VILLAGE OF CHATHAM, ILLINOIS
APPLICATION FOR ADULT USE PERMIT
Directions to Applicant: All information requested must be supplied.
Use a continuation sheet if needed.
The undersigned hereby applies for an adult use renewal permit from the Village of Chatham in accordance with Chapter 161 of the Village of Chatham Code of Ordinances.
1. Date of approval of original permit:
2. Name, address and telephone number of applicant:
3. Type of business entity:
None-the applicant is an individual or individuals. If proposed use is "adult club" as defined in Chapter 161 of the Chatham Code of Ordinances, identify all members on a separate sheet.
Corporation* LLC*
Other-please specify
*Attach a certificate of good standing from the Illinois Secretary of State.
4. Names and addresses of all persons with a 5% or greater ownership interest in the applicant, if the applicant is other than an individual or individuals:
5. Name and address of person to contact regarding this application, and such person's relationship to the applicant:
6. Address of the premises at which the adult use will be conducted:
7. Nature of applicant's interest in the premises, if different from original permit:
Ownership (attach copy of deed) Leasehold (attach copy of lease)
Contract for deed (attach copy of contract)
Other (please specify and attach evidence of interest)
8. Applicant hereby certifies that the use of the premises is the same as set forth in the original permit.
9. Names, addresses and phone numbers of managers of adult use:
I hereby certify under penalty of perjury that the foregoing statements are true and correct. I have reviewed Chapter 161 of the Village of Chatham Code of Ordinances and will abide by its terms. I attach a check in the amount of $50.00 to cover the cost of the permit application.
Signature:
Date:
For Chief of Police Use Only
I have performed a criminal background check on all persons listed in this application as owners of a 5% or greater interest in the applicant or as the manager of the facility. I find that:
no such persons have been convicted of the crimes of prostitution or obscenity, or other crimes of a sexual nature.
the following persons listed in this application have been convicted of the crimes of prostitution or obscenity or other crimes of a sexual nature:
Name Date of Conviction Description of Crime
Date Chief of Police
For Village President's Use Only
This renewal application is approved denied for the following reasons:
Village President