PLCB-1708 10/04 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPLICATION FOR EXTENSION OF WHOLESALE LICENSE TO COVER ADDITIONAL PREMISES BUREAU OF LICENSING (SEE INSTRUCTIONS ON REVERSE) 1. NAME OF LICENSEE LID NO. 2. TRADE NAME (IF ANY) LICENSE NO. 3. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) 4. NAME OF MUNICIPALITY (POST OFFICE) TYPE OF MUNICIPALITY CITY TWP. BORO (STATE) INC. TOWN (ZIP) COUNTY 5. A. PROPOSED NEW ADDITIONAL PREMISES ADDRESS DESCRIPTION DESIGNATED USE (SALES, STORAGE COLD STORAGE) NAME AND ADDRESS OF OWNER 1 2 B. APPLICATION TO BE CONSIDERED FOR “PRIOR APPROVAL”? YES NO 6. A placard, PLCB-1296, Public Notice of Application Alcoholic Beverages, was posted on (DATE) ___________________________________________ in a conspicuous place on the outside of the premises as required by the Liquor Code, and will remain posted until a notice of approval or refusal is received by the applicant. 7. ADDRESS OF ADDITIONAL PREMISES IN USE NOW 8. ADDRESS OF ADDITIONAL PREMISES TO BE DISCONTINUED RESOLUTION (CORPORATIONS ONLY) 9. At a regular or special meeting held on __________________________________________________ , 20 _________ by the applicant corporation, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that _____________________________________________ and/or _______________________________________________ is/are (NAME OF OFFICER/TITLE) (NAME OF OFFICER/TITLE) hereby authorized to execute said application, and any other papers required by the Board. I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §4-436(j), that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE NAME OF ATTORNEY REPRESENTING YOU IN THIS MATTER, IF ANY HOME ADDRESS PHONE ADDRESS ( ) SIGNATURE TITLE HOME ADDRESS PHONE PHONE ( ( ) DATE SIGNED ) DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS This form is to be used to report an addition to the approved licensed premises by wholesale licensees (Distributors and Importing Distributors). To report a change or addition to a retail licensees (restaurant, hotel, club) use form PLCB-49, Application for Extension of Retail License to Cover Additional Premises. 1. A fee made payable to "PLCB" or "Commonwealth of Pennsylvania of $220.00 MUST accompany this form. 2. Complete information must appear on this form. This form MUST be signed. State type of building and purpose for which required. List all additional premises now in use which will continue to be used, even if this application is approved. Attach additional sheets, if necessary. List any presently licensed premises which will no longer be used if this application is approved. Attach additional sheets, if necessary. List exact address of proposed new additional premises. If no additional premises will be used, it is not necessary to execute this application. Notification by letter will suffice. 3. Distributors and Importing Distributors shall submit one (1) photograph, 4" x 6" in size, of the exterior of the additional premises. The photograph must have a matte finish. The application may be considered prior to completion of alternations or constructions. Submit a site plan on 8½" x 11" paper depicting the location of the premises proposed to be licensed as it will be after the alterations or construction are completed, depicting the location of the proposed premises in relationship to identifiable lines or easily identifiable landmarks or reference points with measurements to the property lines, landmarks or reference points. The plan must be clear and readable. 4. A Placard, PLCB-1296, Public Notice of Application Alcoholic Beverages, MUST be posted on the licensed premises. (Manufacturers are not required to post notice UNLESS the extension is for a brewery pub area, and are then required to file PLCB-49, Application for Extension of Retail License to Cover Additional Premises.) INFORMATION a. No additional premises shall be used by any licensee until approved by the Board. b. Distributors and Importing Distributors cannot have additional storage in another municipality, except for necessary cold storage. c. The owner of the building cannot be interested in any business covered by any Retail Dispenser, Retail Liquor, Distributor, Importing Distributor or Manufacturer’s License. d. Photograph and/or plan MUST be provided to the investigation officer at the time of inspection. e. If vehicles are used to transport alcoholic beverages, you are required to: 1. Display on each side of each vehicle used to transport malt or brewed beverages, the license number (preceded by PLCB), the licensee name and address including the street name and number as shown on the license in letters no smaller than 4 inches in height. 2. Own or lease the vehicle used. The vehicle owner may not have any proprietary interest in any business licensed by the board. DO NOT SUBMIT ANY OTHER DOCUMENT (E.G.; LEASE, AGREEMENT) WITH THIS APPLICATION PACKET. SHOULD YOU BE REQUIRED TO SUBMIT SUCH DOCUMENTATION, OTHER THAN FOR THE INVESTIGATION OFFICER’S REVIEW, YOU WILL BE NOTIFIED IN WRITING. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION PACKET, CALL THE LICENSING INFORMATION CENTER AT (717) 783-8250, OPTION #7. American LegalNet, Inc. www.FormsWorkflow.com