Special License Application - Michigan Department of Licensing and

Michigan Department of Licensing and Regulatory Affairs

Liquor Control Commission (MLCC)

Constitution Hall - 525 W. Allegan, Lansing, MI 48933

Mailing Address: P.O. Box 30005, Lansing, MI 48909

Toll-Free: 866-813-0011 - www.michigan.gov/lcc

Business ID:

Request ID:

(For MLCC Use Only)

Special License Application

Part 1 - Applicant Organization Information

Applicant organization name:

Applicant address:

City:

Contact name:

Address of event location:

City, township, or village where event will be held:

Phone: Email:

Zip Code:

Yes No

2. Do you have permission from the property owner of the location listed above to hold your event(s) on

the date(s) listed below (see pages 2-3) at this location?

1. Has the applicant organization previously received a Special License?

2. Has the applicant organization been established for one (1) year or longer?

Date the applicant organization was established (month/day/year):

3. Is the applicant organization a municipality?

NoYes

Yes No

Part 2 - Event Information - For requests at more than one location, submit separate forms for each location.

3. Has the local law enforcement agency with primary jurisdiction over the event location approved this

application for a Special License? (See Part 5 on Page 5)

4. Is the event location within 500 feet of a church or school?

If Yes, the church or school must consent to the event(s). (See Part 6 on Page 5)

Yes No

Page 1 of 8

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

County:

Michigan organizations must provide current articles of incorporation filed with Michigan Corporations Division.

Out-of-state organizations must provide: (a) current articles of incorporation from state of issuance; (b) current

certificate of good standing from state of incorporation; and (c) current Certificate of Authority to Transact Business in

Michigan issued by the Michigan Corporations Division.

Email:Phone:

Alternate

contact name:

Yes No

Leave Blank - MLCC Use Only

A completed Special License application must be submitted as early as possible before your event(s) to avoid any delays in processing. It is

strongly recommended that you submit the application as soon as you know the date of your event(s). Failure to submit a completed application at

least ten (10) business days prior to the event(s) may result in no Special License being issued, pursuant to administrative rule R 436.575.

1. Will you submit your completed application at least ten (10) business days before your event?

It is strongly recommended that you submit the application as soon as you know the date of your event(s).

5. Is the event location outdoors or partially outdoors?

If Yes, list the exact dimensions of the outdoor area:

Submit a clear diagram of the outdoor service area

with your application form.

Describe type and height of the barrier that will be used to enclose the outdoor area:

6. Describe type of security that will be used for event(s) and how it will be utilized to secure and monitor to prevent sales to minors

and visibly intoxicated persons:

feet X feet = square feet

Yes No

Width Length

LCC-110 (01-23)

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Yes No NoYes

Start Time End Time

Describe event being held:

12. The applicant organization may request up to twelve (12) Special Licenses total (one Special License per day) in a calendar year. Please

complete the information below for each individual date for which you are requesting a Special License at this location. If you are

requesting Special Licenses for consecutive days, completely fill out a separate box for each date. If you request a Special License for

on-premises consumption AND for a Wine Auction both on the same date at the same location, you are requesting two (2) separate

licenses and you must pay a license fee for both licenses.

Date

Beer & Wine Service Beer, Wine, & Spirit Service Wine Auction

Special License will be used for:

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

Wine Auction

Beer, Wine, & Spirit ServiceBeer & Wine Service

Yes No

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

Wine Auction

Beer, Wine, & Spirit ServiceBeer & Wine Service

Yes No

Page 2 of 8

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

Wine AuctionBeer, Wine, & Spirit ServiceBeer & Wine Service

Yes No Yes No

9. Will the event(s) involve an auction of donated wine?

Yes No

10. Will marijuana be sold and consumed under a Temporary Marihuana Event License issued by the Cannabis

Regulatory Agency (CRA) within the proposed event area where alcoholic liquor will be sold and consumed?

Yes No

If Yes, the existing licensee must request to place its license in escrow during the event(s). (See Part 7 on Page 5)

8. Is there an existing liquor licensee issued at the event location, such as a Class C or Club license?

Yes No

If Yes, please check "Wine Auction" for the applicable event date(s) on pages 2-3. Only donated wine may be auctioned under a Special License; beer and spirits

cannot be auctioned. If you request a Special License for on-premises consumption AND for a Wine Auction both on the same date at the same location, you are

requesting two (2) separate licenses and you must pay a license fee for both licenses.

7. Is the event location situated in or on state owned land, such as a state park or National Guard armory?

If Yes, attach a copy of your documentary proof of approval to use the state owned land.

