PLCB-1689 2/06 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD BUREAU OF LICENSING APPLICATION FOR RETURN OF LICENSE FROM SAFEKEEPING 8A (SEE INSTRUCTIONS ON REVERSE) The undersigned hereby requests the License be reissued from safekeeping pursuant to the provisions of the Liquor Code and Regulations of the Board. 1. NAME OF APPLICANT LID NO. 2. TRADE NAME (IF ANY) LICENSE NO. 3. ADDRESS OF PREMISES (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) 4. GIVE NAME OF MANAGER/STEWARD/RESPONSIBLE OFFICER 5. EXPIRATION DATE OF LEASE (MM / DD / YYYY) 8. (ZIP) NAME AND ADDRESS OF OWNER OF PREMISES 6. (STATE) HOTELS ONLY. GIVE NUMBER OF PERMANENT BEDROOMS AVAILABLE FOR GUESTS. PHONE NO. LICENSED PREMISES ( ) 17. GIVE DATE PREMISES WILL BE OPEN FOR BUSINESS (MM / DD / YYYY) HAS ANY CHANGE BEEN MADE SINCE LICENSE WAS PLACED IN SAFEKEEPING AS PER ANY OR ALL OF THE FOLLOWING: A. Size or the number of kitchen, serving or storage area(s)? If ‘yes’, was the change reported to the Board? B. Members, officers, directors, stockholders, trustees, steward, manager or responsible officer? If ‘yes’, was the change reported to the Board? C. Is a current valid health license posted on the premises? If ‘yes’, when does it expire? Give month, day, year. (MM / DD / YYYY) 10. FOR CLUBS ONLY A. Is the charter in the possession of the original incorporators? If ‘no’, is it in the possession of their direct or legitimate successors? B. Are the bylaws consistent with the charter of the organization? C. Are all provisions of the bylaws adhered to by the organization? 9. 11. YES NO FOR DISTRIBUTORS OR IMPORTING DISTRIBUTORS ONLY A. Is there a separate office on the premises? B. Are there toilet facilities on the premises? C. Has total area remained the same (1,000 square feet for distributor, 2,500 square feet for importing distributor? RESOLUTION (CORPORATIONS, LIMITED LIABILITY COMPANIES AND CLUBS ONLY) 12. 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 (NAME/TITLE) is/are (NAME/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 47 P.S. §4-403(h) and/or §4-436(j) and/or §5-504(b) and/or §7-704, 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 have a license reissued from safekeeping. If there had been an approved manager at the time the license was put in safekeeping, and that person is to be replaced at the time the premises is opened, PLCB-706, Application for Approval of Appointment of Manager, must be filed. 1. FEES – A fee of $150.00 is required. Only $50.00 is required if an investigation is not necessary (e.g., license in safekeeping less than 90 days, no changes to premises, seasonal reissuance). The fee MUST accompany the application. Make remittance payable to “PLCB” or “Commonwealth of Pennsylvania.” 2. All applicable questions must be answered and the form must be signed. NO CHANGES TO NAME OR ADDRESS OF LICENSEE CAN BE MADE ON THIS FORM. If there has been a change, include a brief written statement to that effect. 3. The form and fee MUST be filed at least 30 DAYS prior to the date the premises will be open for business. A physical inspection of the premises will be required before the license is issued. INFORMATION a. All retail establishments (except clubs but including restaurants, hotels, eating place retail dispensers) MUST be stocked with food, equipped to meet minimum requirements, possess a valid health license and be ready for operation at the time of the inspection. b. Sale of alcoholic beverages SHALL NOT begin until formal Board authority is in your possession. 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 INVESTIGATIVE 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. 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