Complete only if you sell food, tobacco, or have vending machines on-premises. Supporting Documents Supplemental Business License Application 43.6 KB Name of Business If you operate a Food Service Establishment, complete the following: Are you and your establishment in compliance with all the applicable federal and state regulations? Are you and your establishment in compliance with all the applicable federal and state regulations? Yes No If yes, attach copies of all documents evidencing such compliance (ie. Lake County Health Department Food Service Permit): One file only.10 MB limit.Allowed types: gif jpg png html pdf doc docx. If no, state the basis for the lack of compliance, reasons therefore, and date after which the establishment will be the full compliance. Do you employ waiters or waitresses? Do you employ waiters or waitresses? Yes No If yes, how many? What is the seating capacity of your establishment? Do you sell or offer for sale prepared food for consumption on or off premises? Do you sell or offer for sale prepared food for consumption on or off premises? Yes No Do you sell or offer for sale food or products intended for off premises preparations? Do you sell or offer for sale food or products intended for off premises preparations? Yes No If you operate one or more food vending machines, complete the following: Total number of machines operated by the applicant Location of the machines Types of products dispensed through each machine Complete this section if your business sells cigarette tobacco or tobacco products ("tobacco"): Conviction of any Offense Has the applicant or any partner ever been convicted of any offense concerning gambling or the manufacture, possession or sale of tobacco or any felony under any federal or state law or local ordinance? Conviction of any Offense Yes No If yes, complete the following with respect to each offense: Date Location Prosecuting Authority Offense Charge Disposition Underlying Facts Question Related to Minors Are the premises in which tobacco will be sold a store or other place of business where the majority of customers are minors and the principal business transacted consists of the sale of schoolbooks, school supplies, food and drinks? Question Related to Minors Yes No The applicant and applicant's officers, principals, and agents understand and agree to all applicable provisions of the Village of Long Grove Licensing ordinance, including the requirement that the applicant shall agree to permit authorized Village officials to make any necessary inspection to determine whether the applicant-licensee has complied with all regulatory requirements. The applicant states that it knows of no violation of the Village of Long Grove Code that would be created or continued as a result of granting this license application. The applicant further states that the applicant has complied with all applicable federal and state laws and local ordinances applying to the business, occupation or activity sought to be licensed. Date Electronic signature agreement: By selecting the "I Accept" button, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement. I (We) certify that the information contained in the above and attached sheets are true to the best of my (our) knowledge. Type Name Electronic Signature Electronic Signature I accept Type Name Electronic Signature 2 Electronic Signature 2 I accept This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. View PDF of Page
