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Application For Alcoholic Beverage Control Retail License (Except On Premises Liquor) Form. This is a New York form and can be use in Division Of Alcoholic Beverage Control Statewide.
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Tags: Application For Alcoholic Beverage Control Retail License (Except On Premises Liquor), New York Statewide, Division Of Alcoholic Beverage Control
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APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL RETAIL LICENSE
(EXCEPT ON PREMISES LIQUOR)
It is not necessary to employ any person, agency or organization to assist you in filing this application. Beware of persons
claiming to be able to assist you in securing action on your application. The payment of money or other thing of value for
the use of influence, or promise of influence in obtaining a license is a violation of law and offenders will be prosecuted.
1. APPLICANT
Name of Applicant:
Trade Name(DBA): (see instructions)
** must be provided if premises will be called
by any name other than as listed in the
"Name of Applicant"
Premises Street Address:
City:
State:
Zip Code:
County:
Telephone Number of Premises (include area code):
Between what streets:
Mailing Address (if different than above):
City:
State:
Zip Code:
E-mail address (if available):
2. CONTACT
Attorney
Name of Contact:
Representative
Contact Person
Office Address:
City:
State:
Zip Code:
Telephone Number of Office (include area code):
E-mail address (if available):
3. For SEASONAL licenses only - beginning and ending months:
4. LICENSE CLASS:
CODE:
(see schedule of fees)
5. Number of ADDITIONAL BARS (if any):
6. TOTAL PAYMENT DUE:
(see instructions)
7a. Federal Tax ID Number:
[OFFICE USE ONLY]
DATE FILED:
SERIAL #:
continued on next page
7b. Worker's Compensation/
Disability Benefits Carrier Name
and Policy Number:
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8. Are there any local option restrictions in this area (DRY, PARTIALLY DRY)?
YES
NO
DO NOT KNOW
If YES, explain:
9. TO BE FILLED IN ONLY BY INDIVIDUAL OR PARTNERS
Name of Individual / Partner
Residence
Citizenship
Date of Birth
Name of Individual / Partner
Residence
Citizenship
Date of Birth
Name of Individual / Partner
Residence
Citizenship
Date of Birth
Name of Individual / Partner
Residence
Citizenship
Date of Birth
Name of Individual / Partner
Residence
Citizenship
Date of Birth
Statutory Disqualification: Identify and explain as described on page II of instructions
10. TO BE FILLED IN ONLY BY CORPORATION OR LLC/LLP APPLICANTS
a. State under what law applicant was organized:
b. Date of organization: (SUBMIT COPY OF FILING RECEIPT)
c. If applicant is a foreign entity, has a Certificate of
Authority been obtained to do business in this
state?
YES
NO
d. If YES, date of certificate:
e. Mailing Address (if different from premises):
City:
State:
Zip Code:
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10. continued
f. List the names and address or Principals (Stockholders, Officers, Directors, LLC Members/Managers, LLP Partners)
Name of Principal
Residence
Citizenship
Title
No. of Shares or % of ownership
Date of Birth
Name of Principal
Residence
Citizenship
Title
No. of Shares or % of ownership
Date of Birth
Name of Principal
Residence
Citizenship
Title
No. of Shares or % of ownership
Date of Birth
Name of Principal
Residence
Citizenship
Title
No. of Shares or % of ownership
Date of Birth
Name of Principal
Residence
Citizenship
Title
No. of Shares or % of ownership
Date of Birth
Name of Principal
Residence
Citizenship
Title
No. of Shares or % of ownership
Date of Birth
Statutory Disqualification: Identify and explain as described on page II of instructions
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11. RIGHT TO PREMISES
a. By what right does the applicant have possession of the premises?
Own
Lease
Sub-Lease
Binding contract to acquire real property
Written intent to Lease
Other (explain):
b. Do the terms of the lease or other arrangement require the applicant to provide any
consideration based on a percentage of the receipts of the business?
