Supplemental Business License Questionnaire Form - Henrico County Permit Center - Virginia Page 2
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1
2SUPPLEMENTAL BUSINESS LICENSE QUESTIONNAIRE
B
B
**COMPLETE FOR COMMERCIAL LOCATION ONLY**
Licensee Information
Description of Business
Be as COMPLETE AND SPECIFIC as possible.
______________________________________
____________________________________________________
Name of Licensee
____________________________________________________
______________________________________
____________________________________________________
Trade Name
____________________________________________________
______________________________________
Address Where Business Will Trade
____________________________________________________
______________________________________
____________________________________________________
Business Phone
__________
Hours of Operation
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
Open:
Open:
Open:
Open:
Open:
Open:
Open:
Close:
Close:
Close:
Close:
Close:
Close:
Close:
Please Complete the Following:
□
□
Does the business have, or intend to apply for, an ABC license?
Yes
No
If yes, what kind of license?____________________________________________________________________
□
□
Will the business involve music, dancing or live entertainment?
Yes
No
If yes, please describe: _______________________________________________________________________
□
□
Will there be video games, billiard tables or similar amusements?
Yes
No
If yes, how many? ________
If yes, please describe: _______________________________________________________________________
□
□
Will the business involve internet sweepstakes, online gambling, games of chance or similar activities?
Yes
No
If yes, please describe: _______________________________________________________________________
□
□
Will the business involve adult-oriented entertainment, merchandise, or other regulated activities*?
Yes
No
If yes, please describe:_______________________________________________________________________
*The county code defines an adult business as “any adult bookstore, adult video store, adult model studio, adult motel, adult movie theater, adult nightclub, adult store,
business providing adult entertainment, or any other establishment that regularly exploits an interest in matters relating to specified sexual activities or specified
anatomical areas or regularly features live entertainment intended for the sexual stimulation or titillation of patrons.
The responses I have provided on this form are true, correct and complete. I understand that incomplete information
may result in processing delays, and further understand that false or misleading information may be grounds for legal
action or revocation of license.
_______________________________________________
__________________________
Signature of Applicant
Date
OFFICE USE ONLY
GPIN: _______________________
□
□
ZONING: ______ PROFFERS CHECKED: ___________
APPROVED
REJECTED BY: __________ DATE: __________
COMMENTS:___________________________________________________________________________________________
______________________________________________________________________________________________________
_________
QUESTIONS CONCERNING SUPPLEMENTAL QUESTIONNAIRE:
Henrico County Permit Center, PO Box 90775, Henrico, VA 23273-0775, (804) 501-7280
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