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S, when the business holds one of the following licenses: Liquor (1470, 1473, 1474, 1475, 1478, 1479, 1480, 1481), Amusement (1046, 1050, 1056), Hotel (1370), Massage Establishment (1524), or Day Care (1584, 1585, 1586, 1587) INSTRUCTIONS: Complete the 4 parts below, being sure to follow all printed instructions carefully. If a section does not apply, mark it “N/A”. If more room is needed to complete any of the following sections, include an attachment. This form must be signed and notarized.

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