YES
NO
If YES, state percentage
and give details:
c. Specify Lease Start Date:
Specify Lease Expiration Date:
12. INTERESTED PARTIES
a. Is there currently a license to traffic in alcoholic beverages in effect for the premises for which this application is filed?
YES
b. Name of current/previous licensee:
NO
Do Not Know
License Serial Number:
c. Are there any disciplinary actions pending against the applicant, current licensee, or prior licensee?
YES
NO
Do Not Know
Any pending disciplinary action may prevent a determination on this application or result in the disapproval of the
application with or without prejudice.
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12. Continued
d.
Does any person, corporate principal, LLC or LLP member, or any person not an officer, director, or stockholder of such
corporation, or member of LLC or LLP, or any other person not identified herein share or will share on a percentage basis
or in any way in the receipts, losses or deficiencies of the business to any extent whatsoever?
YES
NO
If YES, state the names and address of such persons, the nature and percent of their share and date acquired.
Name
Address
Nature of interest
Date Acquired
Name
Address
Nature of interest
Date Acquired
Name
Address
Nature of interest
Date Acquired
Name
Address
Nature of interest
Date Acquired
Name
Address
Nature of interest
Date Acquired
e. Does the applicant or, if a partnership any of the partners, or if a corporation any of the officers, directors or
stockholders or if a limited liability company (LLC), or a limited liability partnership (LLP) any members have
any interest, direct or indirect, in any other premises or business where any alcoholic beverage is manufactured
or sold at wholesale or retail, whether by stock ownership, interlocking directors, mortgage or lien on, or ownership
YES
NO
of any real or personal property, or by any other means including loans?
If YES, state the name and address of the premises, the license number, the date the interest was acquired and the
exact nature of the interest.
Name
Address
Date Acquired
Name
Nature of interest
Address
Date Acquired
Name
Date Acquired
License Number
License Number
Nature of interest
Address
License Number
Nature of interest
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LANDLORD IDENTIFICATION INFORMATION
1. Name of Landlord:
2. Mailing address of Landlord:
3. Telephone Number of Landlord:
4. Landlord Principals
Name
Address
Name
Address
Name
Address
Name
Address
5(a).
Are any persons listed on this form currently or previously
licensed under the ABC Law?
5(b).
If YES, list the names and license numbers:
6(a).
Are any persons listed on this form police officers:
6(b).
If YES, list the names :
YES
YES
NO
NO
7. List number of years real property has been owned by landlord:
Signature of Landlord
Date
IMPORTANT: SIGNATURE MUST BE THE SAME AS SIGNATURE ON THE ORIGINAL LEASE. IF NOT, FURNISH
EITHER AN AFFIDAVIT IN EXPLANATION, AFFIX LEGIBLE CORPORATE SEAL OR SUBMIT OTHER PROOF OF
SIGNATURE'S AUTHORITY
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LIST OF EXPENSES FOR THIS VENTURE
Expense Item (Actual or Estimated)
1. Real Property:
2. Purchase/Contract price (submit copy of contract):
3. Security Deposit:
4. Operating Capital:
5. Miscellaneous Expenses (include Attorney/Representative fee):
6. SLA Fees:
7. First month's rent and any paid to date:
8. Renovations:
9. Other:
(See Instructions, Page IV, Section B for
required verifications)
10. TOTAL CASH
11. TOTAL DEFERRED
(Total deferred includes loans, mortgages, lines of credit, notes, etc. Attach copies of EACH source
of deferred monies)
Explain in detail how deferred
12. TOTAL COST
NOTE: The amounts in items 1 through 9 must total the amount reflected in item 12.
The amounts in items 10 and 11 must total the amount reflected in item 12.
IMPORTANT: Submit any and all records, documents and affidavits that you feel may assist
you in explaining the source of monies as per instruction sheet.
List bank accounts numbers from which "total cash" will derive.
