PERMIT -30 APPLICATION FOR PERMIT TO CONDUCT WINE TASTING FUNCTION (WINERY, FARM WINERY OR WHOLESALE) AUTHORIZED TO SELL WINE) (MISCELLANEOUS) Form 115 (W) Miscellaneous (09/02) STATE OF NEW YORK LIQUOR AUTHORITY Section 99-b, subdivision 1 (k) of the A.B.C. Law provides that a permit may be issued to purchase, receive or sell alcoholic beverages, certificates, contracts or other documents pertaining to alcoholic beverages, in cases not otherwise expressly provided for by this chapter, when in the judgment of the Liquor Authority such would be appropriate and consistent with the purpose of this chapter. Pursuant to that Section, this application is submitted by a Winery, Farm Winery or a Wholesaler authorized to sell wine for a permit to conduct wine tasting functions. A wine tasting is a presentation of samples of one or more wines for the purpose of acquainting the tasters with the characteristics of the wine or wines tasted. This application must be properly executed by the applicant and filed with the Office of the State Liquor Authority at the appropriate zone office and must be accompanied by a certified check, bank officer’s check or draft, personal check or money order for the required fee payable to the order of the State Liquor Authority. SCHEDULE OF FEES (Check one) Wholesale Liquor Wholesale Wine Winery Farm Winery ____ $ ____ ____ ____ Single Function ____ $ 26 + $ 10 filing fee ____ 26 + 10 filing fee ____ 26 + 10 filing fee ____ 26 + 10 filing fee Annual 256+ $ 20 filing fee 256 + 20 filing fee 256 + 20 filing fee 51 + 20 filing fee ALL ANSWERS BELOW MUST BE TYPEWRITTEN OR PRINTED IN DARK INK. (IF MORE SPACE IS NEEDED, ATTACH RIDER) ANY FALSE ANSWER OR STATEMENT MADE BY THE APPLICANT/LICENSEE MAY SUBJECT THE LICENSEE TO DISCIPLINARY PROCEEDINGS SECTION A Give full name of Applicant/Licensee Type of License (Check one) Serial # _____ Winery _____ Farm Winery _____ Liquor Wholesaler _____ Wine Wholesaler ________________________ License Certificate # County Telephone Number Street address of licensed premises City, Town or Village – Zip Code APPLICANTS SEEKING A WINE TASTING PERMIT FOR A SINGLE FUNCTION ONLY MUST COMPLETE THE QUESTIONS IN SECTION B BELOW. ANNUAL PERMIT APPLICANTS SHOULD DISREGARD THIS SECTION. SECTION B 1. State date, day of the week and time of the day when wine tasting function will be held: Date ___________ Day of Week _____________________ Time ____________________ 2. State the estimated number persons attending such function: Number of Persons______________________ State address of premises where function is to be held: Street address________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com PERMIT City, Town or Village-Zip Code __________________________________________County ___________________ 4. Indicate, by checking appropriate box, type of premises wherein wine tasting function will be held: ( ) Hotel ( ) Restaurant ( ) Club ( ) Ballroom or Banquet Hall ( ) Office Bldg. ( ) Other (describe) ___________________________________________________________ See reverse side Form 115 ( W) Miscellaneous (03/11) 5. If premises where function is to be held is currently licensed (other than applicant’s licensed premises), give name and serial number of licensee. Page 2 5. Name of licensee Serial Number The applicant/licensee hereby represents that if a permit is issued for the purpose above mentioned, the following conditions will be complied with: 1. 2. 3. 4. 5. Permittee shall comply with Federal and State Tax requirements. The permittee shall supply all wines used for wine tasting. Such wines shall be in original sealed containers and must comply with the Authority’s regulations pertaining to Brand Label Registration and size limitations. No liquor or beer is permitted at the wine tasting. The permit (or a copy thereof) shall be displayed on the premises where the wine tasting shall be held. A licensee holding an annual wine tasting permit shall keep and maintain upon the licensed premises, adequate books and records and all details of all wine tastings conducted by such licensee. THE APPLICANT HEREBY AGREES THAT ALL PAPERS FILED IN SUPPORT OF THIS APPLICATION AND ANY APPLICATION FILED UNDER THE ALCOHOLIC BEVERAGE CONTROL LAW BY ANY PERSON HAVING ANY INTEREST, DIRECT OR INDIRECT, EITHER IN THE PREMISES OR IN THE BUSINESS TO BE LICENSED, FOR ANY LICENSE OR PERMIT, SHALL BE DEEMED AND MADE A PART HEREOF AND CONSIDERED BY THE STATE LIQUOR AUTHORITY IN ACTING UPON THIS APPLICATION. SECTION C THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL APPLICANT AND EACH MEMBER OF PARTNERSHIP The undersigned, each for themselves, certifies that he/she is the applicant above named; that he/she knows the contents of the above application and the statements contained therein and the same are true of his/her own knowledge. Dated__________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ (Signature of applicant or of each partner) THIS CERTIFICATION TO BE SIGNED AND DATED WHEN AN APPLICANT IS A CORPORATION American LegalNet, Inc. www.FormsWorkFlow.com PERMIT ___________________________________________________, certifies that he/she is____________________________________________ (Title) of the above named applicant corporation; that he/she knows the contents of the above application and the statements and answers therein; that the same are true of his/her own knowledge; that he/she has been authorized, by order of the Board of Directors of said applicant corporation to make the statements and answers in this application in behalf of said applicant corporation with the same force and effect as if said corporation made such statements and answers itself. Dated __________________________________________ ________________________________________________________ ( Signature of authorized officer) Wine Tasting (revised 03/11) Form 115 (w) miscellaneous Completed applications and any supporting information should be mailed to: NEW YORK STATE LIQUOR AUTHORITY PO BOX 3796 NEW YORK, NY 10008-3796 American LegalNet, Inc. www.FormsWorkFlow.com