PETITION FOR REMOVAL (Retail Liquor or Wine Store) Form 805-LS (revised 09/2002) STATE OF NEW YORK LIQUOR AUTHORITY This petition is to be used by a RETAIL LIQUOR OR WINE STORE LICENSEE for permission to remove the licensed premises to a new location. This petition must be executed by the licensee and filed with the appropriate Zone Office of the State Liquor Authority whichever office has jurisdiction over the PROPOSED premises, and must be accompanied by the following: CHECK, BANK OFFICER’S CHECK or DRAFT, or MONEY ORDER for the required fee, payable to the STATE LIQUOR AUTHORITY. (The law does not provide for any refund of removal fees prescribed under Section 99-d.) $ 192.00 where the annual license fee is $500 – or more $32.00 in all other instances SEE PETITION FOR REMOVAL INSTRUCTIONS FOR ADDITIONAL REQUIRMENTS ALL QUESTIONS MUST BE ANSWERED IN BOXES BELOW. (If more space is needed, attach rider.) Any false answer or statement made by the applicant constitutes perjury and will subject any license issued hereunder to revocation. The licensee named below hereby requests the permission of the State Liquor Authority for the REMOVAL of the licensed premises to the proposed premises set forth below. Full name of Applicant-Licensee Trade name or other names under which applicant will do business PRESENT PREMISES – (Street address) Post Office address of premises (if different) City, town or village-Zip Code City, town or village –Zip Code (if different) License No. Telephone No. PROPOSED PREMISES Trade name or other names under which applicant will do business Street address of premises to be licensed City, town or village, - Zip Code Post Office address of premises (if different) County City, town or village, - Zip Code (if different) Telephone No. Between what streets or avenues. (If outside city or village limits and not known by a house number, specify location in re to nearest intersecting road or highway) Name of owner of building in which the premises to be licensed are located Address of owner of building 1. Yes or No (a) Will applicant occupy said premises under a written lease or option to lease? (b) If so, state name and address of the immediate lessor, the date of the lease and the date of expiration thereof. (c) Do the terms of such lease require payment by the applicant of any Consideration based on a percentage of the receipts of the business? (d) If so, state percentage and give details. 1. (a) Yes or No (c) 2. (a) Is any part of the proposed premises located within 200 feet of a building or any part of which is occupied as a school, church, synagogue or other place of worship? (b) If so, is any part of such school or place of worship located on the same street or avenue as the proposed premises? (c) If so, is such building occupied exclusively as a school, church, synagogue or other place of worship? Date of Lease Date of Expiration (b) Name and address of the immediate lessor Percentage and details (d) Yes or No 2. (a) Yes or No (b) Yes or No (c) Where all three parts of this question are answered in the affirmative, submit survey prepared by a registered or licensed surveyor or architect, showing both the proposed premises and such building and giving the exact distance as measured in a straight line from the center of the nearest entrance to the building occupied as a school, church, synagogue or other place of worship to the center of the nearest entrance of the proposed premises. 3. Are PROPOSED premises located in a district created under any zoning law, Yes or No which restricts the maintenance of retail liquor or wine store at said premises? 3. 4. Do proposed premises comply with all building, fire and health laws, ordinances Yes or No and regulations? 4. Form 805-LS (revised 09/2002) American LegalNet, Inc. www.FormsWorkflow.com PAGE 2 PETITION FOR REMOVAL Form 805-LS (revised 09/2002) STATE OF NEW YORK LIQUOR AUTHORITY 5. (Retail Liquor or Wine Store) (a) Is any license, under the Alcoholic Beverage Control Law, now in effect for the premises for which this application is filed, or for any part of the building containing the same? (b) If so, state full name of licensee and license number. Yes or No 5. (a) 6. Are PROPOSED premises located: (a) In a street level store? (b) On an arcade or sub-surface thoroughfare leading to a railroad terminal? (c) In a modern shopping center? (d) In a corner store? If so, state names of streets or avenues on which located. Yes or No Yes or No Yes or No 6. (a) (b) (c) 7. No. of Entrances Yes or No 7. (a) (b) License Number (b) Name of Licensee Yes or No Streets or Avenues (d) (a) State number of entrances to said premises, including doors classified as “Fire Exits” or delivery entrances. (b) Is there direct access between the premises sought to be licensed and any other part of the building containing the premises? If so, describe in blank space below. 8. Set forth approximate time licensee will require to move to proposed premises after date of approval of this petition for removal, if granted. 8. Length of time THE APPLICANT HEREBY AGREES THAT THE DIAGRAMS, SURVEY AND ALL OTHER PAPERS FIED IN SUPPORT OF THIS APPLICATION AND ANY APPLICATION FILED UNDER THE ALCOHOLIC BEVERAGE CONTROL LAW BY ANY EPRSON HAVING ANY INTEREST, DIRECT OR INDIRECT, EITHER IN THE PREMISES OR IN THE BUSINESS TO BE LICENSED, FOR ANY LICENSE OR PERMIT, SHALL BE DEEMED AND MADE A PART HEREOF AND CONSIDERED BY THE STATE LIQUOR AUTHORITY IN ACTING UPON THIS APPLICATION. THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL OR PARTNERS The undersigned, each for themselves, certifies that he/she is the applicant above named; that he/she knows the contents of the above application together with all other papers filed in support thereof and the statements contained therein and the same are true of their own knowledge. Dated: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ (Signature of Petitioner or of Each Partner) THE FOLLOWING CERTIFICATION TO BE SIGNED AND DATED IF A CORPORATION _________________________________________________ certifies that he/she is ________________________________________________ of the above names (Title) applicant corporation’ that he/she knows the contents of the above application together with all other papers filed in support thereof and the statements and answers therein; that the same are true of his/her own knowledge, that he/she has been authorized, by order of the Board of Directors of said applicant corporation to make the statements and answers in this application in behalf of said applicant corporation with the same force and effect as if said corporation made such statements and answers itself. Dated: _________________________________________________________________ ________________________________________________________________ (Signature of Authorized Officer) SLA Form 805-LS (revised 09/2002) American LegalNet, Inc. www.FormsWorkflow.com PETITION FOR REMOVAL INSTRUCTIONS Submit One Original of Each: - Petition for Removal Appropriate Fee – Refer to Petition for Removal Exterior & Interior Diagrams (on paper not more than 8 1/2” x 11”) of proposed premises. Lease (not required for grocery store) Any Contracts for purchase of business and/or real property On-Premises Licensees: - Complete the Following Sections of the Application for Alcoholic Beverage Control Retail License - SLA Form 260-040: Section: B, D, E, G, H, I, O NOTE: SECTION C & F Must ALSO be completed for ALL ONPREMISES LIQUOR ONLY Off-Premise Beer Licensees: - Complete the Following Sections of the Application for Alcoholic Beverage Control Retail License - SLA Form 260-040: Section: B, E, H, K, O Off-Premise Liquor Store Licensees: - Complete the Following Sections of the Application for Alcoholic Beverage Control Retail License - SLA Form 260-040: Section: B, D, E, G, H, J, O Intra-County Licensees: (Moving from One County to Another County) - Complete All Sections of the Application for Alcoholic Beverage Control Retail License - SLA Form 260-040. SLA form REM-i (03/2004) American LegalNet, Inc. www.FormsWorkflow.com