Yes No

End TimeStart Time

Yes No11. Is the event location within the commons area of a Social District?

If Yes, you must obtain written documentation from the local governmental unit, including a clear diagram, that delineates the part of the commons

area of the Social District to be used exclusively for your event and the part to be used exclusively by the Social District permittees during the time

period for your event pursuant to MCL 436.1551(3). Submit the documentation and the diagram with this application.

LCC-110 (01-23)

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

Wine Auction

Beer, Wine, & Spirit ServiceBeer & Wine Service

Yes No

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

If Yes, will alcohol be served between 7:00AM and 12:00 Noon?Is this date a Sunday?

Describe event being held:

Date

Special License will be used for:

Wine Auction

Beer, Wine, & Spirit ServiceBeer & Wine Service

Yes No

12. Special license date information Continued from Page 2.

Part 3 - Special License Fees - Complete the Special License fee calculation on Page 4

For Organizations established less than one year or are municipalities - a $50.00 Special License base fee for each separate, consecutive day

of the event is required. If the event is held on a Sunday and spirits will be served after 12:00 Noon, an additional $7.50 Sunday Sales Permit (P.M.)

fee is required. In addition, if any alcoholic beverages, including beer, wine, and spirits, will be served between 7:00AM and 12:00 Noon, an

additional $160.00 Sunday Sales Permit (A.M.) fee is required. Sunday Sales Permit (A.M.) and/or Sunday Sales Permit (P.M.) fees will be required

for each date that is a Sunday. If you request a Special License for on-premises consumption AND for a Wine Auction both on the same

date at the same location, you are requesting two (2) separate licenses and you must pay a license fee for both licenses.

For Organizations established one year or more - a $25.00 Special License base fee for each separate, consecutive day of the event is required.

If the event is held on a Sunday and spirits will be served after 12:00 Noon, an additional $3.75 Sunday Sales Permit (P.M.) fee is required. In

addition, if any alcoholic beverages, including beer, wine, and spirits, will be served between 7:00AM and 12:00 Noon, an additional $160.00

Sunday Sales Permit (A.M.) fee is required. Sunday Sales Permit (A.M.) and/or Sunday Sales Permit (P.M.) fees will be required for each date that

is a Sunday. If you request a Special License for on-premises consumption AND for a Wine Auction both on the same date at the same

location, you are requesting two (2) separate licenses and you must pay a license fee for both licenses.

The fees must be paid by check, bank or postal money order, or by credit card, using the attached Credit Card Authorization Form (LCC-300).

Checks and money orders should be made payable to State of Michigan.

Page 3 of 8

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

A completed Special License application must be submitted as early as possible before your event(s) to avoid any delays in processing. It is

strongly recommended that you submit the application as soon as you know the date of your event(s). Failure to submit a completed application at

least ten (10) business days prior to the event(s) may result in no Special License being issued, pursuant to administrative rule R 436.575.

End TimeStart Time

LCC-110 (01-23)

Special License Base Fee:

x Number of Special Licenses:

= Special License Fees:

+ Sunday Sales Permit (P.M.) Fees:

+ Sunday Sales Permit (A.M.) Fee:

(per Special License requested)

= TOTAL FEES DUE:

MLCC Fee Code: 4008

MLCC Fee Code: 4032

MLCC Fee Code: 4033

Make checks payable to:

State of Michigan

Leave Blank - MLCC Use Only

Part 3 Continued - Special License Fees Calculation

Part 4 - Signatures of Applicant Organization's Officers, Witnesses, and Notary

Pursuant to administrative rule R 436.575, the president and secretary of the organization making application shall sign the application and the signatures shall

be notarized . Political candidates only need to sign the president section and have it notarized.

By signing below the applicant organization's officers attest that:

We certify that all profits from the sale of beer, wine and/or spirits or from a wine auction will go to the applicant organization and not to any individual.

We further certify that any license issued by the Michigan Liquor Control Commission is a contract subject to suspension or revocation by the

Commission, that there shall be no liability on the part of the State of Michigan, the Commission, or any of its officers or employees by reason of such

suspension or revocation, and that the granting of the license does not create a vested right.

Under administrative rule R 436.1003, the licensee shall comply with all state and local building, plumbing, zoning, sanitation, and health laws, rules, and

ordinances as determined by the state and local law enforcements officials who have jurisdiction over the licensee. Approval of this application by the

Michigan Liquor Control Commission does not waive any of these requirements. The licensee must obtain all other required state and local licenses,

permits, and approvals for this business before using this license for the sale of alcoholic liquor on the licensed premises.

