For Official Use Only DCPLC � Removal App Rev 11/11 1 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Liquor Control Division Telephone: (860) 713-6210 Email: liquor.control@ct.gov Web Site: www.ct.gov/dcp REMOVAL APPLICATION (FOR ON-PREMISES AND OFF-PREMISES LIQUOR PERMITS) Section A: PROPOSED BUSINESS LOCATION 1. Proposed Business Street Address City State Zip Code 2a. Proposed Phone Number: 2b. Proposed Fax Number: 2c. E-mail Address 3. Are you Requesting a Removal on Stipulation? YES NO 4. Will there be an Additional Consumer Bar? 5. Will there be a Patio? YES NO N/A YES NO N/A If you answer "YES" to #'s 3, 4, or 5, please read and complete the applicable form attached to this application packet Section B: APPROVAL/CERTIFICATION OF LOCAL OFFICIALS Please Note: Only ON-Premises Liquor Permits must complete the Fire Marshal's Approval (This applies only to restaurant, caf�, tavern, hotel, and theater permits) 6. Fire Marshal's Approval: I certify that the premises identified in Section A, item #1 of this application is physically constructed in a manner that is safe for the type of business that will be operated there. Signature of Fire Marshal X _________________________________________Print Name ____________________________________ Title of Official ______________________________________________________________________ Date ______ /______ /________ 7. Zoning Authority Approval: I certify that I am familiar with the zoning ordinances and bylaws of the city/town identified in Section A, item #1 of this application and they do not prohibit the sale of alcoholic beverages under the type of liquor permit/establishment identified in this application. Signature of Zoning Official X _______________________________________Print Name ____________________________________ Title of Official ______________________________________________________________________ Date ______ /______ /________ 8. Certification of Town Clerk: The town in which the business identified in Section A, item #1 of this application is to be operated, has no ordinance restricting the hours of sale of alcoholic liquors beyond those set forth in State law except as indicated in the box below. (If none, please enter "NONE") Additional Restrictions: Signature of Town Clerk X _________________________________________Print Name _____________________________________ Title of Official ______________________________________________________________________ Date ______ /______ /________ American LegalNet, Inc. www.FormsWorkFlow.com DCPLC � Removal App Rev 11/11 2 Section C: CURRENT BUSINESS LOCATION/PERMITTED PREMISES 9. Permit Number 10. Trade Name (DBA) 11. Current Business Street Address City State Zip Code Section D: PERMITTEE INFORMATION 13. Permittee Name (First, Middle, Last) 14. Permittee Residence Street Address City State Zip Code 15a. Phone Number: 15b. Fax Number: 15c. E-mail Address Section E: BACKER-OWNER INFORMATION 16. Backer Name (Corporation, LLC, Partnership, Sole Proprietorship, etc.) Section F: PREFERRED MAILING ADDRESS 17. Name 18. Address City State Zip Code Section G: CERTIFICATION OF PERMITTEE APPLICANT AND BACKER OR AUTHORIZED REPRESENTATIVE OF BACKER 19. Permittee Certification (To be signed by permittee applicant, identified Signed by Permittee Applicant in "Section A" of this application) I certify that the information provided in this application is true to the best of my X__________________________________________________ knowledge. 20. Backer Certification (To be signed by backer or the authorized representative Signed by Backer or Authorized Representative of Backer of the backer) Date Date I certify that the information provided in X__________________________________________________ this application is true to the best of my knowledge and that the permittee Print name of Backer or Representative Title of Backer or applicant identified in "Section A" of this Representative application is designated as my principal representative on the premises for which this application is being submitted. American LegalNet, Inc. www.FormsWorkFlow.com