plcb-26 02/12 commonwealth of pennsylvania pennsylvania liquor control board application for retail liquor or retail dispenser license and permits (see instructions page 3) bureau of licensing page 1 of 3 (ansWer all questions) the undersigned hereby applies for : hotel liq. hotel ret. disp. brewery pub restaurant liq. 1. name of applicant 2. trade name (if any) 3. address of premises new transfer of a airport restaurant liq. privately-owned public golf course rest. liq. privately-owned public golf course ret. disp. continuing care retirement community restaurant liq. continuing care retirement community eating place ret. disp. gaming restaurant liq. gaming eating place ret. disp. eating place ret. disp. off-track wagering rest. liq. munic. golf course liq. munic. golf course ret. disp. (street, rural route, p.o. box no.) (post office) (state) (zip) 4. name of municipality 5. amusement permit type of municipality city boro twp. inc. town county yes no will you permit dancing, provide floor shows, or any other entertainment? 6. sunday sales permit (PERMIT IS NOT NECESSARY FOR CONTINUING CARE RETIREMENT COMMUNITY APPLICANTS) will you sell liquor and/or malt or brewed beverages on sunday? 7. extended hours food license will you serve food until 7:00 a.m. of any day? 8. is the application to be considered for prior approval? yes yes yes no no no 9. has the applicant previously filed an application for any other plcb license? if "yes", when and where? if "yes", when does it expire? give month, day, year. yes yes no no deed book volume no. page no./instrument no. lease expiration date 10. is a current health license posted on the premises? 11. name of current owner of premises address of current owner of premises 11(a). name of officers, directors, shareholders, partners or members of property owner. (attach separate sheet if necessary) title 12. economic development (new license application only) are you applying for a new restaurant liquor or eating place retail dispenser on the basis of economic development? if yes, are you applying on the basis of (a), (b), or (c)? check one: a. the proposed premises is located within a keystone opportunity zone. b. the proposed premises is located within an area designated as an enterprise zone. c. the governing body of the municipality has approved the applicant for local economic development. yes yes yes yes no no no no do not Write BeloW tHis line new appl: co/mncp _ _ - _ _ _ zip _ _ _ _ _ - _ _ _ _ American LegalNet, Inc. www.FormsWorkFlow.com 13. if the premises to be licensed is in a pa gaming facility: a. who is the gaming license issued to? b. gaming license number c. name of the gaming facility d. are there any other plcb licenses issued for this premise? if yes, what are the plcb license numbers? 14. complete in detail - attach separate sheet, if necessary. name of individual applicant, partners, members, or officers & directors a. name b. name c. name d. name e. name f. name title home address date and place of birth length of residence in pa. u.s. citizen? yes no 15. for corporations and limited liability companies only a. registered as: profit registered name nonprofit incorporated/organized place date if foreign corporation give date of certificate of authority or if foreign llc give date registered in pa b. type of permit to be granted resolution new license transfer of license 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 and/or is/are hereby (name/title) (name/title) authorized to execute said application, and any other papers required by the board. 16. for corporations only list all stockholders - attach separate sheet, if necessary. name of stockholder a. name b. name c. name d. name e. name f. name home address date & place of birth u.s. citizen? yes no no. of shares of stock held American LegalNet, Inc. www.FormsWorkFlow.com plcb-26 2/12 commonwealth of pennsylvania pennsylvania liquor control board application for retail liquor or retail dispenser license and permits bureau of licensing page 2 of 3 17. is a management company employed or otherwise contracted to operate, manage or otherwise supervise all or part of the operation? yes no if yes, list the name and address of the entity: 18. name of manager name home address date & place of birth u.s. citizen? yes no 19. conviction record: the following is a record of all felony and misdemeanor convictions of the individual owner, all partners, all mem- bers, the manager and all corporate officers, directors and stockholders. (Attach separate sheet, if necessary.) if there have been no such convictions, check here: no such convictions name date of conviction charge disposition location of court (county and state) 20. Neither the applicant nor any member, officer, director, stockholder, agent or employee has any financial interest, either directly or indirectly, in any other class of license or permit issued by this board, or in the ownership, leasehold, or equipment, of any property used by such other licensee or permittee, or mortgage lien against the same, nor have they loaned any money, or given credit, or anything of value, for equipping, maintaining or conducting an establishment used in such other license or permit, except as follows: no exceptions 21. No person having any financial interest as an individual, or as a member, officer, director, stockholder, agent or employee in another class of license or permit issued by this board will be in any manner interested, either directly or indirectly, in the business proposed to be licensed under this application, or in the ownership or leasehold of the property or equipment to be used in the operation of the said business, or any mortgage lien against the same, nor have they loaned any money, or given credit, or anything of value, to the applicant, or any member, officer, director, stockholder, servant, agent or employee of said applicant, for equipping, maintaining or conducting this business, except as follows: no exceptions 22. None of the applicants hold any public office involving the enforcement of penal laws, or penal ordinances or resolutions, except as follows: no exceptions 23. the building to be licensed is not located within 300 feet of any church, school, hospital, public playground or charitable institution, except as follows: no exceptions 24. if an application for continuing care retirement fa