PLCB-1229 11/06 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPLICATION FOR SPECIAL OCCASION PERMIT BUREAU OF LICENSING (SEE INSTRUCTIONS PAGE 2 OF 2) PAGE 1 OF 2 The undersigned hereby applies for a SPECIAL OCCASION PERMIT for: 1. a. Nonconsecutive dates of: Mo./Date/Year Mo./Date/Year Mo./Date/Year Mo./Date/Year Mo./Date/Year Mo./Date/Year ____ / ____ / ____ ____ / ____ / ____ ____ / ____ / ____ ____ / ____ / ____ ____ / ____ / ____ ____ / ____ / ____ b. Consecutive dates from: to 2. EVENT DAYTIME PHONE NO. CHAIRMAN/CONTACT PERSON 3. TYPE OF GROUP ZOOLOGICAL INSTITUTION ARTS FACILITY OR MUSEUM FRATERNAL BENEFIT SOCIETY HOSPITAL CHURCH/SYNAGOGUE NATIONALLY CHARTERED VETERANS' ORGANIZATION SPORTSMEN’S CLUB (Ten Years Existence) NONPROFIT AGRICULTURAL ASSOC. (Ten Years Existence) VOLUNTEER FIRE CO. VOLUNTEER RESCUE SQUAD PERFORMING ARTS NONPROFIT ORGANIZATION FOR ARCHITECTURAL HERITAGE PROTECTION UNIT OF A NATIONAL CHARTERED CLUB VOLUNTEER AMBULANCE CO. MUSEUM NONPROFIT ORGANIZATION FOR REGATTA OR WELCOME AMERICA ARTS COUNCIL LIBRARY CITY OF THE 3RD CLASS OTHER 4. NAME OF APPLICANT GROUP ADDRESS PRIMARY AFFILIATED LODGE OR SUBDIVISION AUXILIARY (STREET, RURAL ROUTE, P.O. BOX NO.) (POST OFFICE) PHONE NO. (STATE) (ZIP) PA NAME OF MUNICIPALITY TYPE OF MUNICIPALITY BORO CITY TWP. INC. TOWN COUNTY 5. NAME AND ADDRESS TO WHICH PERMIT SHOULD BE MAILED, IF DIFFERENT FROM ABOVE APPLICANT 6. NAME AND ADDRESS OF PRIMARY ORGANIZATION, IF ANY 7. LIST LOCATION OF PREMISES OR AREA TO BE LICENSED STREET, RURAL ROUTE, P.O. BOX NO. COUNTY CITY, BOROUGH, TOWNSHIP, INC. TOWN LIST DESCRIPTION OF PREMISES OR AREA TO BE LICENSED INSIDE AREA WIDTH LENGTH OUTSIDE AREA 8. ARE PUBLIC STREETS, ROADS OR THOROUGHFARES BEING CLOSED FOR THIS EVENT? YES NO If ‘yes,’ attach written approval from municipal authority. DO NOT WRITE BELOW THIS LINE CO/MNCP _ _ - _ _ _ ZIP _ _ _ _ _ - _ _ _ _ American LegalNet, Inc. www.FormsWorkflow.com 9. HAS A SPECIAL OCCASION PERMIT EVER BEEN GRANTED TO THIS ORGANIZATION? YES NO If ‘yes,’ give License Identification Number LID If ‘yes,’ give date (Months/Year) Give NUMBER OF PERMITS this calendar year 10. HOW LONG HAS THE APPLICANT GROUP BEEN IN EXISTENCE? (Sportsmen’s Club and Nonprofit Agricultural Association must have ten years of existence.) YES 11. ARE LICENSED PREMISES TO BE LEASED? NO If ‘yes,’ property owner’s/lessor’s NAME 12. IF APPLYING FOR A FAMILY-ORIENTED CELEBRATION AS PART OF WELCOME AMERICA, IS PROPERTY LEASED FROM THE CITY? YES Lease Effective Date ________________ Expiration Date _______________ NO 13. HAS CHARTER BEEN GRANTED BY NATIONAL VETERANS’ ORGANIZATION? YES NO YES NO Tax Exempt? YES NO Promoting Visual and/or Performing Arts? YES NO Receiving Funds Under the Local Arts Services Program Administered by the Pennsylvania Council on the Arts? YES NO If ‘yes,’ date granted 14. IS THE PROPERTY OWNER OR LESSOR A LICENSEE OF THIS BOARD? If ‘yes,’ give LICENSE NUMBER 15. IF APPLYING AS AN ARTS COUNCIL, IS THE APPLICANT: 16. IF APPLYING AS A VOLUNTEER FIRE COMPANY, VOLUNTEER AMBULANCE COMPANY, OR VOLUNTEER RESCUE SQUAD, DOES THE APPLICANT HOLD A PLCB LICENSE? YES NO If ‘yes,’ is the facility owned by the licensee? YES NO If ‘yes,’ is the special occasion permit to be used in conjunction with the areas presently licensed by the organization? YES NO If ‘yes,’ give LICENSE IDENTIFICATION NUMBER 17. RESOLUTION (CORPORATIONS AND CLUBS ONLY) At a regular or special meeting held on ______________________________________________ , 20 __________ by the applicant corporation/club, 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 and 47 P.S. §4-403(h) that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE TITLE PRINT NAME OF PERSON SIGNING PRINT NAME OF PERSON SIGNING HOME ADDRESS SIGNATURE PHONE HOME ADDRESS PHONE American LegalNet, Inc. www.FormsWorkflow.com PLCB-1229 11/06 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD APPLICATION FOR SPECIAL OCCASION PERMIT BUREAU OF LICENSING PAGE 2 OF 2 INSTRUCTIONS This form is to be used to apply for a Special Occasion Permit for use at a special event including, but not limited to bazaars, picnics and clam bakes. The event must be one which is used by the applicant as means of raising funds for itself. 1. A fee of $30.00 per day MUST accompany this form. If the applicant is a bona fide sportsmen’s club, nonprofit agricultural association or museum or performing arts facility and this is the FIRST Special Occasion Permit application filed with the Board, the fee is $85.00 for the first day and $30.00 for each subsequent day. 2. This form and fee MUST be filed at least 30 days prior to the date of the event. 3. All questions must be answered, even if the answer is “NONE” or “NOT APPLICABLE.” This form MUST have an original signature. 4. Applications from an auxiliary group must be signed by an officer from the primary organization. If the application is from a church or synagogue AND is signed by the minister, priest, or rabbi, question 17 (Resolution) does not have to be completed. Separate applications are required for EACH non-consecutive day. 5. Applications from affiliated lodges or subdivisions of nationally chartered veterans' organizations MUST submit copy of documentation proving affiliation with national veterans. 6. Applications from fraternal benefit societies MUST submit proof that society is licensed to do business in Pennsylvania. 