Adult Entertainment License
Checklist
Application:
1. Legal description of real estate
a. Deed
b. Plat
2. Diagram/sketch of premises
a. Total floor space occupied by business
b. Dimensions of interior space (within 6’’ accuracy)
c. Configurations
I. Film/video operations: (diagram street/north oriented; scale)
1. Operator station location
2. Booths/viewing room location
3. Overhead lighting fixtures
4. Required restrooms (no viewing equipment permitted)
5. Designate non-patron space
6. License display location (conspicuous)
7. Lighting in patron access area > 5.0 foot candles at floor level
8. Required sign: (interior)
a. Occupancy of viewing room (less than 150 square feet) limited to one person
b. Specified sexual activity prohibited
i. Intercourse
ii. Oral copulation
iii. Masturbation
iv. Sodomy
v. Excretory functions as a part of or connected with any of activities b(i) to b(iv)
c. Making openings between viewing rooms prohibited
d. Violators required to leave premises
e. Violations of these regulations are illegal
f. Operator station must have unobstructed line of sight view of all patron access areas, except restrooms
g. Exterior Monitoring
i. Signs; Two “No Loitering” conspicuous
ii. Inspection:
1. Designated employees, every ninety minutes or
2. Video cameras
3. Lighting sufficient to provide visual/video monitoring
4. Lighting at least 1.0 foot candle at ground level
iii. Fences, walls, similar barriers preventing visibility from public rights-of- way prohibited.
Inspection
Application received: ________________ New: ______ Renewal:__ Provisionals_____
Temporary licensed issued: ______________________
Inspection requested (planning & zoning): ______________________
Inspection report received:______________________
DAVIESS COUNTY, KENTUCKY
APPLICATION FOR LICENSE TO OPERATE
AN ADULT ENTERTAINMENT ESTABLISHMENT
Applicant’s full legal name: _______________________
State whether you are (check one):
_______ an individual (complete Sections A and D)
_______ a partnership (complete Sections B and D)
_______ a corporation or limited liability company (complete Sections C and D)
A. 1) State your full legal name: _______________________
2) State any other names/aliases used in the last five years: ______________________________________
3) Current business/mailing address: _______________________________________________________
_______________________________________________________________
4) Are you over 18 years of age? Yes No
Attach written proof of age (current driver’s license OR a copy of your birth certificate accompanied by a picture identification document issued by a government agency)
B. 1) State full name of partnership: _______________________
2) Identify all persons with an influential interest (see KOC 1030.3 (2008), including all names/aliases used by them in the last five years:
___________________________________________________________________
___________________________________________________________________
3) Business/mailing address(es) of persons identified in B.2 above: ___________
___________________________________________________________________
___________________________________________________________________
For each person listed in B.2 above, attach written proof of age (current driver’s license OR a copy of birth certificate accompanied by a picture identification document issued by a government agency) _________________________________________
C. 1) State full name of corporation or LLC: _____________________________
_________________________________________________________________
2) Business address: ______________________________________________
_________________________________________________________________
3) Identify all persons with an influential interest (see KOC 1030.3 (2008), including all names/aliases used by them in the last five years: _______________________
__________________________________________________________________
4) Business/mailing address(es) of persons identified in C.3 above: __________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
For each person identified in C.3 above, attach proof of age (current driver’s license OR a copy of birth certificate accompanied by a picture identification document issued by a government agency)
(If additional space is needed, check here ____ and respond further on a separate sheet.)
D. 1) Please state the doing business as name of the adult entertainment establishment:
___________________________________________________________________
2) Please state the name and business address of the statutory agent or other agent authorized to receive service of process:
Name: ______________________________________________________________
Address: ____________________________________________________________
____________________________________________________________________
3) Has any person identified in response to section A, B, or C been convicted of or pled guilty or nolo contenders to a specified criminal activity? (see KOC 1030.3 (2008) for definition of “specified criminal activity”.)
Yes No
If yes, then for each such conviction, guilty plea, or plea of nolo contenders, state:
a) The person and the offense: _________________________________________
b) Court in which charged:____________________________________________
c) The date of conviction or plea: _______________________________________
d) The place of conviction or plea: ______________________________________
e) Date of release from confinement: ___________________________________
(If additional space is needed, check here ____ and respond further on a separate sheet.)
