-29 SECTION A NEW YORK STATE LIQUOR AUTHORITY THIS IS AN APPLICATION FOR ALCOHOLIC BEVERAGE RETAIL LICENSE - VESSEL 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. Coast Guard Registration # 1. Full Name of Applicant: Submit copy of registration Mooring Place of Vessel - Street Address City, Town or Village ZIP 2. Name of Vessel: Office Address of Applicant City, Town or Village ZIP County Telephone No. 3. Attorney/Representative Name Office Address ZIP City/Town/Village Telephone No. CODE: 4. Alcoholic Beverage License Class $ 5. TOTAL PAYMENT DUE: [OFFICE USE ONLY] Date filed: STATE LIQUOR AUTHORITY action: County Code # Approval Disapproval SERIAL NUMBER: Zone: Deposit Date: County: Serial No: Slip No: Fee: Class: Audited By: 1 American LegalNet, Inc. www.FormsWorkflow.com 6. INDIVIDUAL OR PARTNERSHIP APPLICANTS ONLY Name of applicant 7. Residence Citizenship DOB LL COMPANY/CORPORATIONS OR LL PARTNERSHIPS ONLY a. State under what law applicant was organized: b. Date of organization: c. Enter the Names of the Members and Manager Positions and ownership interest: Name Member or Manager Position 8. % of Ownership Interest CORPORATE APPLICANTS ONLY (a) State under what law applicant was organized: (b) Date of organization: (c) List names and addresses of the STOCKHOLDERS, all OFFICERS and DIRECTORS as of the date of filing of this application: Name Residence Citizenship Title # of shares Birth Date 2 American LegalNet, Inc. www.FormsWorkflow.com 9. (a) (b) LEASE ARRANGEMENTS Does applicant occupy said premises under a written lease or option to lease? NO YE S NO YE S If YES, state name and address of immediate lessor. SUBMIT COPY OF LEASE WITH ALL TERMS! (c) (d) 10. (a) Do the terms of the lease or other arrangement require payment by the applicant of any consideration based on a percentage of the receipts of the business? If YES, state percentage and give details: VESSEL LICENSE HISTORY Has any license ever been issued under the Alcohol Beverage Control Law for the vessel for which this application is filed? NO YE S NO YE S (Give name of current/previous licensee & license number (b) If so, was any such license ever revoked or canceled? (c) If so, give date of such revocation or cancellation. (attach details of revocation/cancellation) 11. INTERESTED PARTIES Has any person not an applicant herein, or, if a corporate applicant, any person not an officer, director, or stockholder of such corporation, or any person not reported in questions above: (a) (b) Any interest, financial, proprietary or other, direct or indirect in the vehicle or in the business to be licensed, or has made any loan to the applicant for said business or has any lien or mortgage on the fixtures in the business? NO YE S Any arrangement to share on a percentage basis or in any way in the receipts, losses or deficiencies of the business, to any extent whatsoever? NO YE S If so, state the names and addresses of such persons, the nature and percent of their share and date acquired. 3 American LegalNet, Inc. www.FormsWorkflow.com -28 SECTION B STATEMENT OF FINANCES State the total amount of money you are investing in the licensed premises. TOTAL DOLLAR AMOUNT: $ BREAKDOWN OF TOTAL Total Cash: Total Deferred: *NOTE $ $ For the purpose of this form, CASH is defined as money that you have in your possession, you don’t have to pay back, and is verifiable (example: stocks, bonds, CD’s, savings accounts, etc.). For the purpose of this form, DEFERRED is defined as money that you have to pay back at some point in time (example: loan, mortgage, line of credit, credit card, note, etc.). 1. Set forth the source of funds for this investment (accounts, loans, gifts, asset sales, etc.) and enter account numbers. 2. Set forth all repayment terms for any deferred monies. 4 American LegalNet, Inc. www.FormsWorkflow.com -49 SECTION C NOTIFICATION OF MUNICIPALITY/COMMUNITY BOARD Applicants for On Premises licenses must complete Section F You are required by the Alcoholic Beverage Control Law, Section 64, Subdivision 2a, upon receipt of an application for a license to sell liquor at retail for consumption on the premises and within the City of New York an application for on premises consumption of beer and on premises consumption of wine, to promptly notify, in writing, the Clerk of the Village, Town or City wherein the premises are located of your application to the State Liquor Authority not less than thirty days prior to the submission of your application to the Authority. → In the City of New York, such notification is to be sent to the community board with jurisdiction over the area in which the premises is located. → Notification pursuant to this Section is to be