Knights of Columbus
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STATE OF NEW
EXECUTIVE DEPA
DMSION OF ALCOHOUC BE
STA TE LIQUOR AUTHORITY
tandardized NOTICE FORM forProvidinga
nee N ee /0 a Local Municipalltv or Community Board
with the submission to the Stale Liquor Authority of a (check one)
lication g'
Alteration Aoolication 0
1. Date the original copy ofthis Notice was mailed to the Local Municipality or Community Board:
THIS 3O-DAY ADVANCE NOTICE IS BEING PROVIDED TO THE CLERK OF THE FOLWWING LOCAL MUNICIPALlIY OR COMMUNITY BOARD
2. Name of the Local Municipality or Community Board: &
FOR'" APPLICUT8, PROVIDB D ata..o1r~TIOIf BBOWlr TO DATB
FOR ALTBMTlO. APPLICAJI'1'8, ATTACH COJIPLBTB ~AlIDDWHtQf 01' l'R.01'OUD ALTBMTIOW(8)
I'OR CO'JtRIJI'l' UtC1UIIdlB8. 8BT ...,. APJIIIOVD IIII!'IIOD 01' OPBRATlOlf OlU.Y
DO ItOT lJU TIIJ8 POD TO 'lOUR IIBTIIOD OF OPBRATlOW
3.
Type(s) of alcohol sold or to be sold under the license
("X"g:
D Beer Only
D Wine and Beer Only
~ Liquor, Wine, and Beer
4.
Extent of
food seNice:
("X"g
II Restaurant (Sale of food primarily; Full food menu;
Kitchen run by chef)
Tavern / Cocktail Lounge / Adult Venue / Bar (Alcohol sales primarily-
meets legal minimum fuod availability requirements)
5.
Type of
establishment:
D Hotel D Live. D Disk
MusIC Jockey
D Juke
Box
D Patron Dancing D Cabaret, Night Club, Discotheque
(Small Scale) (Large Scale Dance Club)
D Capacity for 600
or more patrons
("X"all
that apply)
'"
fVI Club (e.g. Golf / 0 Bed &
~ Fraternal arg.) Breakfast
IVl Catering
D Facility
D Karaoke 0 Top-
Bar less
Ent.
o
Restaurant
D Recreational Facility
(Sports Facility /VesseQ
6.
Licensed
outdoor area:
~ None D Rooftop
D Patio
or Deck
D Freestanding
Covered Structure
D Garden /
Grounds
D Sidewalk
Cafe
7. Will the license holder or a manager be physically present within the establishment during all hours of operation?
8. License serial number:
10.
11.
12.
14.
The establishment is located on the fo11owing floor(s) of the building at the above address:
IX!
13. City, Town, or Village:
15. Within the building at the above address, the establishment is located within the room(s) numbered as follows:
16. Business telephone number of app1icant/licensee:
17. Business fax number of applicant/licensee:
18. Business e-mail address of applicant/licensee:
19.
Does the app1icant or license holder
own the building in which the
establishment is located? ( "X" 2IW
Yes .Kf
If "YES', SKIP items No. 20-23.
Complete the 3 entries
at Item No. 24.
NoD
If"NO", ANSWER items No. 20-23,
and complete the 3 entries
at Item No. 24.
OWNER OF THE BUIIDING IN WHICH THE UCENSED ESTABUSHMENr IS LOCATED
20. Building owner's full name is:
21. Building owner's street address:
23. Business telephone number of building owner:
22. City, Town, or Village:
1 am the applicant or hold the license or am a prindpal of the legal entiW that holds or ill applying lOr the license. Representatioos in this 10rm are in confOrmity with
representations made in submitted documents relied upon by the Authority when granting the!iQense. I understand that representatioos made in this form will also be
relied upon, and that itIse representations may result in disapproval of the application or revooatlon of the license.
24. By my signature, I a1Iirm - under PeaaIty or P'wjIuy - that the repreaentations made in this form are true.
l'rin1lld Name
f ) ~ 1-), Scho)1..-
I'll r
x
SignatUre
,.
TOWN CLERK
Chris Masterson
DEPUTY SUPERVISOR
William H. Beale
~
TOWN OF WAPPINGER
20 MlDDLEBUSH ROAD
W APPlNGERS FALLS, NY 12590
WWW.TOWNOFWAPPlNGER.US
(845) 297-4158 - Main
(845) 297-5771 - Direct
(845) 298-1478 - Fax
TOWN BOARD
William H. Beale
Vincent Bettina
Ismay Czarniecki
Joseph P. Paoloni
Office of the Town Clerk
August 10, 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
The 4065 Club, Inc., located at 339 Route 82, Hopewell Jct., 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,
JCMlcf