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Petition For Removal (On Premises Consumption Retail) Form. This is a New York form and can be use in Division Of Alcoholic Beverage Control Statewide.
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Tags: Petition For Removal (On Premises Consumption Retail), LB-17, New York Statewide, Division Of Alcoholic Beverage Control
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PETITION FOR REMOVAL
(On Premises Consumption Retail)
Form LB - 17 (6/2004)
STATE OF NEW YORK
LIQUOR AUTHORITY
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
Type of building. (Check appropriate box)
Ƒ Residence
Ƒ Apartment House
Ƒ
Address of owner of building
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.
Ƒ
Taxpayer
Ƒ Apartments & stores
Yes or No
1. (a)
Name of Licensee
License Number
Yes or No
(b)
Name of Licensee
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?
(b) If so, state name and address of the immediate lessor, the date of the lease
And the date of expiration thereof.
(c) 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.
4. (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 restaurant or eating place.
5.
Are proposed said premises located in a residential district created under any
zoning law, which restricts the maintenance of a restaurant or eating place
at the premises to be licensed?
6.
Do proposed premises comply with all building, fire and health laws,
Ordinances and regulations pertaining to restaurants or eating places?
Sla Form LB-17 (revised 06/2004)
2.
(a)
Yes or No
Date of Lease
(b)
Date of expiration
Name and address of the immediate lessor
Yes or No
(c)
Yes or No
3. (a)
Details
(b)
4.
(a)
Percentage and details
(d)
Yes or No
Date
(b)
5.
Yes or No
6.
Yes or No
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Page 2
PETITION FOR REMOVAL
(On Premises Consumption Retail)
Form LB-17 (06/2004)
STATE OF NEW YORK
LIQUOR AUTHORITY
(a) Will any dancing, music or entertainment be provided at any time whatsoever
for guests or customers on the proposed premises?
(b)If so, has licensee 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.
8. (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?
7.
(a)
(b) If so, set forth the names and addresses of such persons, the nature of the
interest and the date acquired.
9.
(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 8 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.
Nature of Interest
(b) If so, set forth the names and addresses of such persons, the nature and
percentage of the share and date acquired.
10. Reasons for requesting permission for removal:
Nature and percentage of share
7.
Yes or No
Yes or No
(b)
8.
(a)
Yes or No
Name
(b)
Address
9.
(a)
Date Acquired
Yes or No
Name
(b)
Address
Date Acquired
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-17 (06/2004)
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