4 Mijas
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STATE OF NEW YO
EXECUTIVE DEPARTM
DIVISION OF ALCOHOUC DEVERA
STATE UQUOR AUTOO
.zed NOTICE FORM forProvidinga
o ce to a Local Municioalitv or Community Board
submission to the State Liquor Authority of a (check one)
Renewal A lication 0
I. Date the original copy of this Notice was mailed to the Local Municipality or Community Board:
THIS 3O-DAY ADVANCE NOTICE IS BEING PROVIDED TO THE CLEt6< OF THE FOLLOWING LOCAL MUNlClPAUTY OR COMMUNITY BOARD
2.
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I'ORIIIIW ~ novJDII ~IOIIIIIIJAJ!IrU8llllGALL ~TlOII"" TOOA....
I'OR AL'l'BRATlOII ~A""ACB ~~ AJrD DWHWIOI' J'RClIlO8BD ALTBRATlOIf(8}
.oR (lOItItUT L~, ., ....~ 8'l'BOD 01' OI'BRATlOII OIILY
00 JIO'l' ....,... PORII TO QallGaYoua 8'l'BOD 01' OI'BRA.'I'IOII
Type(&) of alcohol sold or to be sold under the license D Beer Only 0 Wine and Beer Only ~ liquor, Wine, and Beer
("X"Jl!!!<l: IAJ
~ Restaurant (Sale of food primarily; Full food menu; D Tavern / Cocktail Lounge / Adult Venue / Bar (Alcohol sales primarily -
Kitchen run by chef) meets legal minimum food availability requirements)
Name of the Local Municipality or Community Boord:
3.
4.
Extent of
food service:
("X".!m)
5.
Type of
establishment:
D H tel I\iI live. 0 Disk
o ~ MuSIC Jockey
D Juke 0 Patron Dancing 0 Cabaret, Night Club, Discotheque
Box (Small Scale) (Large Scale Dance Club)
D Capacity for 600
or more patrons
("X" all
that apply)
O Club (e.g. Golf / 0 Bed &
Fraternal Org.) Breakfast
O catering
Facility
O Karaoke 0 ~o:
Bar Ent.
~ Restaurant
O Recreational Facility
(Sports Facility/Vessel)
,
6.
licensed
outdoor area:
D 0 ru Pati
None Rooftop Ln or ~k
O Freestanding
Covered Structure
O Garden /
Grounds
O Sidewalk
Cafe
7. Will the license holder or a manager be physically present within the establishment during all hours of operation? ('X" Jl!!!<l:
8.
10.
11.
12.
13.
City, Town, or Village:
The establishment is located on the following Ooor(s) of the building at the above address:
Within the building at the above address, the establishment is located within the room(s) numbered as follows:
Zip Code: \8590
14.
15.
16.
Business telephone number of applicant/licensee:
17.
Business fax number of applicant/licensee:
18.
Business e-mail address of applicant/licensee:
19.
Does the applicant or license holder
own the building in which the
establishment is located? ( "X" Jl!!!<l
If "YES", SKIP items No. 20-23.
Complete the 3 entries
at Item No. 24.
If "NO", ANSWER items No. 20-23,
and complete the 3 entries
at Item No. 24.
Yes 0
No~
OWNER OFTHE BUIlDING IN WHICH THE UCENSED ESTABUSHMENT IS LOCATED
21.
20. Building owner's full name is:
22.
City, Town, or Village:
23.
Business telephone number of building owner:
24.
1 am the applicant or hold the 1i<:enae or am Ii, principal of the lepl entity that boIds or Is appq.ing fOr the 1icen8e. Representations in this form are in conformity with
representations made in submitted documents re1ied upon by the Authority when granting the 1iccnlle. I uttderstand that repreaentatlons made in this form will also be
reUed upon, and that false representations may remit in disapproval of the appllcatlon or revocation of the Jlc:ense.
By my signature, 1 aftirm - under ~ oflWJu7 - that the repreaentatlons made in this form are true.
Title
OU) '(\'€- t...
..
TOWN CLERK
Chris Masterson
TOWN SUPERVISOR
Christopher J. Colsey
20 MlDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
WWW.TOWNOFWAPPINGER.US
(845) 297-4158 - Main
(845) 297-577] - Direct
(845) 298-]478 - Fax
TOWN BOARD
William H. Beale
Vincent Bettina
lsmay Czarniecki
Joseph P. Paoloni
Office of the Town Clerk
April 13, 2011
New York State Liquor Authority
80 South Swan Street
Suite 900
Albany, New York 12210
Attn: Renewals
Dear Sirs:
Please be advised that the Town Board of the Town of Wappinger has been notified by
Tammy Moniz (4 Mijas), located at 150 Osborne Hill Rd, Wappingers Falls, New York,
of intention to file an application with the New York State Liquor Authority.
As this location is within the Town of Wappinger, the Town Board has received and
directed that this application be placed on file with no comment.
Sincerely,
rlRf!?
Town Clerk
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