We certify that the information contained in this form is true and accurate to the best of our knowledge and belief. We agree to comply with all

requirements of the Michigan Liquor Control Code and Administrative Rules. We also understand that providing false or fraudulent information is a

violation of the Liquor Control Code pursuant to MCL 436.2003.

Date

Signature of President

Print Name and Phone Number of President

My commission expires

Print Name of Notary Signature of Notary Date

Notary Public, State of Michigan, County of Acting in the County of

DateSignature of SecretaryPrint Name and Phone Number of Secretary

My commission expires

Print Name of Notary Signature of Notary Date

Notary Public, State of Michigan, County of Acting in the County of

Page 4 of 8

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

If you request a Special

License for on-premises

consumption AND for a

Wine Auction both on

the same date at the

same location, you are

requesting two (2)

separate licenses and

you must pay a license

fee for both licenses.

A completed Special License application must be submitted as early as possible before your event(s) to avoid any delays in processing. It is

strongly recommended that you submit the application as soon as you know the date of your event(s). Failure to submit a completed application at

least ten (10) business days prior to the event(s) may result in no Special License being issued, pursuant to administrative rule R 436.575.

LCC-110 (01-23)

Part 5 - Local Law Enforcement Approval*

The local law enforcement agency with primary jurisdiction over the event location must complete this section.

Part 7 - Existing On-Premises Licensee Escrow Request (If Applicable)

If the event location is currently licensed with an on-premises license, the licensee must request that its license be placed into escrow

for the date(s) and time(s) of the Special Licenses issued for use at the event location requested on this application. If the existing

license would prefer to temporarily drop space from its licensed premises, it must submit a letter to the Commission requesting to drop

space temporarily from its licensed premises during the event date(s) and time(s), accompanied by a diagram showing the area where

the license will temporarily drop space from its licensed premises to accommodate the applicant organization.

Part 6 - Church/School Consent (If Applicable)*

If the event location is located within 500 feet of a church or school, the applicant organization must obtain the consent of the church or school. A

church or school within 500 feet of the event location may object based on such the sale of alcohol at the location adversely affecting the church or

school's operations. If a proper objection is filed, the Commission shall hold a hearing to determine whether the granting of the application will

adversely affect the operation of the church or school.

Name of law enforcement agency:

Name & title of reviewing officer:

Phone number of officer: Email of officer:

I certify that I have reviewed the application of the applicant

organization for a Special License and approve the issuance of a

Special License by the Michigan Liquor Control Commission at

the proposed event location.

Signature of Reviewing Officer Date

Date

Name of church or school:

Name of licensee: Business ID Number:

Name of clergy member or superintendent:

Address of church or school:

Phone number: Email:

I, the authorized representative of the above named church or

school, state that the church or school has no objection to the

issuance of a Special License to the applicant organization at its

proposed event location.

Signature of Clergy Member or Superintendent

Zip Code:City:

Yes

If event will be held on a Sunday, is the sale of alcohol from 7:00am to 12:00 Noon on Sunday allowed in this local governmental unit?

Yes

If the event will be held on a Sunday, is the sale of alcohol after 12:00 Noon on Sunday allowed in this local governmental unit?

*Please note: the Commission has the sole and only right to approve or deny this request for a Special License.

Name of authorized signer for licensee:

Type of license held at this location (e.g. Class C, Club, Tavern, etc.):

Phone number: Email:

I, the authorized signer, for the above named on-premises

licensee, request that the licensee's licenses at this location be

placed into escrow during the date(s) and time(s) specified for

the Special Licenses issued for use at this location.

Signature of Authorized Signer for Licensee

Page 5 of 8

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

LCC-110 (01-23)

Michigan Department of Licensing and Regulatory Affairs

Liquor Control Commission (MLCC)

Constitution Hall - 525 W. Allegan, Lansing, MI 48933

Mailing Address: P.O. Box 30005, Lansing, MI 48909

Toll-Free: 866-813-0011 - www.michigan.gov/lcc

Business ID:

Request ID:

(For MLCC Use Only)

Certified Resolution of the Membership or Board of Directors Authorizing the Application for Special License

(Required under Administrative Rule R 436.576 - Not Required for Candidate Committee)

(Date) (Time)

(Name of Organization)

for a Special License to serve alcohol on

(Event Date or Dates)

to be located at

(Physical Address - Include Location Name, Street Address, City, State, & Zip Code)

It is the consensus of this body that the application be for issuance.

