Sla Form 180-058 - Application For Temporary Retail Permit 2011 Page 2
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1
2NEW YORK STATE
APPLICATION FOR TEMPORARY RETAIL PERMIT
LIQUOR AUTHORITY
[See Reverse Side for Conditions of Issuance]
FOR OFFICIAL USE ONLY-DO NOT WRITE IN THIS BOX
Expiration/Surrender/Safekeeping Date:__________
Pending Disciplinary-Location ___YES ___NO (Seller)
Original or Renewal (circle one)
Pending Disciplinary-Principals ___YES ___NO (Seller)
Pending Disciplinary-Principals ___YES ___NO (Buyer)
(1) NAME OF APPLICANT___________________________________________
Date Filed ______/____/______
(2) SELECT ONE OF THE FOLLOWING:
Purchase of an Existing Business:
___ Transfer or Sale of a business in a premises that is currently LICENSED* for alcoholic beverage sales. Submit a Contract
of Sale or Conveyance.
Application for a New Business:
___ A new or existing business in a proposed premise that is currently UNLICENSED for alcoholic beverage sales, is not a wine
or liquor store, is not subject to the 500’ Rule and is not located in New York City (
).
Kings, Queens, Bronx, New York, Staten Island
___ A new business in a premise that is currently LICENSED for alcoholic beverage sales, where a Transfer or Sale of the
previous business is NOT taking place, is not a wine or liquor store, is not subject to the 500’ Rule and is not located in New
York City (
).
Kings, Queens, Bronx, New York, Staten Island
*The subject premises must have been operating under a retail license within thirty days of the filing of the application for this permit.
(3) NAME OF CURRENT LICENSEE (if any) _______________________________________ Serial Number __________
(4) ADDRESS OF PREMISES ________________________________________________Telephone #__________________
As an authorized signatory of the current applicant, I certify that I have read and understand the foregoing
conditions for temporary retail permit and represent that I am eligible for such permit.
_______________________
_______________________________________
________________
TITLE
APPLICANT’S SIGNATURE
DATE
The above party agrees that any false statement in the above certifications will constitute grounds for
disapproval of the permit and the license applications.
FOR OFFICIAL SLA USE ONLY - DO NOT WRITE IN THIS BOX
Serial Number ___________________ Date of Issuance ____________
SLA Action:
Effective From: __________ To: __________ Fee Amount: _________
Approved
Disapproved
By: ________________ Date: ___________
SLA form 180-058 (revised 5/11)
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