plcb-1685 3/12 commonwealth of pennsylvania pennsylvania liquor control board application for additional board-approved location (see instructions page 2 of 2) bureau of licensing 13e page 1 of 2 approval is hereby requested for a limited winery, or limited distillery additional board-approved location, for the l icense period expiring december 31, . 11. name of licensee 12. trade name (if any) lid no. license no. contact phone no. principal manufacturing location (exactly as it appears on current license) 13. address of premises 14. name of municipality (street, rural route, p.o. box no.) (post office) (state) (zip) type of municipality proposed additional location 15. trade name (if any) 16. address of premises 17. name of municipality city boro twp. inc. town county contact phone no. (street, rural route, p.o. box no.) (post office) (state) (zip) type of municipality city 18. give space no. if mall or other multi-store area 19. application to be considered for "prior approval"? boro twp. inc. town county yes 10. premises to be licensed room width length located on what floor no designated use: (sales, production, storage, bottling, serving, etc.) 11. if proposed location is to be operated in conjunction with another licensed limited winery(ies), or limited distillery(ies) list the license number(s), lid(s) and licensees name: do not Write beloW tHiS line American LegalNet, Inc. www.FormsWorkFlow.com 12. reSolUtion (corporationS onlY) at a regular or special meeting held on __________________________________________ , ________by the applicant corporation, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that _________________________________________ and/or _______________________________________ is/are hereby (name of officer/title) (name of officer/title) authorized to execute said application, and any other papers required by the board. 13. list any other businesses at this location. include a sketch showing location of business in relation to proposed licensed location. name description name(s) of owner and operator 14. name and address of owner of proposed location lease expiration date telephone no. of licensed premises 14(a). name of officers, directors, shareholders, partners or members of property owner. (attach separate sheet if necessary) title 15. address and license no. of additional locations now in use license number a b c d e 16. address and license no. of additional locations to be deleted and the date to be effective effective date a b c d e American LegalNet, Inc. www.FormsWorkFlow.com plcb-1685 3/12 commonwealth of pennsylvania pennsylvania liquor control board application for additional board-approved location bureau of licensing 13e page 2 of 2 17. proposed manager name of manager for additional location name home address date and place of birth 18. state present employment or other business for manager applicant 19. conviction record: the following is a record of all felony and misdemeanor convictions of the individual owner, all partners, the manager and all corporate officers, directors and stockholders. (Attach separate sheet, if necessary.) if there have been no such convictions, check no such convictions. name date of conviction charge disposition location of court (county and state) 20. is the proposed manager to act as manager for other licensed limited winery(ies), or limited distillery(ies), operated in conjunction at the applicant location? yes no if "yes," list license number(s), lid(s) and licensee(s) names: I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904 and 47 P.S. §5-504(b), 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 phone home address phone date signed email address American LegalNet, Inc. www.FormsWorkFlow.com inStrUctionS the enclosed forms are to be submitted by limited wineries, or limited distilleries to apply for a new board approved location other than the licensed premises. all attached separate sheets must include the applicant's name and the address of the main licensed premises and the address of the satellite store. fees and documents to be submitted include: 1. application for additional board-approved location (plcb-1685) all questions must be answered even if the answer is none or not applicable. any presently licensed locations which are no longer to be used if this application is approved. if the location is to be deleted immediately, the license must be attached to this application. 2. a fee in the amount of $220.00 3. One (1) recent, individual photograph of the proposed manager, 1½" x 1½" in size, identified with the individual's name and address of the premise on the reverse. The photograph must have a matte finish. 4. recent premises photographs, 4" x 6" in size, of the exterior of the premises showing the main entrance and the main interior serving/sales area with the applicants name and address on the reverse. photographs must have a matte finish. 5. plcb-1773, appendix social security information must be submitted showing the social security number and name of the manager. 6. a request for criminal record check (plcb-2018) must be submitted for the proposed manager with a $10.00 fee. 7. owner of premises name, address, principals and their titles must be listed inforMation a. a separate application packet must be submitted for each additional location to be licensed. a maximum of five (5) satellite stores may be licensed for limited wineries. Limited distilleries can have two (2)additional locations. no additional location(s) may be used by any licensee until approved by the board. b. An application may be filed for PRIOR APPROVAL of planned alterations or construction. Submit a site plan clearly showing the premises proposed to be licensed as it will be upon completion of the alterations or construction of the building. a site plan must be on 8½" x 11" paper 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. c. the owner of the building cannot be interested in any business covered by any retail or distributor or importing distributor license. d. two (2) or