Application for Distributor or Importing Distributor License

Document Sample
Application for Distributor or Importing Distributor License Powered By Docstoc
					pLCB-35 2/08
       CoMMoNWeaLTh of peNNSYLvaNIa            application for distributor or                                         BUReaU of LICeNSINg
               pennsylvania
           liquor control board                importing distributor license
                                                         (see instructions paGe 2 oF 2 reverse)                                             page 1 of 2


     The undersigned hereby applies for a          NeW                          DISTRIBUToR             IMpoRTINg DISTRIBUToR LICeNSe, oR
                                       for a       TRaNSfeR of a                DISTRIBUToR             IMpoRTINg DISTRIBUToR LICeNSe, for

     the term ending                                                . If for transfer, give license number                                          .
1.   NaMe 0f appLICaNT


2.   TRaDe NaMe (If aNY)


3.   aDDReSS of pReMISeS                  (STReeT, RURaL RoUTe, p.o. BoX No.)                  (poST offICe)             (STaTe)            (ZIp)



4.   NaMe of MUNICIpaLITY                                     TYpe of MUNICIpaLITY                           CoUNTY
                                                                                                        INC.
                                                                    CITY         BoRo       TWp.        ToWN
5.   WILL YoU SeLL MaLT/BReWeD BeveRageS oN SUNDaY?                 YeS          No
6.   CoMpLeTe IN DeTaIL - aTTaCh SepaRaTe SheeT, If NeCeSSaRY.

                                                                                                                DaTe aND           LeNgTh of    U.S.
NaMe of INDIvIDUaL appLICaNT, paRTNeRS,                                                                                            ReSIDeNCe CITIZeN?
                                                   TITLe                        hoMe aDDReSS                     pLaCe               IN pa.
  MeMBeRS, oR offICeRS & DIReCToRS
                                                                                                                of BIRTh           YRS. MThS. YeS No
a. NaMe




B. NaMe




C. NaMe




D. NaMe




7.   The foLLoWINg IS a LIST of aLL pLaCeS To Be USeD IN The opeRaTIoN of The BUSINeSS:
     (If oNLY a poRTIoN of The pReMISeS IS To Be LICeNSeD, gIve DeTaILS UNDeR “LoCaTIoN”).
                                 pURpoSe         NaMe of oWNeR of pReMISeS              DeeD BooK   LeaSe             NaMe aND TITLe of offICeRS,
           LoCaTIoN             foR WhICh                                                                        DIReCToRS, ShaRehoLDeRS, paRTNeRS,
                                pReMISeS                                                voL. page eXpiration       oR MeMBeRS of pRopeRTY oWNeRS
                                               aDDReSS of oWNeR of pReMSIeS             No.   no.    date
                               WILL Be USeD                                                                    (aTTaCh a SepaRaTe SheeT If NeCeSSaRY)
a.




B.




C.




8.   STaTe oTheR eMpLoYMeNT oR BUSINeSS                                                          LoCaTIoN




9.   Do YoU INTeND To SeLL aNY ITeMS oTheR ThaN MaLT oR BReWeD BeveRageS?                  YeS          No
     LIST ITeMS - aTTaCh SepaRaTe SheeT, If NeCeSSaRY.




                                                         do not Write beloW tHis line

Co/MNCp _ _ - _ _ _ ZIp _ _ _ _ _ - _ _ _ _
10.                                resolution (corporations and limited liabilitY companies onlY)

      at a regular or special meeting held on                                 , 20          by the applicant,
      it was resolved that said application be filed with the pennsylvania Liquor Control Board, and that
                                                     and/or                                           is/are
                                  (NaMe/TITLe)                                                      (NaMe/TITLe)

      hereby authorized to execute said application, and any other papers required by the Board.

11. foR CoRpoRaTIoNS aND LLCs oNLY
      (a)   DeSCRIpTIoN:
                                                                             INCoRpoRaTeD/oRgaNIZeD                iF ForeiGn corporation Give
                           RegISTeReD NaMe                                                                             date oF certiFicate oF
                                                                               pLaCe                DaTe            autHority or iF ForeiGn llc
                                                                                                                     Give date reGistered in pa



12. foR CoRpoRaTIoNS oNLY
      (a)   NUMBeR of ShaReS of SToCK ISSUeD:
            CoMMoN                                              pRefeRReD                      ToTaL


      (B)   LIST aLL SToCKhoLDeRS - aTTaCh SepaRaTe SheeT, If NeCeSSaRY.

