Standardized Notice Form For Providing 30-Day Advanced Notice To A Local Municipality Or Community Board - 2016

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rev 1/22/16
OFFICE USE ONLY
49
Original
Amended
Date
Standardized NOTICE FORM for Providing 30-Day Advanced Notice to a
Local Municipality or Community Board
(Page 1 of 2 )
1. Date Notice Was Sent:
1a. Delivered by:
2. Select the type of Application that will be filed with the Authority for an On-Premises Alcoholic Beverage License
New Application
Renewal
Alteration
Corporate Change
Removal
Class Change
For New applicants, answer each question below using all information known to date.
For Renewal applicants, set forth your approved Method of Operation only.
For Alteration applicants, attach a complete written description and diagrams depicting the proposed alteration(s).
For Corporate Change applicants, attach a list of the current and proposed corporate principals.
For Removal applicants, attach a statement of your current and proposed addresses with the reason(s) for the relocation.
For Class Change applicants, attach a statement detailing your current license type and your proposed license type.
This 30-Day Advance Notice is Being Provided to the Clerk of the following Local Municipality or Community Board
3. Name of Municipality or Community Board:
Applicant/Licensee Information
4. License Serial Number, if Applicable:
Expiration Date, if Applicable:
5. Applicant or Licensee Name:
6. Trade Name (if any):
7. Street Address of Establishment:
,NY
8. City, Town or Village:
Zip Code :
9. Business Telephone Number of Applicant/Licensee:
10. Business Fax Number of Applicant/Licensee:
11. Business E-mail of Applicant/Licensee:
12. Type(s) of Alcohol sold or to be sold:
Beer & Cider
Wine, Beer & Cider
Liquor, Wine, Beer & Cider
13. Extent of Food Service:
Full food menu;
Menu meets legal minimum food availability requirements;
Full Kitchen run by a chef or cook
Food prep area at minimum
14. Type of Establishment:
15. Method of Operation:
Seasonal Establishment
Juke Box
Disc Jockey
Recorded Music
Karaoke
(Check all that apply)
Live Music (Give details: i.e. rock bands, acoustic, jazz, etc.):
Patron Dancing
Employee Dancing
Exotic Dancing
Topless Entertainment
Video/Arcade Games
Third Party Promoters
Security Personnel
Other (specify):
Freestanding Covered Structure
None
Patio or Deck
Rooftop
Garden/Grounds
16. Licensed Outdoor Area:
(Check all that apply)
Sidewalk Cafe
Other (specify):
Print Form

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