit être remplie pour toutes les personnes morales indiquées comme étant associées.
1.
2.
3.
4.
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4. Organization Details / Détails relatifs à l’établissement
4.1 Is the Liquor Delivery Service part of another business? /
Est-ce que le service de livraison d’alcool fait partie d’une autre entreprise?
❑ Yes /
Oui
❑ No /
Non
4.2 If yes, provide details describing the other business. / Dans l’affirmative, veuillez décrire l’autre entreprise.
4.3 How much do you charge for the delivery of liquor? /
Combien facturez-vous pour le service de livraison d’alcool?
5. Applicant Signature / Signature de l’auteur(e) ou des auteurs de la
demande
If the applicant is a sole proprietor, he/she must sign below.
If the applicant is a corporation, a person with authority to bind the corporation must sign below.
It the applicant is a partnership, all partners must sign below.
La demande doit être signée ci-dessous par la ou le propriétaire de l’entreprise lorsqu’il s’agit d’une
entreprise personnelle.
La demande doit être signée ci-dessous par une personne habilitée à engager l’entreprise lorsqu’il s’agit
d’une personne morale.
La demande doit être signée ci-dessous par tous les associés lorsqu’il s’agit d’une société en nom collectif.
By signing this form I/we solemnly declare that all information provided in this application is true and correct. /
En signant cette formule, je déclare (nous déclarons) solennellement que les renseignements fournis sont fidèles et
exacts.
Print name / Nom en lettres moulées
Signature
Date
Print name / Nom en lettres moulées
Signature
Date
Print name / Nom en lettres moulées
Signature
Date
Notification
The above information is collected pursuant to the Liquor Licence Act, R.S.O. 1990, chapter L.19. The principal purpose
of the collection is to determine eligibility for the issuance of a licence. The information may also be disclosed pursuant
to the Freedom of Information and Protection of Privacy Act, R.S.O. 1990, chapter F.31. For questions about the collection
of this information, please contact the Manager, Manufacturer & Special Licensing, Advertising & Promotions, Alcohol
and Gaming Commission of Ontario, 90 Sheppard Ave E, Suite 200, Toronto ON M2N 0A4, telephone 416 326-8700,
toll free in Ontario 1 800 522-2876. Email address: [email protected]
Avis
Les renseignements fournis dans la présente formule sont recueillis aux termes de la Loi sur les permis d’alcool, L.R.O.
1990, chap. L.19, dans le but premier de déterminer l’admissibilité à un permis. Ces renseignements peuvent également
être divulgués aux termes de la Loi sur l’accès à l’information et la protection de la vie privée, L.R.O. 1990, chap. F.31.
Les questions relatives à la collecte de renseignements doivent être adressées à la ou au chef du service Délivrance des
permis aux fabricants et des permis spéciaux, publicité et promotion, Commission des alcools et des jeux de l’Ontario,
90, av. Sheppard Est, Bureau 200, Toronto ON M2N 0A4. Tél. : 416 326-8700 ou 1 800 522-2876 (interurbains sans frais
en Ontario). Courriel : [email protected]
Clear Form Entries / Effacer des entrées de la Formule
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