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opla-rev12312021 OFFICE USE ONLY 0 Original O Amended Date 49 16. List the floor(s) of the build Ing that the establishment Is located on: G_r_o_u_n_d_F_lo_o_r_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ._I 17. List the room number(s) the establishment ls located in within the building, if appropriate: N/A '------------------' 18. Is the premises located within 500 feet of three or more on-premises llquor establishments? 0Yes 19. WIii the license holder or a manager be physlcal!y present within the establishment during all hours of operation? 0 Yes O No 20. If this Is a transfer appllcatlon (an existing llcensed business 1s being purchased) provlde the name and serlal number of the llcensee: Name Serial Number 21. Does the appltcant or llcensee own the building in which the establishment Is located? 0 Yes (if YES, SKIP 23-26) 0No Owner of the Building In Which the Licensed Establishment Is Located 22. Building Owner's Full Name: F_B_B_T_/_U_S_P_ro~p_e_rt_ie_s_,_L_L_C_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ._I 23. Building Owner's Street Address: ~'7_9_7_8_C_o_o_p_e_r_C_r_e_e_k_B_lv_d_._#_1_00_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ 24. city, Town or VIiiage: ._Iu_n_l_ve_r_s_lty~P_a_rk_ _ _ _ _ _ _ _ _ _ _~I State: ~IF_L_ _ _ _ _ _ _ _ _~I Zip Code: ~I3_4_2_0_1_ _ _~ 25. Business Telephone Number of Building Owner: 11..7_1_6_-8_8_6~·-0_2_11_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.., 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 26. Representative/Attorney's Fuil Name: IJustin Juliano (Empire State Liquor Licensing) 27. Representative/Attorney's Street Address: P_._o_._B_o_x_1_9_2_0_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _... 1..I 28. City, Town or Village: ~IB_u_ff_a_lo_ _ _ _ _ _ _ _ _ _ _ _ _ _~ State: l~N_Y_ _ _ _ _ _ _~I Zip Code:!..._1_4_22_5_ _ __, 29. Business Telephone Number of Representative/Attorney: 11..7_1_6_-8_6_4_-_90_5_3_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ 30. Business E-mail Address of Representative/Attorney: E_m~p_ire_S_t_a_te_L_lq~u_o_r_Ll_c_e_ns_l_ng~@~g_m_a_ll_.c_o_m_ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ ._I I am the applicant or licensee holder or 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. 31. Printed Principal Name: 11..o_u_c_V_u_ _ _ _ _ _ _ _ _ _ _ _ _ _.., I Title: LLC Member Principal Signature: QJll Page 2 of 2