-38 Form 805 GS (06/2004) STATE OF NEW YORK LIQUOR AUTHORITY See Petition for Removal Instructions for Additional Requirements PETITION FOR REMOVAL (Grocery Store) This petition is to be used by a GROCERY STORE LICENSEE to request permission to remove the licensed premises to a new location. This petition must be filled out and signed by the licensee and filed with the appropriate zone office of the county in which the premises to be licensed are located, together with CHECK, or DRAFT, or MONEY ORDER for the removal application fee of $32.00 prescribed in Section 99-d, subd.3 of the Alcoholic Beverage Control Law. (The law does not provide for any refund of fees prescribed under Section 99-d. 1. CERTIFICATE OF SERVICES properly filled out, on Form LB-33. ALL QUESTIONS MUST BE ANSWERED IN THE BOXES BELOW. (If more space is needed, attach a rider). Any false answer or statement made by the applicant constitutes and will subject any license issued hereunder to revocation. The licensee named below hereby request the permission of the Liquor Authority for the REMOVAL of the licensed premises to the proposed premises set forth below. Full Name of Applicant-Licensee Trade name or other name which applicant will Licensee No. do business Present Premises (Street Address) Post Office address of premises (if different) City, town, or village – Zip Code City, town or village – Zip Code Telephone No. PROPOSED PREMISES Trade name or other names under which applicant will do business Street address of premises to be licensed City, town or village, - Zip Code Post Office of premises (If different) County City, town or village – Zip Code (If different) Telephone No. Between what streets or avenues. (If outside city or village limits and not known by a house number, specify location in relation to nearest intersecting road or highway. Name of owner of building in which the premises to be licensed are located Address of owner of building Type of building. (Check appropriate box) Ƒ Residence Ƒ Apartment House Ƒ Office Building 1) Is any license, under the Alcoholic Beverage Control Law, now in effect for: a) The premises for which this application is filed? If so, state full name of licensee and license number, Or b) Any other part of the building containing the premises? If so, state full name of licensee and license number. 2) (a) Will applicant occupy proposed premises under a written lease or option to lease? Ƒ Taxpayer 1. (a) Yes or No Ƒ Apartments & stores License Number Name of Licensee 1. (b) Yes or No License Number Name of Licensee (c) Date of Lease 2. (a) (b) Yes or No (b) If so, state name and address of the immediate lessor, the date of the lease and the date of expiration thereof. Do the terms of such lease require payment by the applicant of any consideration based on a percentage of the receipts of the business? (d) If so, state percentage and give details. 3. (a) Will any other business of any kind be carried on in proposed premises? (b) If so, give details. Date of expiration Name and address of the immediate lessor Yes or No Percentage and details (c) (d) Yes or No 3. (a) Details Will there be any direct access between the proposed premises and living Quarters? If so, (a) Does applicant plan to occupy these living quarters? (b) If answer to 4(a) is “No” give name and family or business relationship of occupant to the applicant 5. Will there be any facilities on the proposed premises for the preparation and service of food for consumption on the premises? If so, describe. SLA form 805GS (revised 06/2004) (b) Yes or No Yes or No 4. 4. (a) Name of Occupant Relationship (b) Yes or No Description 5. American LegalNet, Inc. www.FormsWorkflow.com Page 2 PETITION FOR REMOVAL (Grocery Store) STATE OF NEW YORK LIQUOR AUTHORITY 6. Estimated total Cost of Inventory at proposed premises $ __________________________________________________________________________________ Estimated percentage of grocery stock at proposed premises _______________________________________________________________________________% 7. (a) Has any person not an applicant herein, or, if a corporate applicant, any person not an officer, director or stockholder of such corporation any interest, financial, proprietary or other, direct or indirect, in the premises 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? Yes or No 7. (a) Name (b) Address (b) If so, set forth the names and addresses of such persons, the nature of the interest and the date acquired. Nature of interest 8. (a) State whether 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 Question 7 above, shares or will share on a percentage basis or in any way in the receipts, losses or deficiencies of the business, to any extent whatsoever other than by fixed salary. Date acquired Yes or No 8. (a) Name (b) Address (b) If so, set forth the names and addresses of such persons, the nature and Percent of the share and date acquired. Nature and percent of share 9. Date acquired Reason for requesting permission for removal: THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL OR 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 together with all other papers filed in support thereof and the statements contained therein and the same are true of their own knowledge. Dated:___________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ (Signature of Petitioner or of Each Partner) THE FOLLOWING CERTIFICATION TO BE SIGNED AND DATED IF A CORPORATION ____________________________________________________________ certifies that he/she is _______________________________________________________ (Title) of the above names applicant corporation; that he/she knows the contents of the above application together with all other papers filed in support thereof and the statements and answers therein; that the same are true of his 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) SLA Form 805GS (revised 06/2004) American LegalNet, Inc. www.FormsWorkflow.com