plcb-2404 08/11 commonwealth of pennsylvania pennsylvania liquor control board APPLICATION FOR LIMITED WINERY FARMERS MARKET PERMIT bureau of licensinG 13 F The undersigned hereby applies for a Limited Winery Farmers Market Permit for Calendar Year 1. Name of Licensee 2. Trade Name (if any) 3. Address of Premises LK License No. LID No. (Street, Rural Route, PO Box No.) (Post Office) (State) (Zip) 4. Name and Address to which Permit should be mailed if different from the above applicant. RESOLUTION (Corporations and Limited Liability Companies Only) At a regular or special meeting held on ,20 by the applicant, it was resolved that said application be filed with the Pennsylvania Liquor Control Board, and that Name of Officer/Title and/or Name of Officer/Title is/are hereby authorized to execute said application, and any other papers required by the Board. I swear and affirm, subject to the penalties provided by 18 Pa. C. S. §4904 and 47 P. S. §5-504 (4)(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 American LegalNet, Inc. www.FormsWorkFlow.com FARMERS MARKET PERMIT INFORMATION 1) Submit the application along with $250.00 made payable to "PLCB" or "Commonwealth of Pennsylvania". 2) The $250.00 Permit fee annually entitles the holder to participate in more than one farmers market at any given time and an unlimited number throughout the Calendar year. 3) The applicant can sell by the bottle or in case lots. 4) All sales must occur during the standard operating hours of the farmers market. 5) Samples must be free and cannot exceed one (1) fluid ounce per brand. 6) Written notice of the dates, times and locations the permits will be used must be provided to the Bureau of Liquor Control Enforcement at least 2 weeks prior to the event. "Farmers market" shall include any building, structure or other place: (a) Owned, leased or otherwise in the possession of a person, municipal corporation or public or private organization. (b) Used or intended to be used by two or more farmers or an association of farmers, who are certified by the Department of Agriculture of the Commonwealth to participate in the Farmers' market nutrition program subject to 7 CFR PT, 249 (relating to senior Farmers' market nutrition program (SFMNP)), for the purpose of selling agricultural commodities produced in this Commonwealth directly to consumers: (1) which is physically located within this Commonwealth; and (2) which is not open for business more than twelve hours each day. Send Applications and fee (if applicable) to : Pennsylvania Liquor Control Board Bureau of Licensing P.O. Box 8940 Harrisburg, PA 17105-8940 American LegalNet, Inc. www.FormsWorkFlow.com