-38 PETITION FOR REMOVAL (Hotel or Club) Form LB - 27 (06/2004) STATE OF NEW YORK LIQUOR AUTHORITY This petition is to be used by a HOTEL OR CLUB 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. The petition shall be accompanied by CHECK, BANK OFFICER’S CHECK or DRAFT or MONEY ORDER for the require fee, payable to the State Liquor Authority. $192.00 where the annual license fee is $500.00 or more, $32.00 in other instances. (the Law does not provide for any Refund on Removal Fees specified in Section 99-d) SEE PETITION FOR REMOVAL INSTRUCTIONS FOR ADDITIONAL REQUIREMENTS 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 present licensed premises to the proposed premises set forth below. Full Name of Applicant-Licensee Trade name or other designation Licensee No. Present Premises (Street Address) Post Office address of premises (if different) City, town, or village – Zip Code City, town or village – Zip Code Trade name or other names under which applicant will do business PROPOSED PREMISES Trade name or other designation Street address of premises to be licensed City, town or village, - Zip Code Telephone No. 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. (a) State whether the proposed premises are now operated as a hotel or club. 1. (b) If so, state whether proposed premises are now licensed for the sale of Alcoholic beverages. Ƒ Taxpayer Yes or No Ƒ Apartments & stores (a) Yes or No (b) 2) (a) Will applicant occupy proposed premises under a written lease or option to lease? (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) Are proposed premises located within 200 feet of a building occupied exclusively as a school, church, synagogue or other place of worship, which is located on the same street or avenue? (b) If so, state since what date said premises have been continuously occupied as a bona fide hotel or club? 4. Are proposed premises located in a residential district created under any zoning law, which restricts the maintenance of a hotel or club at the premises to Be licensed? 5. Do proposed premises comply with all building, fire and health laws, ordinances any regulations pertaining to hotels or clubs? 6. (a) Is any dancing, music or entertainment provided at any time whatsoever for guests or customers on the proposed premises? (b) If so, has applicant obtained a license or permit therefor from the local authorities? (If none is required, attach letter to such effect from local sheriff or chief of police, as the case may be). SLA form LB –27 (revised 06/2004) Date of expiration Name and address of the immediate lessor Yes or No Percentage and details (c) Yes or No 3. (a) Date (b) (d) 4. Yes or No 5. Yes or No 6. Yes or No (a) Yes or No (b) American LegalNet, Inc. www.FormsWorkflow.com Page 2 PETITION FOR REMOVAL (Hotel or Club) Form LB-27 (06/2004) STATE OF NEW YORK LIQUOR AUTHORITY 7. (a) 7 (a) Will any other business of any kind be carried on in proposed premises? (b) If so, give details. Yes or No Details (b) 8. (a) 8 (a) State whether any bar, counter or similar contrivance will be maintained in said proposed premises, at which any alcoholic beverages will be sold. Yes or No Location and size of bar (b) If so, give exact location and size of such bar, including return. 9. (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? (b) If so, set forth the names and addresses of such persons, the nature of the interest and the date acquired. 10. (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 9 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. (b If so , set forth the names and addresses of such persons, the nature and per cent of the share and date acquired. (b) 9. (a) TO BE ANSWERED BY CLUB ONLY 11. (a) State whether the building in which the premises to be licensed are located is used exclusively for club purposes. (b) If not, state whether such building is in an office or business building. TO BE ANSWERED BY HOTELS ONLY 12. (a) State number of tables and/or booths to be located in the proposed premises and the total seating accommodations to be provided at such tables and/or booths. (b) State number of rooms available for lodging guests for compensation. 13. Reason for requesting permission for removal: 11. Yes or No (a) Yes or No (b) 12. (Number of tables) (a) Yes or No Name (b) Address Nature of interest Date acquired 10. Yes or No (a) Name (b) Address Nature of interest (Total Seating Accommodations) Date acquired (Number of booths) (Number of Rooms) (b) THE FOLLOWING CERTIFICATION MUST BE SIGNED AND DATED BY INDIVIDUAL AND/OR 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 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/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) SLA Form LB-27 (06/2004) American LegalNet, Inc. www.FormsWorkflow.com