plcb-4 1/12 commonwealth of pennsylvania pennsylvania liquor control board application for new public service license (see instructions on reverse) bureau of licensing 1c the undersigned hereby applies for a public service _____________________________________________________________license for the calendar year ending december 31, ____________ . 11. name of applicant 12. trade name (if any) 13. address of headquarters [if corporation or limited liability company (llc)] (liquor or malt beverage) (street, rural route, p.o. box no.) (post office) (state) (zip) 14. address of premises in pa (if not a corporation, llc or different from above) (street, rural route, p.o. box no.) (post office) (state) (zip) 5. for corporations and llcs only registered name incorporated place date if foreign corporation give date of certificate of authority, or if foreign llc give date registered in pa 16. Isamanagementcompanyemployedorotherwisecontractedtooperate,manageorotherwisesuperviseallorpartoftheoperation? yes no if yes, list the name and address of the entity: 17. the applicant has never been refused a license, nor held a beverage or liquor license which was revoked, except as follows: (give details) if there are no exceptions, check here: 18. no exception the applicant, if granted a license, will operate not exceeding ___________________________________________________________ cars or aircraft within the commonwealth on any one day. (not required for vessel or steamship operators) it is requested that the following named vessel or steamship be licensed in accordance with this application. (not required for railroad, pullman or airline companies) 19. 10. 11. amusement permit (vessels, steamships or aircraft only ­ see instruction 3 on reverse) Willyoupermitdancing,providefloorshows,oranyotherentertainment? ifanairline,willliquorormaltbeveragesbestoredofftheaircraft? yes yes no no if "yes," state location the employees of the applicant by whom liquor and/or malt or brewed beverages will be handled and sold are familiar with the conditions under which such beverages may be sold in pennsylvania under the applied for license. do not write below this line zip American LegalNet, Inc. www.FormsWorkFlow.com 12. for corporations and llcs only resolution at a regular or special meeting held on , by the applicant, it was resolved that said application be filed with the pennsylvania liquor control board, and that (name/title) and/or (name/title) is/are hereby authorized to execute said application, and any other papers required by the board. Iswearoraffirm,subjecttothepenaltiesprovidedby18Pa.C.S.§4904and47P.S.§4-403(h)and/or§4-436(j),thattheforegoinganswersand statements provided herein are true and complete to the best of my knowledge and belief. signature home address title phone name of attorney representing you in this matter, if any address phone signature title home address phone premises phone no. date signed e-mail address instructions the enclosed forms are to be submitted to apply for a new public service license. all attached separate sheets must include the applicant's name and the address. fees and documents to be submitted include: 1. plcb-4, application for new public service license 2. plcb-1773, appendix social security information must be submitted showing the social security number(s), name(s), andtitles(s)ofeachindividualapplicant,partner,memberORforacorporationofeachofficer,director,stockholder, and manager. 3. fees - made payable to "plcb" or "commonwealth of pennsylvania." fees submitted by applicants out of pennsylvaniaMUSTbecertifiedchecksormoneyorders. Afilingfeeof$700.00ANDalicensefeeof$65.00perdining,cluborbuffetcar,OR$260.00pervessel,steamship oraircarrierforliquorlicenseapplicantOR$40.00perdining,cluborbuffetcar,OR$160.00pervesselorsteamship, OR$55.00peraircarrierformaltbeveragelicenseapplicant. Anamusementpermitfeeequaltoone-fifthoftheannuallicensefee,minimum$40.00,ifentertainmentisfurnished, suchasdancing,floorshows,movingpictureexhibitionsortheatricals.Singingorvocalsolosbymembersofanorchestra or individuals or any other entertainment whether amateur or professional, instrumental music alone, provided by a mechanical device, orchestra, organ, piano or other musical instrument does not require an amusement permit. 4. PLCB-1898,TaxCertificationStatement 5. PLCB-1898A,TaxCertificationStatementforManagementCompany,isalsorequiredifamanagementcompany(any entity employed or otherwise contracted by the licensee or the applicant to operate, manage or supervise all or part of the operation of the licensed premises) is utilized. if a transfer application and if both buyer and seller use a management company, each company must submit the form. inforMation if you require assistance in completing the application pacKet, call the licensing information center at (717) 783-8250. send the application pacKet to: pennsylvania liquor control board, bureau of licensing, p.o. box 8940, harrisburg, pa 17105-8940. American LegalNet, Inc. www.FormsWorkFlow.com