                                                                                           DaTe aND       LeNgTh of    U.S.        KIND aND
            NaMe of SToCKhoLDeR                               hoMe aDDReSS                                ReSIDeNCe citiZen?
                                                                                            pLaCe           IN pa.                aMount oF
                                                                                           of BIRTh       YRS. MThS. YeS No       stocK Held
 1) NaMe




 2) NaMe




 3) NaMe




 4) NaMe




 5) NaMe




13. foR CoRpoRaTIoNS, LLCs, oR paRTNeRShIpS oNLY
                                                                                                                                        U.S.
              NaMe of MaNageR                                    hoMe aDDReSS                          DaTe & pLaCe of BIRTh          citiZen?
                                                                                                                                     YeS     No




14. CoNvICTIoN ReCoRD: The following is a record of all felony and misdemeanor convictions of the individual owner, all partners, all
      members, the manager and all corporate officers, directors and stockholders. (Attach separate sheet, if necessary.)
      If there have been no such convictions, check here:        no such convictions
                                                  DaTe of                                                            LoCaTIoN of CoURT
                     NaMe                        conviction              ChaRge               DISpoSITIoN            (county and state)




15. Is a management company employed or otherwise contracted to operate, manage or otherwise supervise all or part of the operation?


            YeS        No      If yes, list the name and address of the entity:
pLCB-35 2/08

        CoMMoNWeaLTh of peNNSYLvaNIa
                peNNSYLvaNIa
                                                     application for distributor or                                       BUReaU of LICeNSINg
            LIqUoR CoNTRoL BoaRD                     importing distributor license
                                                                     (See INSTRUCTIoNS oN ReveRSe)                                                  page 2 of 2

16.      application to be considered for prior approval?                                                                          YeS         No


17.      Has the applicant previously filed an application for license or held a license issued by this Board?                     YeS         No


         If ‘yes’, when and where?

18.      Neither the applicant nor any member, officer, director, stockholder, agent or employee has any financial interest, either directly or
         indirectly, in any other license or permit issued by this Board, or in the ownership, leasehold, or equipment, of any property used by such
         other licensee or permittee, or mortgage lien against the same, nor has the applicant loaned any money, or given credit, or anything of
         value, for equipping, maintaining or conducting an establishment used in such other license or permit, except as follows:




         If there are no exceptions, check here:                No exception

19.      No person having any financial interest as an individual, or as a member, officer, director, stockholder, agent or employee in another
         license or permit issued by this Board will be in any manner interested, either directly or indirectly, in the business proposed to be
         licensed under this application, or in the ownership or leasehold of the property or equipment to be used in the operation of the said
         business, or any mortgage lien against the same, nor has he loaned any money, or given credit, or anything of value, to the applicant,
         or any member, officer, director, stockholder, servant, agent or employee of said applicant, for equipping, maintaining or conducting this
         business, except as follows:




         If there are no exceptions, check here:                No exception

20.      None of the applicants hold any public office involving the enforcement of penal laws, or penal ordinances or resolutions, except as
         follows:




         If there are no exceptions, check here:                No exception

21.      a placard, pLCB-1296, public Notice of application alcoholic Beverages, was posted on (DaTe)________________________ in a
         conspicuous place on the outside of the premises for which the license is applied, as required by the Liquor Code and the Regulations
         of the Board, and will remain posted until the license or a notice of refusal of the application is received by the applicant.


