DCPLC-ExtensofUseRequestform Rev 10/08 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Fax: (860) 713-7235 Website: http://www.ct.gov/dcp EXTENSION OF USE REQUEST FORM PERMITTEE:___________________________________________________PERMIT #_____________________________ BACKER:____________________________________________________________________________________________ ADDRESS:___________________________________________________TOWN__________________________________ TRADE NAME:_______________________________________________________________________________________ BUSINESS PHONE:_____________________FAX #______________________HOME PHONE:_____________________ WILL EXTENSION BE PERMANENT: YES_________ NO____________ If Extension is going to only be used Temporarily, List exact dates needed:________________________________________ DIRECTIONS: ON THE BACK OF THIS SHEET MAKE A SKETCH OF THE EXISTING PERMIT PREMISES AND INCLUDE THE FOLLOWING 1. 2. 3. 4. 5. The Extension in relation to the permit premises. List all dimensions of Extension in feet. All entrances & exits leading to and from the extension. Portion of sketch that shows Permit Premises must be labeled with all the Dining Rooms, Barrooms, Kitchen, etc If extension is outside, include property boundaries and height of fencing, if any. Indicate how alcoholic beverages are going to be served in Extended area. Show all consumer bars &Service Bars NOTE: If a Consumer Bar is going to be used in the Extension, an application for Additional Consumer Bar permit together with a $150.00 fee must be Submitted with this application. IF THIS SHEET IS NOT LARGE ENOUGH, CONTINUE SKETCH ON ONE ADDITIONAL SHEET. 1. 2. 3. 4. 5. 6. If access to Extension is through the Barroom, the area is considered an extension of the Barroom (NO MINORS ALLOWED) Unless allowed by Section 30-86(b). If access to Extension is through a Dining Room, the extension is considered part of the Dining Room. If Alcoholic Beverages are to be made from a Service Bar in extended area-NO additional fee if required. (Service must be made by Waitstaff only). If Alcoholic Beverages are to be made from an Additional Consumer Bar Located in Extension area--area is considered Barroom-(NO MINORS ALLOWED) No alcoholic beverages are to leave the extended area (away from premises.) NO DEVIATIONS FROM THE PLAN SHOWN ON THIS FORM ARE ALLOWED WITHOUT WRITTEN APPROVAL FROM THIS DEPARTMENT. SIGNATURE:_______________________________________________________________ PERMITTEE _________________ DATE SIGNATURE:_______________________________________________________________ PERMITTEE _________________ DATE ---------------------------------------------------------------MUNICIPAL APPROVALS ZONING: SIGNATURE:______________________________________________________________DATE______________________ FIRE DEPT. SIGNATURE:_____________________________________________________________DATE_____________________ HEALTH: SIGNATURE:_______________________________________________________________DATE_____________________ DEPARTMENT OF CONSUMER PROTECTION PATIO APPROVAL THIS MUST BE DISPLAYED NEXT TO YOUR PERMIT OR PERMIT MUST BE ENDORSED. LIMITATIONS OR CONDITIONS: APPROVED BY:______________________________________________________________DATE:___________________________ American LegalNet, Inc. www.FormsWorkflow.com