Standardized Notice Form For Providing 30-Day Advanced Notice To A Local Municipality Or Community Board - 2016 Page 2

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rev 1/22/16
OFFICE USE ONLY
Original
Amended
Date
Standardized NOTICE FORM for Providing 30-Day Advanced Notice to a
Local Municipality or Community Board
(Page 2 of 2)
17. List the floor(s) of the building that the establishment is located on:
18. List the room number(s) the establishment is located in within the
building, if appropriate:
No
Yes
19. Is the premises located within 500 feet of three or more on-premises liquor establishments?
Yes
No
20. Will the license holder or a manager be physically present within the establishment during all hours of operation?
21. If this is a transfer application (an existing licensed business is being purchased) provide the name and serial number of the licensee.
22. Does the applicant or licensee own the building in which the establishment is located?
Yes (If Yes SKIP 23-26)
No
Owner of the Building in Which the Licensed Establishment is Located
23. Building Owner's Full Name:
24. Building Owner's Street Address:
25. City, Town or Village:
State:
Zip Code :
26. Business Telephone Number of Building Owner:
Representative or Attorney representing the Applicant in Connection with the
application for a license to traffic in alcohol at the establishment identified in this notice
27. Representative/Attorney's Full Name:
28. Street Address:
29. City, Town or Village:
State:
Zip Code :
30. Business Telephone Number of Representative/Attorney:
31. Business Email Address :
I am the applicant or hold the license or am a principal of the legal entity that holds or is applying for the license. Representations
in this form are in conformity with representations made in submitted documents relied upon by the Authority when
granting the license. I understand that representations made in this form will also be relied upon, and that false representations
may result in disapproval of the application or revocation of the license.
By my signature, I affirm - under Penalty of Perjury - that the representations made in this form are true.
32. Printed Name:
Title
Signature: X
Print Form

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