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List lenders and amounts (to be) loaned from which "total deferred" will derive.
Dollar(s) Amount
Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.)
Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires)
Dollar(s) Amount
Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.)
Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires)
Dollar(s) Amount
Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.)
Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires)
Dollar(s) Amount
Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.)
Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires)
Dollar(s) Amount
Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.)
Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires)
Dollar(s) Amount
Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.)
Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires)
Dollar(s) Amount
Type of Investment ( Accounts, Loans, Gifts, Asset Sales, etc.)
Source of Funds (Identify by Name - Lender, Giftor, Asset Sales, etc. - Provide Personal Questionnaires)
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STATEMENT OF AREA PLAN
Is the premises within 200' of ANY SCHOOL, CHURCH or PLACE OF WORSHIP?
(Exclusive use as a church or place of worship will be determined by this agency)
(Please respond "YES" if ANY school, church or place of worship is within 200')
YES
NO
List the name, address and distance from the premises to the CLOSEST SCHOOL, CHURCH,
or PLACE OF WORSHIP regardless of the distance in the area below
If within 200' submit a BLOCK PLOT DIAGRAM or AREA MAP showing the location of any
school, church or place of worship in proximity to your proposed premises ( 8½" x 11")
Indicate distance in feet from the proposed premises. Attach additional sheets if necessary.
ATTACH A STATEMENT INDICATING HOW THESE MEASUREMENTS WERE TAKEN
1. Name of church/school:
Address:
Distance:
2. Name of church/school:
Address:
Distance:
3. Name of church/school:
Address:
Distance:
4. Name of church/school:
Address:
Distance:
If applying for a full liquor license (beer, wine and liquor) and the premises is within 200' of a school, church or
place of worship, the application may be denied.
If any discrepency in the measurements is brought to the attention of the Authority during the examination of
the application, it may be necessary for the applicant to supply a certified survey showing the actual measurement
from the premises to the closest school, church or place of worship.
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ESTABLISHMENT QUESTIONNAIRE
1. Describe the area where the premises is to be located:
Residential
Business
Shopping Mall
1a. State what the area is zoned for:
2. Premises
a. Describe the type of building and list the number of
floors where premises is to be located.
( Example: single unit, multi unit, shopping mall, etc. )
b. Has the building/premises been known by any other address?
YES
NO
If YES. please specify:
c. Has the premises to be licensed and/or any other floor in the building been
previously licensed or currently licensed for the sale of alcoholic beverages?
YES
NO
d. What was prior use of premises to be licensed?
e. Any outside area or sidewalk café used for the sale or consumption
YES
NO
of alcoholic beverages? (such as roof, yard, deck)
If YES: 1. Describe below and show on diagram.
2. Is a permit required by locality for outside area?
YES
NO
3. Explain how area is contained (use box below or separate sheets)
f. If applying for an on premises license does the premises have a
VALID CERTIFICATE OF OCCUPANCY and ALL appropriate permits?
YES
NO
SUBMIT A COPY OF THE CERTIFICATE OF OCCUPANCY OR A LETTER FROM MUNICIPALITY STATING NONE IS NEEDED.
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g. Are the premises to be licensed divided in any way, by a public or private passageway,
etc., over which the applicant does not have exclusive possession and control?
YES
NO
If YES, describe:
3. Premises (interior) Helpful hint: Drawing your diagram first may assist you in completing the remainder of this section.
a. On what floor(s) are the premises located?
How many room(s) on each floor?
b. Use of room(s)?
c. If more than one floor, what is the access between floors (i.e. stairs)?
d. If more than one floor, is there interior access to the other floors including the basement?
e. How many public bathrooms?
g.
YES
NO
f. Location of public bathrooms
(include in diagram)
What is the maximum number of persons that can legally occupy the premises
to be licensed pursuant to the current Certificate of Occupancy?
What is the maximum number of persons you anticipate occupying
the premises to be licensed?
h. Number of tables?
i. Number of seats at tables?
j. Is the interior view unobstructed throughout?
