Supporting Documentation · Jan 8, 2025
Exhibit A 1 Amendment application filed 4 10 24
d0597015545aa2f0bd7182b46c36971276e239813d9049ea6efb54ad672f2078Indexed text · page 5
Show all pagesPage 4 PLEASE TYPE OR PRINT ALL INFORMATION 0722 33 015 001 STATE ASSIGNED LICENSE NUMBER - od - 4.4 42 43 44 45 \S THE NEAREST ENTRANCE OF THE PLACE TO BE LICENSED WITHIN 200 FEET OF THE NEAREST ENTRANCE OF ANY CHURCH OR SCHOOL? Yes No IF THE ANSWER IS “YES,” IS A WAIVER SIGNED BY THE APPROPRIATE OFFICIAL ATTACHED TO THIS. APPLICATION? Yes No DOES THE APPLICANT INTEND TO USE ANY VEHICLES FOR THE TRANSPORT OR DELIVERY OF ALCOHOLIC BEVERAGES? Yes No (A TRANSIT INSIGNIA IS NECESSARY BEFORE ALCOHOLIC BEVERAGES MAY BE TRANSPORTED.) 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? Yes No 6 IF “YES,” DATE FILED Z / / fe WILL ANY BUSINESS OTHER THAN THE SALE OF ALCOHOLIC BEVERAGES BE CONDUCTED ON THE PREMISES TO BE LICENSED? __X_ Yes No IF THE ANSWER IS “YES,” INDICATE THE NATURE OF THE BUSINESS AND WHO WILL CONDUCT IT BY RESPONDING TO THE FOLLOWING QUESTIONS: ___ Restaurant pout Applicant ___ Other ___ Catering ___ Applicant ___ Other __ Hotel/Motel ___ Applicant _____ Other _____ Amusements ___ Applicant ___ Other ___N.J. Lottery ____ Applicant ___ Other ____ Grocery or Delicatessen __ Applicant ___ Other _x Other (specify) golf course x Applicant ____ Other IF SOMEONE OTHER THAN THE APPLICANT WILL OPERATE THE OTHER BUSINESS ON THE LICENSED PREMISES, ANSWER THIS QUESTION. IF THERE IS MORE THAN ONE INDIVIDUAL OR COMPANY, ATTACH A SEPARATE PAGE LISTING THE REQUESTED INFORMATION FOR EACH OPERATOR, Business to be operated Name of company/individual (Last Name, First Name or Corporate Name) Street Address Number Street Name Municipality State Zip - NJ Sales Tax Certificate of Authority No.
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- Sep 29, 2026
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