plcb-2217 2/12 commonwealth of pennsylvania pennsylvania liquor control board application for public venue or performing arts facility restaurant liquor license (see instructions page 3) bureau of licensing 1g page 1 of 3 (ansWer all questions) the undersigned hereby applies for the following type of license: or 1. name of applicant 2. trade name (if any) 4. address of premises 5. name of municipality (street, rural route, p.o. box no.) public venue restaurant liquor, performing arts facility restaurant liquor 3. facility/premises Known as (post office) (state) (zip) type of municipality city 6. describe primary use(s) of facility: boro twp. inc. town county 7. is the applicant a concessionaire? if yes, for whom? 8. is the application to be considered for prior approval? yes no yes 19. has the applicant previously filed an application for any other license? if "yes", when and where? no yes yes no if "yes", when does it expire? give month, day, year. 10. is a current health license posted on the premises? no deed booK volume no. page no./ instrument no. lease expiration date 11. name of current owner of premises address of current owner of premises 11(a). name of officers, directors, shareholders, partners or members of property owner. (attach separate sheet if necessary) title 12. complete in detail - attach separate sheet, if necessary. name of individual applicant, partners, members, or officers & directors a. name b. name c. name d. name e. name title home address date and place of birth length of residence in pa. u.s. citizen? yes no Do not Write beloW tHis line co/mncp _ _ - _ _ _ zip _ _ _ _ _ - _ _ _ _ American LegalNet, Inc. www.FormsWorkFlow.com 13. for corporations only (check one) profit nonprofit u.s. citizen? yes no no. of shares of stocK held 13a. list all stocKholders - attach separate sheet, if necessary. name of stocKholder a. name home address date & place of birth b. name c. name d. name e. name f. name 14. for corporations only and limited liability companies only 14a. resolution at a regular or special meeting held on ________________________________________________ , 20 ________ by the applicant, it was resolved that said application be filed with the pennsylvania liquor control board, and that _________________________________________and/or ________________________________________ is/are hereby (name/title) (name/title) authorized to execute said application, and any other papers required by the board. 14b. registered name incorporated/organized place date if foreign corporation give date of certificate of authority or if foreign llc give date registered in pa 15. is a management company employed or otherwise contracted to operate, manage, or otherwise supervise all or part of the operation? yes 16. no if yes, list name and address of entity: name of manager name home address date & place of birth u.s. citizen? yes no 17. conviction record: the following is a record of all felony and misdemeanor convictions of the individual owner, all partners, all members, the manager and all corporate officers, directors and stockholders. (Attach separate sheet, if necessary.) if there have been no such convictions, check here: no such convictions name date of conviction charge disposition location of court (county and state) 18. Neither the applicant nor any member, officer, director, stockholder, agent or employee has any financial interest, either directly or indirectly, in any other class of license or permit issued by this board, or in the ownership, leasehold, or equipment, of any property used by such other licensee or permittee, or mortgage lien against the same, nor have they loaned any money, or given credit, or anything of value, for equipping, maintaining or conducting an establishment used in such other license or permit, except as follows: no exceptions 19. No person having any financial interest as an individual, or as a member, officer, director, stockholder, agent or employee in another class of license or permit issued by this board will be in any manner interested, either directly or indirectly, in the business proposed to be licensed under this application, or in the ownership or leasehold of the property or equipment to be used in the operation of the said business, or any mortgage lien against the same, nor have they loaned any money, or given credit, or anything of value, to the applicant, or any officer, director, stockholder, servant, agent or employee of said applicant, for equipping, maintaining or conducting this business, except as follows: no exceptions American LegalNet, Inc. www.FormsWorkFlow.com plcb-2217 2/12 commonwealth of pennsylvania pennsylvania liquor control board application for public venue or performing arts facility restaurant liquor license (see instructions on page 3) bureau of licensing page 2 of 3 20. None of the applicants hold any public office involving the enforcement of penal laws, or penal ordinances or resolutions, except as follows: no exceptions 21. premises to be licensed a. list complete information for every area which is to be used in the operation of the licensed business, including a separate Kitchen, if any, any area to be used for storage of alcoholic beverages, restaurant facilities and club seats. attach separate sheet, if necessary. room/area width length located on what floor/level seating capacity public venue applicants alcoholic beverages sold? checK all that apply liquor malt beverage designate use: serving, Kitchen or storage, public seating, club seating b. total seating capacity c. occupancy of remainder of building American LegalNet, Inc. www.FormsWorkFlow.com 22. no other type of business licensed by the liquor control board is conducted in the building, except as follows: no exceptions 23. list name(s) and lid numbers of any other concessionaire(s) operating in the facility no other concessionaire(s) 24. for performing arts facility applicants only a placard, plcb-1296, public notice of application alcoholic beverages, was posted on (date) __________________ in a conspicuous place on the outside of the premises as required by the liquor code and regulations of the board, and will remain posted until a notice of approval or refusal is received by the applicant. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §4-403(h) and/or §4-436(j), that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belie