MAINE DEPT OF PUBLIC SAFETY STATE OF MAINE Liquor Licensing & Inspection Division 164 State House Station Augusta ME 04333-0164 Tel: (207) 624-7220 Fax: (207) 287-3424 APPLICATION FOR SPECIAL PERMIT FOR CATERING PRIVILEGES OFF PREMISES $10.00 (per day) Check Payable: Treasurer State of Maine License No.: _________ Name of Licensee: _______________________________________ Mailing Address: _______________________________________________________________ Town/ City: _________________ State: Telephone: __________________________ _______________ Zip Code: ___________ Fax: ______________________ Title and Purpose of Event: _______________________________________________________ Location of Event: ______________________________________________________________ Physical Address: ______________________________________________________________ Town/City: __________________________ State: ________________ Zip Code: _________ ‫ ڤ‬Indoor Event ‫ ڤ‬Outside Event (IF OUTSIDE AREA, DIAGRAM MUST BE INCLUDED) Describe specific indoor and/or outdoor area to be licensed: _____________________________ ______________________________________________________________________________ Date of Event: _________________ Time – From: ________ To: ________ Number of Persons Attending: _______________ Name of Sponsor: ______________________________________________________________ Address: ________________________________ Town/City: ________________________ State: ______________ Zip Code: ________________ Telephone Number: _____________ _____________________________________ Signature of Licensee or Corporate Officer ________________________ Date _____________________________________ Print Name of Licensee or Corporate Officer FOR USE ONLY BY DEPT. OF PUBLIC SAFETY – LIQUOR LICENSING RESTRICTIONS: [ ] APPROVED – PERMIT # ________ DATED: ___________ [ ] NOT APPROVED ISSUED BY: _______ OffPremCater / 2003 American LegalNet, Inc. www.FormsWorkflow.com This Off Premise Catering Permit is not assignable and is valid for use only by the Licensee named heron for the date, time, and location indicated heron. This permit is issued subject to the Laws, Rules and Regulations of the Division and is issued subject to the penalties as provided for in Title 28A, Chapter 33. NOTE: TO MUNICIPAL OFFICERS & COUNTY COMMISSIONERS This application must be approved by the Municipal Officers of the municipality in which the function is to be held or, if held in an unincorporated place, by the County Commissioner. Title 28A, Section 1076, Subsection 7D grant authority for this approval without public notice. Dated at: _____________________________________, Maine _______________________________ ss City/Town (County) On: _________________________________________ Date The undersigned being: ‫ ڤ‬City ‫ ڤ‬Town ‫ ڤ‬Municipal Offices ‫ ڤ‬Plantation ‫ ڤ‬County Commissioners ‫ ڤ‬Unincorporated Place of the of: ______________________, Maine Hereby certify that we have given public notice on this application and held public hearing thereon as required by Section 653 Title 28A, Maine Revised Statutes and herby approve said application. Signature Print 72 Hours in Advance of Said Event or Gathering REQUESTED OffPremCater / 2003 American LegalNet, Inc. www.FormsWorkflow.com