Approval Vote Tally

(Recommended or Not Recommended)

At a

meeting of the

that the application from

the following resolution was offered:

called to order by

Moved by

Yeas:

Nays:

Absent:

and supported by

I hereby certify that the foregoing is true and is a complete copy of the resolution offered and adopted by the

meeting held onat a

(Date)

DateSignature of Authorized OfficerPrint Name & Title of Authorized Officer

Certification by Authorized Officer of Organization:

Page 6 of 8

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

Regular Special Membership Board of Directors

SpecialRegularBoard of DirectorsMembership

LCC-110 (01-23)

Michigan Department of Licensing and Regulatory Affairs

Liquor Control Commission (MLCC)

Constitution Hall - 525 W. Allegan, Lansing, MI 48933

Mailing Address: P.O. Box 30005, Lansing, MI 48909

Toll-Free: 866-813-0011 - www.michigan.gov/lcc

Business ID:

Request ID:

(For MLCC Use Only)

Wine Auction Special License Wine Donation Record

List the name and address of each person that has donated wine to the applicant organization for the wine auction and list the brand(s)

and quantity donated. The applicant organization shall not accept donations of wine from a business licensed by the Michigan Liquor

Control Commission. An authorized officer of the applicant organization must sign this donation record form.

Donor Name Donor Address Wine Brand(s) Donated Quantity Donated

DateSignature of Authorized OfficerPrint Name of Authorized Officer

Page 7 of 8

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

Applicant organization: Wine auction date:

Signature of Authorized Officer

I hereby certify that all persons listed above have donated wine to the applicant organization listed above for this wine auction, to be

conducted pursuant to the Michigan Liquor Control Code, MCL 436.1527. The persons listed above have donated wine to the applicant

organization as individuals and not for or on behalf of any retail or nonretail business licensed by the Michigan Liquor Control

Commission.

LCC-110 (01-23)

Credit Card Authorization Form

Michigan Department of Licensing and Regulatory Affairs

Finance and Administrative Services

Revenue Services

Name on Card:

Card Number:

Security Code/CVV Code:

Billing Address:

City: State: Zip Code:

Phone:

Email:

Payment is for:

Applicant/Licensee Name: Request or Business ID #:

Payment Amount:

Check One:

Signature

* * FAX COMPLETED FORM TO SECURE FAX LINE: 517-284-8557 * *

* * DO NOT EMAIL OR MAIL THIS FORM * *

Requests with credit card payments that are not faxed to the above secure fax line will be destroyed along with the credit card authorization in

order to ensure the security of applicants’ personal credit card numbers.

* *IF YOU ARE NOT SUBMITTING AN APPLICATION FORM WITH THIS CREDIT CARD AUTHORIZATION, YOU MUST PROVIDE AN

ITEMIZATION OF THE FEES FOR WHICH YOU ARE SUBMITTING PAYMENT OR YOUR PAYMENT WILL NOT BE PROCESSED* *

LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

LCC-300 (10-20)

IF YOU ARE NOT SUBMITTING AN APPLICATION FORM WITH THIS

CREDIT CARD AUTHORIZATION, YOU MUST PROVIDE AN

ITEMIZATION OF THE FEES FOR WHICH YOU ARE SUBMITTING

PAYMENT OR YOUR PAYMENT WILL NOT BE PROCESSED.

Credit Card Payment Itemization:

Special License Fee(s):

Sunday Sales Permit (AM):

Sunday Sales Permit (PM):

Catering Permit:

New Add Bar Transfer Add Bar:

License Renewal Fee(s):

New Retailer License(s):

Manufacturer License(s):

Transfer Retailer License(s):

Temporary Authorization Fee:

Inspection Fee(s):

Fee Amount

MLCC

Fee Code

4036

4008

4037

4004

4038

4012

4034

4033

4032

4031

4012/4034

Fee Type

4085

Wholesaler License(s):

LARA Revenue Services is not a part of the Michigan Liquor Control

Commission (MLCC). Receipt of payment and application forms by

LARA Revenue Services does not constitute receipt of an application

by the MLCC. Applications submitted through LARA Revenue

Services may take up to two (2) additional business days to be

received by the MLCC after receipt by LARA Revenue Services.

For requests that require a timely receipt of an application by the

MLCC to be processed, such as Special Licenses and temporary

requests, please ensure that your application will be received in

adequate time to be processed by the MLCC after the payment is

received and processed by LARA Revenue Services.

LARA Revenue Services is not a part of

the Michigan Liquor Control

Commission (see note below).

Conditional License

4012

Expiration Date:

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