HomeMy WebLinkAboutRogue Creek Cidery notice to Town of application for NYSLA licenserev 1/22/16 OFFICE USE ONLY
10 Original O Amended Date
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State
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State Liquor Standardized NOTICE FORM for Providing 30-Daiy Advanced Notice to a
STATE OF {,,
OPPORTUNRY AlitflOflt
y Local Municipality or Communitv Board,
(Pane 1 of 2 )
1. Date Notice Was Sent: 12/19/2018 I 1 a. Delivered by: Personal Delivery with Proof of Receipt
2. Select the type of Application that will be filed with the Authority for an On -Premises Alcoholic Beverage License
X❑ New Application ❑ Renewal ❑ Alteration ❑ Corporate Change ❑ Removal ❑ Class Change
For New applicants, answer each question below using all information known to date.
For Renewal applicants, set forth your approved Method of Operation only.
For Alteration applicants, attach a complete written description and diagrams depicting the proposed alteration(s).
For Corporate Change applicants, attach a list of the current and proposed corporate principals.
For Removal applicants, attach a statement of your current and proposed addresses with the reason(s) for the relocation.
For Class Change applicants, attach a statement detailing your current license type and your proposed license type.
This 30 -Day Advance Notice is Being Provided to the Clerk of the following Local Municipality or Community Board
3. Name of Municipality or Community Board:lDanby
Applicant/Ucensee Information
4. License Serial Number, if Applicable: I
S. Applicant or Licensee Name: (Jordan Estate -Vineyard & Orchard,LLc
6. Trade Name (if any): lRogue Creek Cidery
7. Street Address of Establishment: 1292 East Miller Rd
8. City, Town or Village: 1Danby
9. Business Telephone Number of Applicant/Licensee: 11-347-419-9373
10. Business Fax Number of Applicant/Licensee: none
11. Business E-mail of Applicant/Licensee: lroguecreek2018@gmaii.com
IExpiration Date, if Applicable: 1
I ,NY Zip Code :114850
12. Type(s) of Alcohol sold or to be sold: ❑X Beer & Cider F� Wine, Beer & Cider E] Liquor, Wine, Beer & Cider
13. Extent of Food Service: ❑ Full food menu; ❑ Menu meets legal minimum food availability requirements;
Full Kitchen run by a chef or cook Food prep area at minimum
14. Type of Establishment: (Farm operation with Cidery
15. Method of Operation: 0 Seasonal Establishment ❑ Juke Box ❑ Disc Jockey [] Recorded Music ❑ Karaoke
(Check all that apply) 0 Live Music (Give details: i.e, rock bands, acoustic, jazz, etc.): (country music
❑ Patron Dancing ❑ Employee Dancing ❑ Exotic Dancing ❑ Topless Entertainment
❑ Video/Arcade Games ❑ Third Party Promoters Security Personnel
❑ Other (specify): l
16. Licensed Outdoor Area: ❑ None ❑ Patio or Deck ❑ Rooftop E]Garden/Grounds ❑ Freestanding Covered Structure
(Check all that apply) ❑ Sidewalk Cafe ❑ Other (specify): IGardenlYgrouMs "Ar' 1
�,, a €Tint Form
rev 1/22/16 OFFICE USE ONLY
Q Original 0 Amended Date l
rrifwvYo�iK State Liquor standardized NOTICE FORM for Providing 30-Dav Advanced Notice to a
u►+m Local Municivality or Community Board
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17. List the floor(s) of the building that the establishment is located on: ground floor
18. List the room number(s) the establishment is located in within the Inside remodelled farm equipment post/beam barn.
building, if appropriate:
19. Is the premises located within 500 feet of three or more on -premises liquor establishments? OYes QNo
20. Will the license holder or a manager be physically present within the establishment during all hours of operation? QYes 0 No
21. If this is a transfer application (an existing_ licensed business is being_ purchased) provide the name and serial number of the licensee.
22. Does the applicant or licensee own the building in which the establishment is located? Q Yes (If Yes SKIP 23-26) 0 No
Owner of the Building in Which the Licensed Establishment is Located
23. Building Owner's Full Name:
24. Building Owner's Street Address:
25. City, Town or Villager I State: I I Zip Code :I
26. Business Telephone Number of Building Owner:
Representative or Attorney representing the Applicant in Connection with the
application for a license to traffic in alcohol at the establishment identified in this notice
27. Representative/Attorney's Full Name: INONE
28. Street Address:
29. City, Town or Village: I State: I Zip Code :I
30. Business Telephone Number of Representative/Attorney:'
31. Business Email Address:
I am the applicant or hold the license or am a principal of the legal entity that holds or is applying for the license. Representations
in this form are in conformity with representations made in submitted documents relied upon by the Authority when
granting the license. I understand that representations made in this form will also be relied upon, and that false representations
may result in disapproval of the application or revocation of the license.
By my signature, I affirm - under Penalty of Perjury- that the representations made in this form are true.
32. Printed Name:D LJORDAN�,.�� Title (PRESIDENT
Signature: X
I Print Form N
Proof of Service Form
Directions: Please complete this form and attach to document when a Proof of Service
by Personal Delivery is required. Retain a copy for your records.
PERS DELIVERY
On te) , I personally delivered the attached to
(Employee`s amel at
(Departure t/Location) /
Briefly explain document being hand delivered.
STANDARDIZED NOTICE FORM; WHICH IDENTIFIES ESTABLISHMENT
OF A CIDERY ON THE FARM LOCATED AT 293 EAST MILLER RD
I declare that I am over the age of 18 years. I also declare under penalty of perjury that
the foregoing is true and correct and that this declaration was executed on:
2/19/2018 (Date)
V�r401-7
(Tuve or Printed Name)
A, NY
f�
(Signature)