YES
NO
If NO, state reason:
k. Any openings to other parts of the building?
YES
NO
If YES, describe:
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4. BARS:
a. How many stand-up bars* are located on the premises?
b. How many service bars*?
c. Describe all bars (length, shape, and location)
d. Any food counters? Do not include bar if listed above
YES
NO
If YES, describe:
* See instructions for definition of stand-up and service bars
5. KITCHEN
a. Does premises have a kitchen?
YES
NO
If NO, does premises have a food preparation area?
If any, show on diagram.
b. Is food available for sale?
If YES, describe type of food and SUBMIT A MENU
c. Is a chef employed at the premises?
If YES, list hours of day chef will devote to the premises:
6. HOTEL
a. Type of Hotel:
Transient
Apartment
Summer
b. Is there a restaurant in the building(s) housing the proposed hotel?
c. How many floors?
YES
NO
d. How many rooms?
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METHOD OF OPERATION
1. Select the type of establishment you are applying for from the list below (based upon your intended method
of operation):
Restaurant (Beer and Wine only)
Other (Explain)
2. Will any other business of any kind be conducted in said premises?
YES
NO
(If YES, provide details on a separate sheet)
3. Will premises have music?
YES
NO
3a. If yes:
LIVE
RECORDED
What type of music? Explain in detail:
List days of week and hours of day premises will have music:
4. Will the premises permit dancing?
YES
NO
4a. If YES, describe:
4b. If YES, and are located in NYC, do you have a Cabaret permit issued by the City of New York ?
YES
NO
PENDING
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5. What are the proposed days and hours each
day of operation?
5a. If applicable, list hours food will be
available for sale.
6. Will the business employ a manager?
YES
NO
If YES, see question 6a.
6a. Name(s) of manager(s):
(Manager(s) MUST complete
a personal questionnaire prior
to employment)
If NO, will principal(s) manage?
YES
NO
7. How many employees?
If answer is "0" provide explanation.
8. Will there be security personnel?
YES
NO
If YES, how many?
(If they are required, are they registered in accordance with New
York State Security Guard Registration or are they not required to
be registered?)
Security personnel you hire may be required to be registered in accordance with NYS Security Guard Registration.
Please contact the NYS Department of State to obtain information.
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NOTICE OF PUBLICATION
Effective August 22, 1999, all applicants for licenses for on premises consumption must publish a NOTICE in a
newspaper, designated by the County Clerk, once a week for two successive weeks as hereinafter provided.
→
If the proposed premises are located in any county other than New York, Kings, Queens, or Bronx, the
NOTICE shall be published in a daily OR weekly newspaper in the county where the premises are located.
→
If the proposed premises are located in the counties of New York, Kings, Queens or Bronx, the NOTICE
shall be published in one daily AND one weekly newspaper published in the county where the premises are
located.
The NOTICE shall be printed in English in substantially the following form:
Notice is hereby given that a license, number (fill in serial number) for (fill in beer, liquor and/or wine, as the case
may be) has been applied for by the undersigned* to sell (fill in beer, liquor and/or wine, as the case may be) at
retail in a (hotel, club, restaurant, vessel, railcar, or other type of establishment, as the case may be) under the
Alcoholic Beverage Control Law at (fill in street address, city, town or village and county in which the premises are
located) for on premises consumption.
(*Applicant's name must appear at the bottom of the advertisement)
The first publication shall be made within 10 days of the filing of the application. Applicant shall obtain two
original copies of proof of publication. One original copy must be submitted to the Authority within 15 days of
receipt. The second original shall be retained by applicant. Except for good cause shown, the Authority shall
not issue the license unless proof of publication is submitted within such 15 day period. The form of proof
of publication shall be as follows:
STATE OF NEW YORK
COUNTY OF ______________________________________
_____________________of____________________being duly sworn, says that (s)he is
_____________________of the publishers of the_____________________ , a (daily) or
(weekly) newspaper (printed and) published in the (city, town, or village and county)
_____________________, and that the notice of which the annexed is a true copy, has been
published in said newspaper for once a week for two successive weeks commencing on the __________day of
______________________________
.
