This is a New York form that can be used for Division Of Alcoholic Beverage Control within Statewide.
Last updated: 4/13/2015
-30 MISCELLANEOUS PERMITS Indicate type of permit you are applying for ______________________________________________ Present Permit No:__________________________________________________________________ 1) Full name of applicant or licensee__________________________________________________ (If partnership, name all partners)_________________________________________________ ____________________________________________________________________________ 2) 3) 4) 5) 6) 7) 8) 9) 10) Street Address of Licensed Premises:_______________________________________________ City, Town or Village, Zip Code: _________________________________________________ County _____________________________________________________________________ Trade Name (d.b.a.) ___________________________________________________________ License Number ________________________________ Date Issued ____________________ Post Office address of premises___________________________________________________ City, Town or Village, Zip Code: _________________________________________________ Telephone Number: ___________________________________________________________ Between what streets (if outside city limit and not known by bldg. #, specify location in relation to nearest road/highway):_______________________________________________________ Title (if applicable) Marshall, Receiver, Executor, etc.________________________________ Specify the date for proposed event, sale, tasting by supplier, auction or semester dates of the class or course of classes to be given: __________________________________________________________ 11) 12) 12A) Indicate the name and address of the licensed establishment where the event, sale, tasting by supplier or auction will take place: · Name __________________________ · Trade Name _______________________ · Premises Address ___________________________________________________________ · City, town or village and zip code_______________________________________________ · License Number ____________________________ · Telephone No._________________ American LegalNet, Inc. www.FormsWorkFlow.com 13) Indicate the location where the alcoholic beverages are stored or where sale, class, auction or rectifying will take place____________________________________________________________ ________________________________________________________________________________ 13A) Name of Rectifier _________________________ License No. ____________________ 13B) 14) Name of Instructor(s)______________________________________________________ Does location where alcoholic beverages are stored have a warehouse permit? Yes ( ) No ( ) If Yes, permit # ______________Date of Issuance ____________ 14A) Will any other business of any kind be carried on in said premises? Yes ( ) No ( ) If yes, give details ________________________________________________________ 14B) Will any alcoholic beverages be subject to any processes while stored on said premises? Yes ( ) No ( ) Does the applicant hold a transportation permit? Yes ( ) No ( ) Please indicate how you came into possession of the alcoholic beverages________________ __________________________________________________________________________ 16A) Were they owned by a licensee or former licensee Yes ( ) No ( ) List name and license number __________________________________________________ __________________________________________________________________________ 17) For Fire Insurance/Salvage Co. Only - Name and address of licensed premises where fire occurred: __________________________________________________________________ __________________________________________________________________________ 18) 19) Date the fire occurred: _______________________________________________________ For Hotel-Off Premises permit (license)- state whether the premises for which this application is filed is within eight (8) miles in any direction of any premises licensed for off-premises sale of liquor or wine at retail _____________________________________________________ Has the applicant or (if partnership) any of the partners or (if a corporation) any of the officers, directors, or stockholders, or any agent or employee of the applicant, ever been CONVICTED (including pleas of guilty or suspended sentences) of any felony or of any other crime or offense of any kind except traffic violations?: Yes ( ) No ( ) · If yes, a CERTIFICATE OF DISPOSITION or a CERTIFICATE OF CONVICTION by the Court Clerk must be attached. 15) 16) 20) American LegalNet, Inc. www.FormsWorkFlow.com 21) Has any license or permit issued for the premises, or any part of the building containing such premises, ever been Revoked or Cancelled? Yes ( ) No ( ) · If so, state date and name of former licensee or permittee and specific location in the building where such business was conducted_____________________________________________ ____________________________________________________________________________ 22) Has any application been made, for said premises as any part thereof, for the issuance of a bonded warehouse permit, under the United State Customs Regulations. Yes ( ) No ( ) · If so, give date of such action, name of former licensee or permittee and the specific location in the building where such business was conducted under said license or permit: ____________________________________________________________________________ 23) Was an application for any license or permit under the Alcohol Beverage Control Laws of this state or country or any other state or country ever been made by the applicant, any partner or any officer of a corporation? Yes ( ) No ( ) · If so, state name of applicant________________________________________________ · Address of premises ______________________________________________________ · Date filed ____________________ Disposition _______________________________ · Has such license or permit ever been Revoked, Cancelled, Suspended or Otherwise Terminated or has any other penalty been imposed at any time? Yes ( ) No ( ) · If so, state what action was taken ____________________________________________ _________________________________________________________________________ ______________________________________________(add rider if more space is needed) 24) Please provide a detailed description of the alcoholic beverages to be stored or sold on an attached sheet. Indicate number of cases, Brand Name, Type and Size of containers. ________________________________________________________________________ Ame