sent by certified mail, return receipt requested. NOTE: FAILURE TO NOTIFY THE APPROPRIATE MUNICIPALITY OR COMMUNITY BOARD AT LEAST THIRTY (30) DAYS PRIOR TO THE SUBMISSION OF YOUR APPLICATION WILL RESULT IN A DELAY IN PROCESSING YOUR APPLICATION. CERTIFICATION RIDER TO APPLICATIONS I hereby certify that on the day of , 20 I complied with the requirements of Section 64.2(a) of the Alcoholic Beverage Control Law, and sent notification of my application to become licensed, by certified mail, return receipt requested to the Clerk of the City Town Village of or, in New York City, the Clerk of Community Board # Borough of , where the premises are located. Signature Date Name of Applicant Trade Name Premises Street Address City, State, Zip PHONE LISTINGS FOR NEW YORK CITY RESIDENTS If you are unsure of which community board serves the area in which your premises are located, call the number listed below for the office of your Borough President: Manhattan Bronx Queens Staten Island Brooklyn 212-669-8300 718-590-3500 718-286-2900 718-816-2200 718-802-3700 5 American LegalNet, Inc. www.FormsWorkflow.com -6 SECTION D NOTIFICATION OF PUBLICATION Applicants for On Premises licenses must complete Section G 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 license 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, car, 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. 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 two successive weeks commencing on the day of . Sworn to before me this day of 6 American LegalNet, Inc. www.FormsWorkflow.com -48 SECTION E LANDLORD VESSEL IDENTIFICATION QUESTIONNAIRE 1.) Owner of Vessel 1(a) Business Address of Owner 2.) Type of ownership: Individual Proprietorship Partnership Corporation 3.) Landlord Principals: NAME RESIDENCE ADDRESS 4(a) Are any persons listed on this form police officers: (b) If YES, list names: 5(a) Are any persons listed on this form currently or previously licensed under the ABC law? (b) NO YE S NO YE S If YES, list names and license numbers: Signature of LANDLORD: Title: IMPORTANT: Phone Number: Signature must be same as signature on original lease--if not: furnish either affidavit in explanation, affix legible corporate seal, or submit other proof of signature’s authority. 7 American LegalNet, Inc. www.FormsWorkflow.com -56 SECTION F ON-PREMISES VESSEL QUESTIONNAIRE See instructions for diagrams & photos required in support of this application! 1. VESSEL - PHYSICAL LAYOUT (a) Type of vessel and list number of decks: (b) What is the access between decks? (c) How many decks do the premises occupy? (d) Any openings to other parts of the vessel? (e) If so, describe: (f) How many rooms on each deck? (g) Use of rooms? (h) How many bathrooms? (i) What is the maximum number of persons that can legally occupy the vessel? (j) Number of tables? (k) Number of seats at tables? (l) Is the interior view unobstructed throughout? (m) If not, state reason: (m) Are premises sufficiently illuminated? 2. BARS (a) How many stand-up bars are located on the vessel? (b) How many service bars? (c) Describe all bars (length, shape and location): (d) Any food counters? NO YES NO YE S NO YE S 8 American LegalNet, Inc. www.FormsWorkflow.com (e) If so, describe (length, shape and location): 3. KITCHEN (a) Location and size of kitchen, if any: (b) Is food available for sale? (c) If so, describe type of food: 4. NO YE S PROPOSED METHOD OF OPERATION (a) For what purpose is said vessel used? (b) Is vessel used on a regular trip schedule OR for chartered purposes? (c) Will vessel provide live music, dancing, or entertainment for passengers? NO NO (d) Will vessel offer gambling? (f) Will the applicant operate gambling outside New York State Territorial Waters? NO YE S If so, describe: (g) YE S If so, describe: (e) YE S 5. (a) PERMITS Has applicant obtained a Federal Tax I.D. Number? NOTE: NO YE S You may submit this application with the above mentioned permit applied for and pending, however, a license cannot be issued until copies of the permit are received by the Liquor Authority. 