Sworn to before me this _______________day of_______________
_______________________________________________________
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PERSONAL QUESTIONNAIRE
a. All principals to the license application must complete this questionnaire in full.
(Lendors, donors, guarantors and managers must also complete this questionnaire.)
b. If you are a lender,donor or guarantor you must state your relationship to the applicant.
c. Make duplicate blank forms as necessary.
d. Answer all questions below.
e. Attach additional sheets if more space is needed.
NAME OF APPLICANT
1. STATEMENT OF IDENTIFICATION
Print YOUR name:
Date of birth
Social Security Number
Residence street address
County
City
State
Zip Code
U.S. Citizen
Email Address
YES
If ALIEN, registration number or VISA type
Residence Telephone
If NOT U.S. citizen - country of citizenship
NO
List any other names that you may have been known by (including maiden name)
HEIGHT
HAIR COLOR
MARITAL STATUS
WEIGHT
EYE COLOR
SPOUSE NAME
SEX
MALE
FEMALE
SPOUSE'S SOCIAL SECURITY #:
2. Residences for the past TEN years.
Address
From (month/year)
To (month/year)
Address
From (month/year)
To (month/year)
Address
From (month/year)
To (month/year)
Address
From (month/year)
To (month/year)
Address
From (month/year)
To (month/year)
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3. Your occupation for the past TEN years
From/To (month/year)
Employer
Employer Address
Type of business
Position
From/To (month/year)
Employer
Employer Address
Type of business
Position
From/To (month/year)
Employer
Employer Address
Type of business
Position
From/To (month/year)
Employer
Employer Address
Type of business
Position
4. Position (or interest) you will hold (check each):
President
Director
Manager
Vice President
Stockholder
Lender*
Secretary
Partner
Donor*
Treasurer
General Partner
Guarantor*
Chairman
Limited Partner
LLC Manager
Officer
Sole Proprietor
LLC Member
*If Lendor, Donor or
Guarantor state your
relationship to the
applicant.
Other
5. LICENSE HISTORY / AFFILIATIONS
If you are an applicant (i.e. proprietor, partner, stockholder, officer or director)
or applicant's spouse, will you continue your present occupation or business?
YES
NO
List hours you will devote to business sought to be licensed:
continued on next page
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Will you take an active part in the operation of the business to be licensed?
YES
NO
If YES, explain nature of activity (hours, day, week):
Do you have any interest, direct or indirect, in any premises currently licensed by the Liquor
Authority or business where any alcoholic beverage is manufactured, transported or sold at
wholesale or retail whether by stock ownership, interlocking directors, mortgage or lien on, or
ownership of any real or personal property, or by any other means including loans?
YES
NO
If YES, provide information below:
Business name
Business address
Date interest began
Liquor License Number
Business name
Business address
Date interest began
Liquor License Number
Business name
Business address
Date interest began
Liquor License Number
Other than as itemized in the above, have you ever applied in New York State or
anywhere for a license or permit to traffic in alcoholic beverages, including any
application as a partnership or corporation in which you are/were a principal?
YES
NO
If YES, provide information below:
Name of applicant
Address of premises
License Number
Disposition
Name of applicant
Address of premises
License Number
Disposition
continued on next page
Date of filing
Date of filing
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Name of applicant
Address of premises
License Number
Disposition
Name of applicant
Address of premises
License Number
14
Date
Date of filing
Disposition
Date of filing
Has a license or permit listed above been REVOKED,
CANCELED or otherwise Involuntarily Terminated?
YES
NO
If YES, state action and date of action, and give details:
Are you a police commissioner or law enforcement/police officer?