7. Applications from a nonprofit organization conducting a regatta or a family-oriented celebration MUST submit proof that the applicant is a nonprofit organization as defined under Section 501(c)(4) of the Internal Revenue Code of 1986 [Public Law 99-514, 26 U.S.C. §501(c)(3)]. 8. Applications from a nonprofit organization whose purpose is to protect the architectural heritage of boroughs MUST submit proof that the applicant is a nonprofit organization as defined under Section 501(c)(3) of the Internal Revenue Code of 1986 [Public Law 99-514, 26 U.S.C. §501(c)(3)], AND MUST submit a copy of the borough's municipal resolution recognizing the applicant as such an organization. INFORMATION Special Occasion Permits may be issued: a. For not more than six (6) consecutive or non-consecutive days during the calendar year. One permit may be issued per calendar year to the following applicants: 11) hospital 12) church or synagogue 13) city of the third class 14) library 15) volunteer fire company or ambulance company or rescue squad 16) nonprofit agricultural association in existence for at least 10 years 17) bona fide sportsman’s club in existence for at least 10 years 18) nationally chartered veterans' organization and any affiliated lodge or subdivision of such organization 19) fraternal benefit society licensed to do business in Pennsylvania and any affiliated lodge or subdivision of such organization 10) unit of a nationally chartered club, which has a club liquor license 11) nonprofit organization as defined by Section 501(c)(3) of the Internal Revenue Code of 1986 whose purpose is to protect the architectural heritage of boroughs 12) a nonprofit corporation that operates an arts facility or museum in a 3rd class city located in a 4th class county 13) a nationally accredited PA non-profit Zoological Institution licensed by U.S. Department of Agriculture 14) nonprofit organization as defined under Section 501(c)(3) of the Internal Revenue Code of 1986 conducting: a) a regatta on State park grounds located in a city of the 2nd class, or b) a family-oriented celebration as part of Welcome America in a 1st class city on property leased from that city for a period of more than 50 years. NOTE: Organizations conducting a regatta may install a security fence or similar enclosure around the boundary of the State park or a portion thereof and charge an admission fee not to exceed $5.00 per day. (INFORMATION CONTINUED ON REVERSE) American LegalNet, Inc. www.FormsWorkflow.com INFORMATION (Cont'd) 15) club licensee that as of 12/31/02 has been in existence for at least 100 years that is in a 3rd class city 16) a nonprofit organization as defined under Section 501(c)(3) of the Internal Revenue Code of 1986 whose purpose is to raise funds for the research and treatment of cystic fibrosis 17) a nonprofit organization as defined under Section 501(c)(3) of the Internal Revenue Code of 1986 whose purpose is to educate the public on issues dealing with watershed conservation 18) a nonprofit organization as defined under Section 501(c)(3) of the Internal Revenue Code of 1986 whose purpose is to provide equine assisted activities for children and adults with special needs 19) a nonprofit economic development agency in a city of the second class with the primary function to serve as an economic generator for the greater southwestern Pennsylvania region by attracting and supporting film, television, and related media industry projects and coordinating government and business offices in support of a production 20) a county tourist promotion agency as defined in Section 3(1) of the act of April 28, 1961, known as the "Tourist Promotion Law," and located in a city of the third class in a county of the fourth class or in a township of the second class in a county of the fifth class 21) a junior league in a 3rd class county that is a nonprofit organization as defined under Section 501(c)(3) of the Internal Revenue Code of 1986 that is comprised of women whose purpose is exclusively educational and charitable in promoting the volunteerism of women and developing and participating in community projects and that has been in existence for over seventy years 22) a nonprofit organization as defined under Section 501(c)(6) of the Internal Revenue Code of 1986 which is located in a city of the third class in a county of the third class and whose purpose is to support business and industry. 23) one auxiliary of any of the foregoing b. For not more than six (6) non-consecutive permits per calendar year, each permit being valid for only one day OR for not more than ten (10) consecutive days per calendar year. Permits may be issued to the following applicants: 11) museum operated by nonprofit corporation located in a 3rd class city or a 1st class township 12) nonprofit corporation engaged in the Performing Arts located in a 3rd class city or an incorporated town 13) an Arts Council, which is a tax-exempt organization promoting visual arts and/or performing arts that receives funding under the local Arts Program Administered by the PA Council on the Arts. PERMITS ARE NOT TRANSFERABLE AND CANNOT BE RENEWED. NO ALTERNATE RAIN DATES MAY BE CONSIDERED. IF YOU REQUIRE ASSISTANCE IN COMPLETING THE APPLICATION, 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. 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