9 American LegalNet, Inc. www.FormsWorkflow.com -1 SECTION G APPLICANTS STATEMENT Any answer or statement, which is false, made by the applicant may constitute perjury and may subject any permit or license issued hereunder to revocation or cancellation. I, ________________________________________________________________________________________, the applicant, (sole proprietor, partner, corporate principal or LLC member) for an Alcoholic Beverage Control Retail License understand that the New York State Liquor Authority will rely on each and every answer in the application and accompanying papers in reaching their determination and state, under penalty of perjury, that all statements therein are true to the best of my knowledge and belief. I further state that the location and layout of the premises to be licensed does not violate any requirement of the ABC Law. I verify if any change occurs prior to the receipt of the license, I will notify the Authority by registered or certified mail within 48 hours or if change occurs after receipt of the license, I will notify the Authority similarly within 10 days. I understand that failure to give the required notice will violate the Alcoholic Beverage Control Law and may result in revocation of the license. Signature Date 10 American LegalNet, Inc. www.FormsWorkflow.com -14 SECTION H PERSONAL QUESTIONNAIRE ♦ All principals to the license application must complete this questionnaire in full. ♦ Make duplicate blank forms as necessary. ♦ Answer all questions below and check the appropriate spaces. ♦ Attach add’l sheets if more space is needed. NAME OF APPLICANT: 1. STATEMENT OF IDENTIFICATION Print YOUR Name: Date of Birth: Residence street address of above: Social Security #: Telephone No.: (H) ( ) _________ - ___________________ (W) ( ) _________ - ___________________ City, State, Zip: County: Place of Birth: U.S. Citizen? If you are NOT a U.S. Citizen, state Country of Citizenship: If Alien, Registration # or Visa Type: NO YES List any other names that you have been known by (including maiden): Are you currently married? NO YES If yes, state the name of your spouse: List any other names that your spouse has been known by (including maiden): 2. BUSINESS RECORD (for the past TEN years - if more space is required, attach add’l sheets!) FROM/TO (Mo./Yr.) Employer Address 3. Type of Business POSITION (or interest) you will hold in the license application (check each): President Vice President Secretary Treasurer Chairman Officer Director Stockholder Partner General Partner Limited Partner Sole Proprietor Manager Lender Donor Guarantor LLC Manager LLC Member Broker Vendor Contractor Franchisor Management Agent SLA FORM 1025 Personal Questionnaire 11 American LegalNet, Inc. www.FormsWorkflow.com 4. LICENSE HISTORY / AFFILIATIONS Do you have any interest, direct or indirect, in any premises 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? NO YES If YES, provide information below: Business Name Type of Business Date Interest Began Business Address Liquor License Other than as itemized in the above, DURING THE PAST 10 YEARS has the applicant (including any officers, directors, shareholders, LLC members or partners listed in the statement of identity above or the spouse of any such person) or the applicant’s spouse ever applied anywhere for a license or permit to traffic in alcoholic beverages, including any application as a partnership or corporation in which they are/were a principal? NO YES If YES, provide information below: Name of applicant Address of premises Date of filing License No. Has a license or permit listed above been REVOKED, CANCELED or otherwise Involuntarily Terminated? If yes, state action and date of action: 5. Disposition NO YES POLICE OFFICIALS Are you or your spouse a police commissioner, other police official or subordinate of any police department in the state? NO YES If YES, provide details: 12 American LegalNet, Inc. www.FormsWorkflow.com 6. CONVICTION RECORD & PENDING CRIMINAL CASES 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 which would forbid a person to traffic in alcoholic beverages? NO YES NO YES If yes, supply details (attach additional pages as necessary): 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 of or charged with a crime that has not resulted in an acquittal, dismissal, pardon, certificate of good conduct or certificate of relief from disabilities? If yes, supply details (attach additional pages as necessary): I understand that the information I submit will be relied upon by the State Liquor Authority and a false statement or misrepresentation will constitute cause for the disapproval of the application or revocation of any license for which this application is submitted. I verify that statements made herein are true and if any change occurs prior to the receipt of the license, I will notify the Authority by registered or certified mail within 48 hours or if change occurs after receipt of the license, I will notify the Authority similarly within 10 days. I understand that failure to give the required notice will violate the Alcoholic Beverage Control Law and may result in revocation of the license. _______________________________________ Signature ______________________ Date Revised 2/09/04 13 American LegalNet, Inc. www.FormsWorkflow.com