YES
NO
If YES, provide details
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6. CONVICTION RECORD AND PENDING CRIMINAL CASES
(a)
Have you or your spouse (or any officer, director, shareholder or partner listed in this
application or the spouse of such person) been convicted of a crime addressed by the
provisions of Section 126 of the ABC Law (see instructions for statutory disqualification)
which would forbid a person to traffic in alcoholic beverages?
YES
NO
If YES, supply details
(b) Have you or your spouse (or any officer, director, shareholder or partner
listed in this application or the spouse of such person) ever been CONVICTED (including
pleas of guilty or suspended sentences) of any felony, misdemeanor (including driving
while intoxicated or impaired) or any other type of offense EXCEPT MINOR TRAFFIC
INFRACTIONS?
(c)
If YES, attach a Certificate of Disposition by the court clerk for each case and a
Certificate of Relief from Disabilities if available and submit an Affidavit explaining all
details. If you have reported all convictions to this Authority and were subsequently
approved for a license, check here:
(d) Are there any ARRESTS, INDICTMENTS or SUMMONSES other than minor
traffic infractions PENDING against you or your spouse (or any officer, director,
shareholder or partner listed in this application or the spouse of such person) including driving while intoxicated or impaired?
YES
NO
Approved:
YES
NO
(e) IF YES, PROVIDE COPY OF ACCUSATORY INSTRUMENT.
7. INFORMATION CONCERNING AVAILABILITY OF PREMISES
Explain how you became aware of the availability of the proposed premises.
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8. FINANCES
IMPORTANT:
Submit any and all records, documents and affidavits that you feel may assist you in explaining the source of monies you
will provide for this venture as per instruction sheet.
State TOTAL AMOUNT OF MONEY you are providing for this venture:
Type of investment
(Investment Loan, Contract Debt)
Type of investment
Dollar ($) Amount
Source of Funds
(Accounts, Loans, Gifts, Asset Sales, etc.)
(enter identification number for accounts)
Type of investment
(Investment Loan, Contract Debt)
Type of investment
Dollar ($) Amount
Source of Funds
(Accounts, Loans, Gifts, Asset Sales, etc.)
(enter identification number for accounts)
Type of investment
(Investment Loan, Contract Debt)
Type of investment
Dollar ($) Amount
Source of Funds
(Accounts, Loans, Gifts, Asset Sales, etc.)
(enter identification number for accounts)
Type of investment
(Investment Loan, Contract Debt)
Type of investment
Dollar ($) Amount
Source of Funds
(Accounts, Loans, Gifts, Asset Sales, etc.)
(enter identification number for accounts)
If you are guaranteed a loan with a co-signer or putting up something of value as
collateral please complete the following.
Identify Co-Signer or Collateral
Identify Loan/Describe Collateral
Identify Co-Signer or Collateral
Identify Loan/Describe Collateral
Identify Co-Signer or Collateral
Identify Loan/Describe Collateral
Identify Co-Signer or Collateral
Identify Loan/Describe Collateral
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PROOF OF CITIZENSHIP AFFIRMATION
Applicants may submit, in lieu of proof of citizenship, a signed and dated copy of a naturalization certificate or green card
with an affirmation on the copy submitted as follows:
NOTE: This affirmation can only be submitted by an Attorney duly admitted to practice in the State of New York. All other
representatives must present original proof(s) to be verified by the Authority personnel.
Applicant/Individual Name:
I, the undersigned, an Attorney at Law duly admitted to practice in the State of New York, have compared the original with this
copy of:
VISA
ALIEN REGISTRATION CARD
OTHER
and affirms under the penalty of perjury that the foregoing copy is a true and complete copy of the original proof of citizenship.
This affirmation is given to the Division of Alcoholic Beverage Control knowing that they will rely upon the same in review of the
license application of:
,
and the applicant has signed his name directly in the space provided below.
