State of New Hampshire LIQUOR COMMISSION Off-Site Caterers License Application Application for Site Approval for Off-Site Caterers as pursuant to RSA 178:20,V(e) ***This application must be submitted at least ten business days prior to the event*** DATE OF EVENT: TIME FROM: TO: APPLICANT DATA APPLICANT: TRADE NAME: BUSINESS ADDRESS: PHONE#: LIQUOR LICENSE NUMBER: CLIENT DATA NAME: PHONE # TYPE OF EVENT: ADDRESS: SITE DATA BUILDING NAME: ADDRESS: BUILDING OWNER’S NAME AND ADDRESS: [ ] Prev viewed/Permanent Authorized Capacity: # attending: Entertainment requires city/town approval. Describe any entertainment to be held in conjunction with the event: [ ] Temporary site LICENSE SPECIALISTS CERTIFICATION I certify the premise meets the requirements as a “public building” for Licensure. License Specialist signature:_____________________________________________________________ Date: _____________________ DOCUMENTATION: Provide copies of the following documentation for the premise. 1. 2. 3. 4. Proof of applicant’s ownership, lease or rental of the premise. Permit of Assembly issued by local or state fire authorities; or [ ] I certify that the state or local authorities do not require permits of assembly. Health Certificate/license issued by local or state health department; or [ ] I certify that the state or local health departments do not require a certificate/license. Written authorization by the city/town for any entertainment to be held; or [ ] I certify that the city/town does not object to the entertainment described above. APPLICANT’S CERTIFICATION: I hereby certify under the penalties of RSA 641:3 that all information is true and correct and all required documentation is attached. _________________________________________________ Owner/Partner/Officer/Member/Manager ___________________ Date Dml rev 1/5/01 American LegalNet, Inc. www.FormsWorkflow.com