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CCC:CHABL.I CASINO HOTEL ALCOHOLIC BEVERAGE LICENSE APPLICATION PLE LT OF LF OP ay Ee, ANMENT G Bo) Ae <t Re Bf) to = \Z Q ff ON \ A Ny o/ a {) ee OuMrsst A> © wd Z4 TES vIR Sy i” et ne hah UNITED STATES VIRGIN ISLANDS Rev. 7/00 CASINO HOTEL ALCOHOLIC BEVERAGE LICENSE APPLICATION Casino Hotel /Casino Service Industry Licensee — Prerequisites for Licensure: a) Acurrent Casino License issued by the Virgin Islands Casino Control Commission. b) A Health Permit from the Division of Environmental Health, Department of Health. c) A “Premises Clearance” by the Virgin Islands Fire Service. d) An initial fee in the amount of $4,000.00 payable to the Virgin Islands Casino Control Commission for the two-year Casino Hotel Alcoholic Beverage License. e) Arenewal fee in the amount of $2,000.00 payable to the Virgin Islands Casino Control Commission for the two-year Casino Hotel Alcoholic Beverage License. U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION [ow USE ONLY KINDLY CHECK THE APPROPRIATE BOX: = This form is submitted as an initial application for a Casino Hotel Alcoholic Beverage License. ete This form is submitted as an application for renewal of a Casino Hotel Alcoholic Beverage license. For a renewal application, state the date on which the current license expires 1 NAME = APPLICANT (INDIVIDUAL OR BUSINESS ENTITY REQUESTING THE LICENSE) 2 DIBIA or Trade Names Tax ID naniber or EIN 3 Contact Person Telephone Title Fax 4. Principal Physical Address Principal Mailing Address: cman Business Phone: Fax:. . Rev. 7/00 5. NAME OF Casino HoTEL 6. Specific Location and/or description of Casino Hotel premises where the business of serving alcoholic beverage will be conducted: 7. Complete where applicable: Category “A” Applicant: Vi Casino Control Commission License number: Date issued: Expiration Date: Category “B” Applicant: VI Casino Control Commission Casino Service industry License number: —_—__ Date issued: Expiration Date: __ " 8. HEALTH PERMIT FROM THE DIVISION OF ENVIRONMENTAL HEALTH, DEPARTMENT OF HEALTH. Date issued: Expiration Date: (Note: Upon receipt of this application, the Casino Control Commission will notify the Division of Environmental Health to proceed with the processing of the Health Permit.) 9. Clearance of Premises from the Virgin Islands Fire Service. Approved: V4, Fire Service TITLE DATE (Note: Upon receipt of this application, the Casino Control Commission will notify the V.I Fire Service to proceed with the processing of the clearance of premises permit.) Rev. 7/00 3 Casino Hotel Alcoholic Beverage License Application Conditions By the signing of this application, the applicant acknowledges that if a Casino Hotel Alcoholic Beverage License be granted, it will become the duty of the applicant to abide by and comply with all Federal, State and Territorial laws as well as the Rules and Regulations promulgated by the U.S. Virgin Islands Casino Control Commission and the Division of Gaming Enforcement, Department of Justice. The Applicant verifies that all statements and reports in this application are true, complete and current. The Applicant understands that each Casino Hote! Alcoholic Beverage License issued is only valid for the specified location indicated in the application. The Applicant agrees that any Casino Hotel Alcoholic Beverage License which may hereafter be granted is predicated upon the statements and answers herein contained, which may be subject to verification by the Commission or the Division of Enforcement and that for any material omission, false or misleading statement or answer said License may be revoked or applicant may be subjected to other sanctions. (Name of Applicant Entity) By: (Signature) (Title) (Print) (Date) Rev. 7/00 4 RELEASE OF ALL CLAIMS THE UNDERSIGNED HAS FILED WITH THE U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION AN APPLICATION FOR A CASINO HOTEL ALCOHOLIC BEVERAGE LICENSE, THE UNDERSIGNED DOES FOR MYSELF, MY HEIRS, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS, HEREBY RELEASE, REMISE AND FOREVER DISCHARGE THE GOVERNMENT OF THE U.S. VIRGIN ISLANDS ITS INSTRUMENTALITIES AND AGENTS, INCLUDING U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION, ITS MEMBERS, AGENTS, AND EMPLOYEES FROM ANY AND ALL MANNER OF ACTIONS, CASUSES OF ACTIONS, SUITS, DEBTS, JUDGMENTS, EXECUTIONS, CLAIMS AND DEMANDS WHATSOEVER, KNOWN OR UNKNOWN, IN LAW OR EQUITY WHICH THE UNDERSIGNED EVER HAD, NOW HAS, MAY HAVE, OR CLAIM TO HAVE, AGAINST ANY OR ALL OF SAID ENTITIES OR INDIVIDUALS ARISING OUT OF OR BY REASON OF THE PROCESSING OF THIS CASINO HOTEL ALCOHOLIC BEVERAGE LICENSURE. |, THE UNDERSIGNED, HAVING READ THIS RELEASE, EXECUTE IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE. (Name of Applicant Entity) By: : Ps (Print Name) (Tifle) (Signature) ~ ~ (Date) SUBSCRIBED AND SWORN BEFORE ME THIS___ DAY OF __ NOTARY PUBLIC COMMISSION EXPIRATION DATE SEAL Rev. 7/00 5