Signature of Applicant
Attorney must complete the following signature form:
ATTORNEY INFORMATION:
Attorney name:
Office address:
City, Town or Village:
Telephone:
State:
Zip code:
E-mail address:
Signature:
Date:
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APPLICANT'S STATEMENT
I, [print name]
corporate principal or
LLC/LLP member )
sole proprietor ,
partner ,
of the applicant for an Alcoholic Beverage Control License understand that the State Liquor Authority will
( the
rely on each and every answer in the application and accompanying documents in reaching its
determination and state, under penalty of perjury, that all statements and representations therein are
true to the best of my knowledge and belief; and
I state that the location and description of the premises to be licensed does not violate any
requirement of the ABC law or other state or local ordinances; and
I understand that if any change occurs in the information provided to the Authority in the
application, the licensee must notify the Authority by certified mail within 48 hours and if any change
occurs after receipt of the license, the licensee must notify the Authority by certified mail within 10 days. I
understand that failure to give such notice may result in disapproval of the application or revocation or
non-renewal of any license for which this application is submitted; and
I understand that the licensee will be bound by the statements and representations made in the
application, including, but not limited to the licensee's method of operation and the identity of persons
with an ownership or financial interest in the licensed premises; and that all statements and
representations made become conditions of the license; and
I understand that any physical alterations to, or changes to the size of the area used for the sale
and consumption of alcoholic beverages, must be reported to the Authority and may require the
approval of the Authority; and
I understand that the licensee must keep the Authority advised of any change in the mailing
addresses of the licensee, the licensee's principals, and the licensee's landlord.
I understand that the licensee's failure to operate the licensed premises in accordance with the
statements and representations made in the application may result in revocation of any license for which
the application was submitted; and
I understand that any false statement or misrepresentation will constitute cause for disapproval of
the application or revocation or non-renewal of any license for which this application is submitted.
Signature
Date
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APPLICANTION FOR LIQUIDATOR'S PERMIT
This application is to be completed by the licensee who is selling or liquidating their business and who proposes to
dispose of the stock of alcoholic beverages in connection with such sale. This application must be accompanied by a
SEPARATE check made payable to the State Liquor Authority for a total fee of $36.00 for each permit.
This permit is valid for one transaction only, and requires the sale of the entire stock of alcoholic beverages by the permittee.
When the sale is approved, an inventory, signed by the Permittee, listing the type, brand name and size and number of the
containers of alcoholic beverages to be sold, must be submitted to the State Liquor Authority.
SELLER’S INFORMATION
Seller’s name:
Trade name:
Premises address:
City, town or village:
Zip Code:
Telephone number:
E-mail address:
License serial number:
County:
License Status:
Liquidation of business ONLY, provide date of sale:
BUYER'S INFORMATION
Buyer's name:
Trade name:
Premises address:
City, town or village:
Telephone number:
Zip Code:
County:
E-mail address:
The applicant hereby represents that if a permit is issued, the following conditions must be complied with:
1. The alcoholic beverages will be sold and delivered only to manufacturers, wholesalers and retailers duly licensed by
the State Liquor Authority.
2. The duplicate permit or photocopy will be delivered to each purchaser.
3. The permittee will pay all excise taxes imposed by or under provisions of Article 18 of the Tax Law and will comply
with the rules and regulations of the State Tax Commission.
4. License must be surrendered or placed in safekeeping before permit can be issued.
ATTACH ADDITIONAL SHEETS LISTING ALL OF THE INFORMATION REQUESTED ABOVE IF THERE WILL BE MORE THAN ONE
LICENSEE PURCHASING YOUR INVENTORY AS PART OF THIS TRANSACTION.
THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY BOTH PARTIES. THE PARTIES SWEAR THAT THE
ANSWERS AND STATEMENTS MADE HEREIN ARE TRUE TO THEIR OWN KNOWLEDGE.
Seller's Signature:
Date:
Buyer's Signature:
Date:
Permits No.
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