STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION LIQUOR CONTROL DIVISION {Instructions on back} APPLICATION FOR REMOVAL 1. NAME AND HOME ADDRESS OF PERMITTEE: ________________________________________________________________________________________________ 2. NAME OF BACKER: ________________________________________________________________________________________________ 3. PERMIT (TYPE & NUMBER): ________________________________________________________________________________________________ 4. PRESENT ADDRESS OF BUSINESS: ________________________________________________________________ (NUMBER) (STREET) ________________________________________________________________________________________________ (TOWN) 5. (STATE) (ZIP) (TELEPHONE NUMBER) PROPOSED ADDRESS OF BUSINESS: ________________________________________________________________ (NUMBER) (STREET) _________________________________________________________________________________________________ (TOWN) (STATE) (ZIP) 6. HOW MANY FEET IS NEW LOCATION FROM PRESENT PERMIT ADDRESS? _____________________________ 7. IS THE ENTRANCE TO THE PROPOSED NEW LOCATION WITHIN 200 FEET IN A DIRECT LINE FROM A CHURCH EDIFICE, PUBLIC OR PAROCHIAL SCHOOL? (¥) YES___ NO ___ NAME:_______________________ 8. GIVE APPROXIMATE DISTANCE TO NEAREST CHARITABLE INSTITUTION, WHETHER SUPPORTED BY PUBLIC OR PRIVATE FUNDS: ______________________________________________________________________ 9. SIGNATURE OF PERMITTEE: ________________________________________________________ 10. SIGNATURE OF BACKER: ___________________________________________________________ 11. IF THIS APPLICATION IS FOR A RESTAURANT, CAFE, TAVERN, HOTEL, CLUB OR THEATER REMOVAL: THIS PART MUST BE FILLED IN BY THE FIRE MARSHAL IN THE TOWN INDICATED IN ITEM #5. THIS IS TO CERTIFY THAT PREMISES DESCRIBED IN ITEM #5 ARE PHYSICALLY CONSTITUTED TO SAFELY CONDUCT THE TYPE OF BUSINESS DESCRIBED IN ITEM #3. ___________________________________________________________________________ FIRE MARSHAL (SIGNATURE & DATE SIGNED) 12. THIS IS TO CERTIFY THAT I AM ACQUAINTED WITH THE ZONING ORDINANCES AND BY LAWS OF THE (¥) TOWN____ CITY _____ OR BOROUGH ____ AND THE SALE OF ALCOHOLIC LIQUOR IS NOT PROHIBITED BY EITHER THE ORDINANCES OR BY LAWS OF SAID TOWN ____ CITY____ OR BOROUGH____ AT THE LOCATION DESCRIBED IN ITEM #5 OF THIS APPLICATION. __________________________________________________________________________ ZONING ENFORCEMENT OFFICER (SIGNATURE & DATE SIGNED) 13. THIS PART TO BE FILLED IN BY THE TOWN, CITY OR BOROUGH CLERK. THE MUNICIPALITY (¥) HAS ____ HAS NOT____ VOTED OR PASSED AN ORDINANCES TO PERMIT THE SALE OF ALCOHOLIC LIQUOR ON SUNDAY. HAVE THE HOURS OF SALE HAS BEEN REDUCED BY VOTE OF CITY____ TOWN____ MEETING OR BY ORDINANCES____? IF SO, THE REDUCED HOURS ARE______________________________________________. _____________________________________________________________ CLERK (SIGNATURE & DATE SIGNED) American LegalNet, Inc. www.FormsWorkflow.com