WEBSTER PARISH POLICE JURY (WPPJ)
VIDEO POKER/ALCOHOL SALES PERMIT
*See INSTRUCTIONS Below*
DATE: _________________
PLEASE INDICATE WHETHER A NEW APPLICATION OR RENEWAL: ________________
NAME: _______________________________________________ TRADE NAME: ______________________________________________
BUSINESS ADDRESS: ________________________________________________ WARD: _________________
CITY: ____________________________________ STATE: ______________ ZIP: ________________________
LOCATION OF BUSINESS: ____________________________________________________________________
MAILING ADDRESS: _________________________________________________________________________
HOME ADDRESS: ___________________________________________________________________________
PHONE #: _____________________________________
1. ARE YOU MORE THAN 18 YEARS OF AGE, A CITIZEN OF THE U.S. AND THE STATE OF LOUISIANA, AND A RESIDENT OF LOUISIANA CONTINUOUSLY FOR THE LAST TWO (2) YEARS, AND OF THE PARISH OF WEBSTER CONTINUOUSLY FOR MORE THEN ONE (1) YEAR?
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2. ARE YOU THE OWNER OF THE BUSINESS PREMISES, OR DO YOU HOLD A BONAFIDE WRITTEN LEASE? ________________________
IF YOU LEASE OR RENT, GIVE NAME AND ADDRESS OF THE LESSOR OR OWNER:
_______________________________________________________________________________________________________________
3. HAVE YOU EVER BEEN CONVICTED ANYWHERE OF A FELONY OR A MISDEMEANOR? ______________________________________
4. THE NAME OF THE PERSON WHO WILL PERSONALLY MANAGE OR SUPERINTEND SAID BUSINESS AT THE PLACE DESIGNATED IS:
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5. THE FOLLOWING IS A STATEMENT OF MY EMPLOYMENT FOR THE PAST FIVE (5) YEARS: (attach additional sheet if necessary)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
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6. I AGREE TO COMPLY WITH ALL LAWS AND ORDINANCES OF THE STATE AND PARISH, AND PARTICULARLY THOSE WHICH CONCERN THE USE OF THE PERMIT APPLIED FOR, CLOSING HOURS, AND OTHER REGULATIONS.
I SWEAR (OR AFFIRM) THAT I HAVE READ EACH OF THE QUESTIONS IN THIS APPLICATION, AND THAT ALL ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
___________________________________________________________ __________________________
SIGNATURE OF APPLICANT DATE
STATE WHETHER INDIVIDUAL OWNER, MEMBER OF PARTNERSHIP, OR IF OFFICE OF CORPORATION, AND GIVE TITLE:
_______________________________________________________________________________________________
SWORN TO AND SUBSCRIBED BEFORE ME THIS _____________ DAY OF _______________, 20_________.
___________________________________________________________ ___________________________
NOTARY PUBLIC DATE
ALCOHOL SALES PERMIT: $35.00
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PLEASE COMPLETE IF YOU HAVE VIDEO POKER MACHINES:
NUMBER OF VIDEO POKER MACHINES IN ESTABLISHMENT: ________________________________________________
OWNER OF MACHINES: _______________________________________________________________________________
WHO PAYS TAX ON MACHINES: ________________________________________________________________________
ANNUAL OCCUPATIONAL LICENSE TAX OF $50.00 PER MACHINE IS DUE AND PAYABLE ON THE 1ST DAY OF OCTOBER EACH YEAR AND SHALL BECOME DELINQUENT IF NOT PAID WITHIN SIXTY (60) DAYS THEREFROM. PER ORDINANCE #896 (9/5/95.)
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INSTRUCTIONS
IF THE APPLICANT IS A PARTNERSHIP, ALL MEMBERS OF THE PARTNERSHIP OR ALL PERSONS FINANCIALLY INTERESTED IN THE BUSINESS MUST FILL OUT THE ABOVE APPLICATION.
IF THE APPLICANT'S BUSINESS IS TO BE CONDUCTED WHOLLY OR PARTLY BY ONE OR MORE MANAGERS, THAT PERSON MUST ALSO FILL OUT AN APPLICATION.
IF THE APPLICANT IS A CORPORATION, ALL OFFICERS AND DIRECTORS AND ALL STOCKHOLDERS OWING IN THE AGGREGATE MORE THAN FIVE (5) PERCENT OF THE STOCK AND THE PERSON OR PERSONS WHO SHALL CONDUCT OR MANAGE THE BUSINESS MUST FILL OUT AN APPLICATION.
(ATTACH BANK MONEY ORDER OR CERTIFIED CHECK, MADE PAYABLE TO THE WEBSTER PARISH POLICE JURY, TO THIS APPLICATION IN THE REQUIRED AMOUNT.)
$35.00 - BEER/ALCOHOL PERMIT
$50.00 - PER EACH VIDEO POKER MACHINE
P.O. BOX 389, MINDEN, LA 71058
WPPJPERMITS@SUDDENLINKMAIL.COM
318-377-7564