4) Has any person identified in response to section A, B, or C had an influential interest in any adult entertainment establishment that, in the past five years, (and while he or she had such influential interest), has been declared by a court of law to be a nuisance or has been subject to a court order requiring closure or padlocking of the business) (See KOC 1030.3 (2008))
Yes No
If yes, state:
a) Person and name of business: ____________________________________
b) City, county, and state where such business is/was located: ____________
_______________________________________________________________
c) Court and date of court’s order: __________________________________
_________________________________________________________________
(If additional space is needed, check here ___ and respond further on a separate sheet.)
5) Location of adult entertainment establishment:
Street address: ______________________________________________________
___________________________________________________________________
Mailing address (if different): _____________________________________________
___________________________________________________________________
Phone number: _______________________________________________________
Legal description of property:_____________________________________________
You must attach a sketch or diagram showing the configuration and total floor space of the premises. The sketch for businesses offering activities covered by KOC 1030.3 (2008).Section 13 and 17 must contain the information required in those sections (configuration of booths, location of stage, location of operator’s station(s), and the like). The sketch need not be professionally prepared but must be drawn to scale and be accurate to plus or minus six inches.
6) Is the required fee attached? (See KOC 1030.3 (2008)) Yes No
7) Certification
By signing the following, I/We agree and certify:
A. To supplement the information contained in this application, in writing to the County Clerk, within ten working days of any change of circumstances that renders the information false or incomplete.
B. That the information contained herein is true, complete, and correct.
This application must be signed by each individual identified in response to sections A, B, and C, and each of those signatures must be notarized.
Signed:________________________________ Date: __________________
Notary: _______________________________ Commission expires: ___________________
Signed:________________________________ Date: __________________
Notary: _______________________________ Commission expires: ___________________
Signed:________________________________ Date: __________________
Notary: _______________________________ Commission expires: ___________________
Signed:________________________________ Date: __________________
Notary: _______________________________ Commission expires: ___________________
DAVIESS COUNTY, KENTUCKY
APPLICATION FOR ADULT ENTERTAINMENT ESTABLISHMENT
EMPLOYEE LICENSE
1. Applicant’s full legal name: _____________________________________________________
2. Any other names/aliases used in last five years: _____________________________________
________________________________________________________________________________
3. Current business/mailing address: ________________________________________________
________________________________________________________________________________
4. Is written proof of age (driver’s license OR a copy of your birth certificate accompanied by a picture identification document issued by a governmental agency) attached? Yes No
5. Have you been convicted of or pled guilty or nolo contendere to a specified criminal activity? (See KOC 1030.3 (2008) for definition of “specified criminal activity”.) Yes No
If yes, then for each such conviction, guilty plea, or plea of nolo contendere, state:
a) The offense: ___________________________________________________________
b) Court in which charged: _________________________________________________
c) The date of conviction or plea: ____________________________________________
d) The place of conviction or plea: ____________________________________________
e) Date of release from confinement: __________________________________________
(If additional space is needed, check here ___ and respond further on a separate sheet.)
6. Have you had an influential interest in any Adult Entertainment Establishment that, in the past five years (and while you had such influential interest), has been declared by a court of law to be a nuisance or has been subject to a court order requiring closure or padlocking of the business? (See KOC 1030.3(2008)) Yes No
If yes, state:
a) Name of business: _________________________________________________
b) City, County, and State where such business is/was located: ________________
____________________________________________________________________
c) Court and date of court’s order: ______________________________________
(If additional space is needed, check here _____ and respond further on a separate sheet.)
7. Is the required fee attached? (See KOC 1030.3 (2008) Yes No
8. If you seek licensure to work in an Adult Entertainment Establishment that is currently licensed by Daviess County, please provide the name and address of that business:
________________________________________________________________________
________________________________________________________________________
By signing this application, you represent that the information contained herein is true, complete, and accurate. This application must be notarized. You must file this application in person. You are responsible to supplement the information provided on this form, in writing to the County Clerk, within ten working days of a change of circumstances which would render the information originally submitted false or incomplete.