      I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, and 47 P.S. §4-436(j), that the foregoing answers and statements provided
      herein are true and complete to the best of my knowledge and belief.
SIgNaTURe                                           TITLe                              NaMe of aTToRNeY RepReSeNTINg YoU IN ThIS MaTTeR, If aNY



hoMe aDDReSS                                        phoNe                              aDDReSS

                                                (           )
SIgNaTURe                                           TITLe



hoMe aDDReSS                                        phoNe                                                                          phoNe


                                                (           )                                                                  (           )
pReMISeS phoNe No.                                                                     DaTe SIgNeD


(          )
                                                      instructions

This form is to be submitted as part of the application packet to apply for a new Distributor or Importing Distributor License, or
to apply for the transfer of an existing Distributor or Importing Distributor License. all questions must be answered. all attached
separate sheets must include the applicant’s name, the address of the establishment and license number. additional fees and
documents to be submitted with this application include:
     1. feeS MaDe paYaBLe To “pLCB” oR “CoMMoNWeaLTh of peNNSYLvaNIa.”
         a. The fee to transfer an existing license is $650.00 for person-to-person, $550.00 for place-to-place, oR $700.00
            for both person-to-person and place-to-place.
         b. The fees for a new license are:
             (1) filing fee of $700.00
             (2) License fee of $600.00 for a Distributor oR $1,350.00 for an Importing Distributor
          c. The fee for a Sunday Sales permit is $100.00.
     2. pLCB-1773, appendix Social Security Information MUST be submitted showing the Social Security Number(s),
        Name(s) and Title(s) of each individual applicant, partner, member, OR for a corporation of each officer, director,
        stockholder, and manager.
     3. PLCB-1898, Tax Certification Statement for the applicant AND if a person-to-person transfer or a double transfer,
        one from both the applicant and the current licensee.
         pLCB-1898a is required if a management company (any entity employed or otherwise contracted by the licensee
         or the applicant to operate, manage or supervise all or part of the operation of the licensed premises) is utilized.
         If a transfer application and if both buyer and seller use a management company, each company must submit the
         form.
     4. PLCB-2018, Criminal History Record Check for each individual applying as an individual licensee, or as a partner,
        or as a member, or as an officer of a corporation, or as manager, with a $10.00 remittance per form.
     5. Recent individual photographs, at least 1½” x 1½” in size, identified with the individual’s name, and applicant’s name
        and address of the premise on the reverse. The photograph(s) must have a matte finish.
     6. Recent premises photographs, 4” x 6” in size, showing the exterior of all premises to be licensed, identified with the
        applicant’s name and address of the premise(s). The photograph(s) must have a matte finish.
         The application may be considered prior to completion of alterations or construction. Submit a site plan on 8½” x 11”
         paper depicting the location of the premises proposed to be licensed as it will be after the alterations or construction
         are completed, depicting the location of the proposed premises in relationship to identifiable lines or easily identifiable
         landmarks or reference points with measurements to the property lines, landmarks or reference points. The plan must
         be clear and readable.
     7. If the application is for transfer, pLCB-21, application for Transfer of License and permit.
     8. owner of premises name, address, principals and their titles must be listed.


                                                       information

Do NoT SUBMIT aNY oTheR DoCUMeNT (e.g.; LeaSe, agReeMeNT) WITh ThIS appLICaTIoN paCKeT.
ShoULD YoU Be ReqUIReD To SUBMIT SUCh DoCUMeNTaTIoN, oTheR ThaN foR The INveSTIgaTINg
offICeR’S RevIeW, YoU WILL Be NoTIfIeD IN WRITINg.
If vehICLeS aRe USeD To TRaNSpoRT MaLT oR BReWeD BeveRageS, YoU aRe ReqUIReD To:
         1. Display on each side of each vehicle used to transport malt or brewed beverages, the license
            number (preceded by pLCB), the licensee name and address including the street name and number
            as shown on the license in letters no smaller than 4 inches in height.
         2. own or lease the vehicle used. The vehicle owner may not have any proprietary interest in any
            business licensed by the Board.
If YoU ReqUIRe aSSISTaNCe IN CoMpLeTINg The appLICaTIoN paCKeT, CaLL The LICeNSINg INfoRMaTIoN
CeNTeR aT (717) 783-8250, opTIoN #7.
SeND The appLICaTIoN paCKeT To: peNNSYLvaNIa LIqUoR CoNTRoL BoaRD, BUReaU of LICeNSINg,
p.o. BoX 8940, haRRISBURg, pa 17105-8940.

				
DOCUMENT INFO
Categories:
Tags:
Stats:
views:6
posted:2/15/2012
language:
pages:4
PermitDocsPrivate PermitDocsPrivate http://
About