Application For Alcoholic Beverage Control Retail License (Vessel) {VL1}

vessel-04/30/13 Original OFFICE USE ONLY Amended Date LICENSE 29 APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL RETAIL LICENSE (VESSEL) FILING CHECKLIST This checklist has been created to better assist you with the application process. All items on the checklist must be complete and accurate to the best of your ability. If all items in the checklist are not submitted, the application may be disapproved for Failure to Comply. Please note that per Section 110(b) of the ABC Law all on-premises applicants (whether applying for beer; beer & wine; or beer, wine & liquor) are required to notify the Municipality or Community Board at least 30 days prior to filing the application with the New York State Liquor Authority. THE COMMUNITY BOARD/MUNICIPALITY NOTICE FORM AND PROOF OF MAILING MUST BE SUBMITTED WITH THIS APPLICATION. All Applicants MUST submit the following Sections of the Retail License Application upon filing of the application: Application (Pages 1-2) Right to Premises Landlord Identification List of Expenses 500 Foot Rule Statement Statement of Area Plan On-Premises Vessel Questionnaire Method of Operation Proof of Citizenship Affirmation (non US born principals) Applicant's Statement Personal Questionnaire (for each Principal, Manager, Lender, Donor, etc.) Notice of Appearance (if represented by someone other than the applicant) All Applicants MUST submit the following Supporting Documents upon filing of the application: Bond, Form L-9 (signed by the applicant and expiring at the end of the initial licensing term) Community Board/Municipality Notification (using the correct Standardized Form, see above for more information) Detailed Diagrams which include Interior and Block Plot (aerial view of the building showing nearby businesses/residences) Investment Records showing the source and availability of the funds to be used for the venture Lease/Deed/Contracts (any applicable for this venture) You must provide proof that you have full control over the premises to be licensed. Letter of request to waive the 2 bathroom rule (if only 1 bathroom) Menu Photo Identification for all applicant Principals and Managers (copies only) Photos of applicant Principals and Managers (Must be in color) Photos of the proposed premises (exterior and interior-including kitchen area) (Must be in color) Proof of Citizenship for all applicant principals NOT currently licensed with the NYS Liquor Authority (copy of Birth Certificate, Passport) All Applicants MUST submit the following Supporting Documents before a license can be issued: Certificate of Authority to Collect Sales Tax Coast Guard Certification Department of State Filing Receipt Newspaper Affidavit Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Photos of the premises showing ready to open and operate Proof that the proposed Vessel is sufficiently covered under The Jones Act (or Workers' Compensation & Disability) vessel-04/30/13 Original OFFICE USE ONLY Amended Date VESSEL 29 APPLICATION FOR ALCOHOLIC BEVERAGE CONTROL RETAIL LICENSE (VESSEL) It is not necessary to employ any person, agency or organization to assist you in filing this application. Beware of persons claiming to be able to assist you in securing action on your application. The payment of money or other thing of value for the use of influence, or promise of influence in obtaining a license is a violation of law and offenders will be prosecuted. 1. APPLICANT Name of Applicant: Name of Vessel: Mooring Address of Vessel: City: County: Office Address (if different than above): City: E-mail address (if available): State: Zip Code: , NY Zip Code: Telephone Number of Vessel (include area code): 2. CONTACT (if other than applicant) Name of Contact: Office Address: City: State: Zip Code: Attorney Representative Contact Person Telephone Number of Office (include area code): E-mail address (if available): Is this application filed under the Self Certification Program? Yes No 3. VESSEL LICENSE TYPE: (see Vessel Fee Schedule) CODE: 4. For SEASONAL licensees only-beginning and ending months 5. Number of ADDITIONAL BARS (if any): (see instructions) 6. TOTAL PAYMENT DUE: Submit copy of permit 7. Federal Tax ID #: 7a. Certificate of Authority Permit# 8. Coast Guard Registration Number (Submit copy of registration): THE COMMUNITY BOARD/MUNICIPALITY NOTICE FORM AND PROOF OF MAILING MUST BE SUBMITTED WITH THIS APPLICATION. [OFFICE USE ONLY] continued on next page DATE FILED: SERIAL #: Page 2 American LegalNet, Inc. www.FormsWorkFlow.com vessel-04/30/13 Original OFFICE USE ONLY Amended Date 29 9. TO BE FILLED IN ONLY BY SOLE PROPRIETOR OR PARTNERS (attach additional sheets if necessary) Name of Individual / Partner Residence Social Security #: Date of Birth Name of Individual / Partner Residence Social Security #: Date of Birth Name of Individual / Partner Residence Social Security #: Date of Birth Name of Individual / Partner Residence Social Security #: Date of Birth 9a. TO BE FILLED IN ONLY IF YOU WILL EMPLOY A MANAGER Name of Manager Residence Social Security #: Date of Birth Name of Manager Residence Social Security #: Date of Birth 10. TO BE FILLED IN ONLY BY CORPORATION OR LLC/LLP APPLICANTS (attach additional sheets if necessary) List the names and address or Principals (Stockholders, Officers, Directors, LLC Members/Managers, LLP Partners) Name of Principal Residence Social Security #: Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Social Security #: Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Social Security #: Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth Name of Principal Residence Social Security #: Title No. of Shares if Corporation or % of ownership if LLC or Partnership Date of Birth 10a. TO BE FILLED IN ONLY IF YOU WILL EMPLOY A MANAGER Name of Manager Residence Social Security #: Date of Birth Name of Manager Residence Social Security #: Date of Birth continued on next page Page 3 American LegalNet, Inc. www.FormsWorkFlow.com vessel-04/30/13 Original OFFICE USE ONLY Amended Date 174 RIGHT TO PREMISES 1. RIGHT TO VESSEL a. By what right does the applicant have possession of the Vessel? Own Lease Sub-Lease Binding contract to acquire real property Written intent to Lease Other (explain): b. Do the terms of the lease or other arrangement require the applicant to provide any consideration based