Signature: ____________________________
Date: _______________________________
DAVIESS COUNTY, KENTUCKY
PROVISIONAL LICENSE
TO CONTINUE OPERATING AN ADULT ENTERTAINMENT
ESTABLISHMENT DURING COURT CHALLENGE
Issued: _____________ Provisional License No. _________________________________
This PROVISIONAL LICENSE to continue operating an adult entertainment establishment EXPIRES upon the court’s entry of a judgment in the following lawsuit:
Case Name: __________________________________________________________________
Case Number: ________________________________________________________________
Court: ______________________________________________________________________
Name of Adult Entertainment Establishment: _______________________________________
Address of Adult Entertainment Establishment: ______________________________________
Names of Licensee(s) on most recently issued Annual License, or names of Applicant(s) listed on completed application:
___________________________ __________________________________
___________________________ __________________________________
___________________________ __________________________________
___________________________ __________________________________
Issued by: _________________________
County Clerk, Daviess County, Kentucky
DAVIESS COUNTY, KENTUCKY
LICENSE TO OPERATE AN
ADULT ENTERTAINMENT ESTABLISHMENT
License No. ________________
Issued: ____________________
EXPIRATION DATE: ______________________________
Name of Adult Entertainment Establishment: _____________________________________
Address of Adult Entertainment Establishment: ___________________________________
___________________________________
Licencee(s): _________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Issued by:____________________________
County Clerk, Daviess County, Kentucky
DAVIESS COUNTY, KENTUCKY
TEMPORARY LICENSE
TO CONTINUE OPERATING A PREEXISTING
ADULT ENTERTAINMENT ESTABLISHMENT
Issued: ______________ Temporary License No. _____________________
This TEMPORARY LICENSE to continue operating a preexisting adult entertainment establishment EXPIRES upon the final decision of Daviess County to deny or grant the annual license, for which a completed application has been submitted on
_______________________________
_______________________________
Name of Adult Entertainment Establishment: _______________________________
Address of Adult Entertainment Establishment: _____________________________
____________________________________________________________________
Temporary Licence(s): ______________________________
______________________________
______________________________
Issued by: _____________________________________
County Clerk, Daviess County, Kentucky
DAVIESS COUNTY, KENTUCKY
LICENSE
ADULT ENTERTAINMENT ESTABLISHMENT EMPLOYEE
License No. ___________________________
Issued: _______________________________
EXPIRATION DATE: _________________________
Name of Licensee: _________________________________________
Address: ______________________________________________
______________________________________________
Issued by: _______________________________
County Clerk, Daviess County, Kentucky
DAVIESS COUNTY, KENTUCKY
PROVISIONAL LICENSE
TO CONTINUE EMPLOYMENT AS AN ADULT ENTERTAINMENT
ESTABLISHMENT EMPLOYEE DURING COURT CHALLENGE
Issued: _______ Provisional License No. ____________________
This PROVISIONAL LICENSE to continue employment as an adult entertainment establishment employee EXPIRES upon the court’s entry of a judgment in the following lawsuit:
Case Name: ____________________________________
Case Number: __________________________________
Court: ________________________________________
Name of Licensee: _________________________________________
Address: ___________________________________________
___________________________________________
Issued by: _________________________________
County Clerk, Daviess County, Kentucky
DAVIESS COUNTY, KENTUCKY
TEMPORARY LICENSE
TO WORK AS AN
ADULT ENTERTAINMENT ESTABLISHMENT EMPLOYEE
IN A LICENSED ADULT ENTERTAINMENT ESTABLISHMENT
Issued: ______________ Temporary License No. ________________________
This TEMPORARY LICENSE to work in a licensed adult entertainment establishment EXPIRES upon the final decision of Daviess County to deny or grant the annual license, for which a completed application has been submitted on
__________________________
__________________________
Name of Temporary Licensee: ______________________________________________
Address: ________________________________________________________________
Name of Licensed Adult Entertainment Establishment: ______________________________
Address of Licensed Adult Entertainment Establishment: ____________________________
_____________________________________________________
Issued by: _________________________________
County Clerk, Daviess County, Kentucky