Filing Letter to Board in Response to M Bennett Email with Exhibits 12 02 2024

Page 4 PLEASE ryPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER 2o2o.3i 4.1 027 oO2 IS THE NEAREST ENTRANCE OF THE PLACE TO BE LICENSED WITHIN 2OO FEET OF THE NEAREST Yes jL ENTRANCE OF ANY CHURCH OR SCHOOL? No IFTHE ANSWER iS'YES,' IS A WAIVER SIGNEO BYTHE APPROPRIATE OFFICIAL ATTACHED TO THIS Yes No APPLICATION? - _ _ DOES THE APPLICANT INTEND TO USE ANY VEHICLES FOR THE TRANSPORT OR DELIVERY OF YES NO (A TRANSIT INSIGNIA IS NECESSARY BEFORE ALCOHOLIC BEVERAGES? ALCoHOLIC BEVERAGES lvlAY BE TRANSPORTED.) -IL 4.3 - HAS THE APPLICANT FILED AN ANNUAL SPECIAL TAX REGISTRATION AND RETURN FORM (TTB F 5630,5) WITH THE FEDERAL ALCOHOL AND TOBACCO TAX AND TRADE BUREAU? _=No Only required if a change in the existing regisLration. I _l tF "YES," DATE FILED _ * _yes 4.4 wlLL ANY BUSINESS OTHER THAN THE SALE OF ALCOHOLIC BEVERAGES BE CONDUCTED ON THE Yes No PREMISES TO BE LICENSED? --I:!- IF THE ANSWER IS'YES,' INDICATE THE NATURE OF THE BUSINESS AND WHOwlLL CONDUCT IT BY RESPONDING TO THE FOLLOWING OUESTIONS: - -xrr- Applicant --rx- Restaurant Other catering Hotel/Motel other Other -APplicant _Amusements -Applicant _ N J. Lottery -Othea -Applicant Other _ Grocery or Delicatessen -Applicant -other Other (specify) country club xx npp1166n1 -Applicant -IIONTHE LICENSED 4.5 IF SOMEONE OTHERTHAN THE APPLICANT WILL OPERATE THE OTHER BUSINESS -Other PREMISES, ANSWER THIS QUESTION. IF THERE IS MORE THAN ONE INDIVIDUAL OR COMPANY, ATTACH A SEPARATE PAGE LISTING THE REOUESTED INFORMATION FOR EACH OPERATOR, Business to be operated Name of company/rndrvrdual StreetAddress Number State Municipality zip Street Name - NJ Sales Tax Certificate of Authority No