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2. Town of Ipswich
4. One Day Application for License to Sell Alcoholic Beverages
6. Type of License (check one)*

   1. One Day All Alcohol License $50 (Non-Profit Only)

   1. One Day Wine & Malt License $30
8. Applicant Applying for License:*
   (Name of the official, employee, or representative that will appear on the license.)
10. Organization Name:*
12. Non-Profit Supporting Documentation*
    Attach sufficient documentation to establish the current legal existence of the Non-Profit Sponsor as a non-profit organization (e.g. Chapter 180 articles of organization, most recent annual report, certificate of legal existence, 501(c) IRS certification or other suitable document) and the authorization or vote of its governing body to seek this license.
14. Address:
16. Phone Number:*
17. Email Address:*
19. Organization Taxpayer ID No.
23. Section 1 - Event Information
25. Date of Event:*
26. Time From: *
27. To:*
29. Purpose of Event:*
30. Maximum number of attendees:*
32. Name and Address of Event Location:*
33. Is this location owned by the organization applying?

    1. Yes
    2. No
35. Approval to Use Location*
    Please attach the approval(s) to use the location. This could be an email communication used to secure usage of the site, an approved Street Blocking permit or approved Use of Town Greens permit.
36. Is this event indoors or outdoors?*

    1. Indoors
    2. Outdoors
37. How will your indoor event be set up?
    -- Select One --Standing OnlyChairsTables/Chairs
39. Site Plan*
    Site plan should indicate pertinent details of your event including where alcohol will be served and consumed, tents for outside events and location of where food will be served, guest seating, parking, potential/expected police details, etc.
40. Site Plan Option 2

    If there is a second site plan allowing for weather change, you may add it here. 

    
    

41. Occupancy Permit*
    Occupancy permits can be provided by the location in which your event will be held.
42. Will there be a tent:*

    1. Yes
    2. No

    If yes, the site plan requested should have the location of the tent(s) marked.
44. Tent Permit*
    A tent permit can be obtained from your tent vendor.
46. Event Contact Person:*
47. Title:
49. Phone Number:*
50. Email Address:*
54. Section 2 - Food
56. Will food be served at this event?*

    1. Yes

    1. No
58. If yes, please list name(s) of Food Provider(s), if more than one, include complete list with application.*
60. What type of food event will you be having?*

    1. Bake Sale - Only nonperishable foods, no refrigeration required.
    2. Private - Member only events not advertised with fliers, banners, newspaper articles, etc.
    3. Other
    4. Pot Luck*

    * Pot Luck - (1) people gather to share food (2) no compensation is provided to people for bringing food (3) the event is not held for commercial purposes and (4) people are informed that neither the facility nor the food has been inspected.
61. Click on the Temporary Food Guidance link below for descriptions.
    BOH Temporary Food Guidance
65. Section 3 - Alcohol Information
67. Name of licensed wholesaler* that liquor will be purchased from:*
    *The receipt from the purchase must be submitted to the office within five (5) business days after the event.
69. How will alcoholic beverages be dispensed or served? Please check all that apply.*

    1. Waitstaff

    1. By the glass

    1. Bar with bartender

    1. By the bottle
71. Who will be serving alcoholic beverages? Please attach documentation of alcoholic beverage service training program.*
72. Proof of Alcoholic Beverage Training *
74. What procedures will be followed to make certain that those under age 21 are not served and are not allowed to consume alcoholic beverages?*
78. Section 4 - FOR EVENTS ON TOWN PROPERTY ONLY
80. Is your event on Town Property?

    1. Yes
    2. No
81. Name of Town Location*
83. 1. Please attach proof of General Liability Insurance and Liquor Liability Insurance, both of which name the Town of Ipswich as an additional insured prior to the event. Attached?

    1. Yes

    1. No
84. General Insurance Liability
85. Liquor Liability Insurance
87. 2. Please attach a detailed map of the defined area where alcohol will be served and/or consumed to the application. The map must include points of access, emergency vehicle access points and details about what will be used to mark the area (ropes, walls, barricades, etc.). Attached?

    1. Yes

    1. No
88. Event Detail Map
92. SIGNATURE:
    I certify under penalty of perjury that:
    a) I am the duly elected/appointed official of the Applicant applying with authority to act on its behalf;
    b) I agree to be responsible for ensuring compliance with all laws and conditions governing this license;
    c) All information contained in this application is true and correct:
    d) The Applicant applying has the right or has made arrangements to use the location for which this License is sought on the date and the time requested (please provide documentation);
    e) The Applicant applying has approved the gathering for which the License is sought and the filing by me of this Application; and
    f) I have reviewed the One Day Liquor License policy and understand all the policy requirements.
94. LIABILITY DISCLAIMER FOR ONE-DAY ALCOHOLIC LICENSES
    By exercising the privileges of this license in serving persons with alcoholic beverages, the license is potentially exposed to significant liability for injuries and damages to persons served or to others who are injured or damaged by the persons served. Your acceptance and exercise of this license will be deemed to be acknowledgment that you are aware of this potential liability. You are encouraged to discuss the risks associated with exercising your privileges of the license and agree, on behalf of the Applicant, that the Town of Ipswich, and the Select Board as Local Licensing Authority, shall not be liable to the licensee or other if injury or damage shall result from the exercise of the license.
96. Signature of Applicant:*
97. Date:*
101. PAY ONLINE!

     1. Online Payment

     A time-saving online payment option is now available. Check the 'Online Payment' box and hit SUBMIT below, you will then be sent directly to the City Hall Systems website to submit payment information.
103. FOR TOWN USE
Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

* indicates a required field