Licensee Certification For Temporary Extension of Licensed
Premises Onto Municipal Property
(To Be Included With Municipality Application)
SERIAL #
LICENSE TYPE
, NY ZIP CODE:
LICENSEE:
DBA (TRADE NAME):
ADDRESS OF THE PREMISES:
CITY:
BUSINESS EMAIL ADDRESS:
BUSINESS PHONE:
rev 06032020
(Signature of Applicant/Representative)
I,
Name of Certificant
hereby certify that I am a duly authorized principal or representative of the above-referenced
license (and if a representative, I am the ________________ [insert title] of the licensee), that I have
reviewed the attached diagram, also signed by me, depicting and identifying the municipal
property that my municipality is applying to temporarily become part of the licensed premises
(the “Municipal Extension”), and that the above-referenced licensee agrees that it will supervise
and maintain the Municipal Extension in accordance with the Alcoholic Beverage Control Laws
just as if such Municipal Extension was part of the licensed premises as set forth in the license,
including any and all Guidance issued by the State Liquor Authority with respect thereto, and
that the above-referenced licensee will also adhere to whatever other and further rules and
requirements are imposed by my municipality in connection herewith, and that the above-
referenced licensee will adhere to these requirements as long as the temporary Municipal
Extension remains in place (or until the above-refenced licensee delivers a written certification
to the Licensing Bureau of the State Liquor Authority expressly advising that such Municipal
Extension is being rejected), after which the above-referenced licensee will no longer be
permitted to treat the Municipal Extension as being part of the licensed premises.
(Date)
