.

)
STATE OF MARYLAND
(MONTGOMERY COUNTY)

APPLICATION FOR RENEWAL OF ALCOHOLIC BEVEMGE LICENSE

NOTE: This application must be filed between2ll/99 and 3/31/99 with the Offlce of the Board of
License Commissioners for Montgomery County, 16650 Crabbs Branch Way, Rockville
Maryland, otherwise Licensees filing late applications during the month of April may
be fined an amount not to exceed $50 for each day the application is late.
---:-:=-- --\-
For the Use of: (Circle One) lndividual Partnership , Q9p:I_q!gn Unincorp. Assn.
Class of Current License: Current License #: cBwLCCool

Circle Beer Wine

One: Beer & Wine L ee!-W!s_9!gye( cly!._, ll4I,J$ 9gq$rv _q I
tU
Circle One: On Sale Only Off Sale Only On/Off Sale Consumption

TO THE BOARD OF LICENSE COMMISSIONERS FOR MONTGOMERY COUNTY:

Application is made by the undersigned under the provisions of Article 28 of the Annotated Code of
Maryland, as amended, for a renewal of the license now held, and the applicant(s) submit(s) and certify(ies)
to the following information required thereby:

(1) Applicant(s): Give name(s) and residence(s): lf corporation, list all officers. PLEASE PRINT.
President
a. Robert F,- Srrl l irrpn 6?O Aqhtnn Bd. Ashton, M.l , ?OR6l (?O1) 77lr -Aoo0
6Jarne & Title) (Home Address/Zip Code) (Home Telephone #)
Vice President
b. lIaril,r,,n Georg 773? Dorwnnd Ri nor."^^,1 , M,1,. ^n85( (30'l) 899-3787..
(Name & Tilef (Home Address/Zip Code) (Home Telephone #)
Secretary
C. Il -izal_^eth T rHerrre,uxl_4_Ll2_ch,a-d.uj-c.Lla__Bocl.,-i 1i o, M.l . ?oRS3 (301) 8
(Name & Title) (Home Address/Zip Code) (Home Teiephone #)

(2) Name of coi-poration (lF AppllcAgt_f;. Irar-.r-r-and cr-ubhouse Services, rnc.

(3) Trade Name: N/A D(. ut-fSr.,,r

(Business Telephone #)
(4) Stockholders:

4,. Name/Add[eSS Wal.lace V. Cunnen 3701 Rossmoor Blvd. S.S. Mrl. _Shares Owned: r

c/o IEISURE \^IORLD COIfl{UNITY CORP.

b. Name/AddfOSS Roherr T- Konnrralz ?7ot Roccmnnr Rtv; e e. r'rr ShafeS Owned: t
c/o LEISURE WORLD C0IO{UNITY CORP.
Name/Add[8SS John Hines 3701 Rossmoor B]vd. S.S. IuId. Shares Owned: I

d. Name/Add;'ggg Lelsure World Foundation 3701 Rossmoor B1vd.

S.S. Md. Shares Owned:497
 A::ress of Licensed Premises: 3Zqo Rossmoor B1vd. S.S. Md. 2A9Ca
[,,\ry'e hereby certify that the facts and information set forth in the applicaiion .rpon whicn tre oreser:
.e'ss w,as issued are unchanged: YES ( x ) No ( ) lf no. EXPLAIN on a separaie p,ece of
pryer-

A AnsuerYES or NO: tf answer is YES, EXPLAIN on a separate piece of paper. During the cr-rrent
license year, has the applicant(s) been convicted of any of the following:

(a) Violation of Liquor Laws NO (b) Violation of Gambling Laws

(c) Commission of a Felony No (d) Violation of Rules/Regulations of Board NO

(e) Offense against Laws of Md. No (f) Offense against Laws of U.S. No

(8) During the current license year, have there been any convictions of any of the clerks, agents,
employees or servants of the licensee for violations of the Alcoholic Beverage Laws of the State of
Maryland or Montgomery County on the licensed premises? Answer YES ( )tttO ( ): x
If YES, EXPLAIN:

(g) What financial interest does the applicant(s) have in the business conducted under the present
license?

(10) ls any other person or corporation in any way financially interested in the license applied for, or in
the business to be conducted thereunder?
Li^IMC ad Trustee owns fee Lo licensed premises.

ALL APPLICANTS MUST SIGN UNDER SECTIONS a. b. or c BELOW

NOTE: VICE P
MUST ALSO SIGN UNDER SECTION (d) IN ADBITION TO SIGNING AS AN APPLICANT
UNDER SECTION (a). (b). OR (ci.

@) (7a,0 f .^ ,/t u
ignature icant)
of Appl
-^.,(S
' Robert E. {ullivan

(si Applicant,

(Signature of Appl icant)

Elizabeth Irllleurepl

(Signature of President or Vice President)

Robert E Sullivan, President
t)

STATEOF MARYI-AhID/COUNW OF MoNreoMsnv : ss:

THIS CERTIFIES that on this I rl, day of Ma rnh 1999 before the subscriber. a
Nota"r Public of the State of llarr'1and , personally appeared@-
Flizchot1. T rI-lo',-o,,*- (onr-

tne applicant(s) named in this renewal application, and made oath in due form of law that the matters and
facls contained in said application are true and correct.

WITNESS my hand and official seal.

(Seal)
Elizabeth LfHeureux

6-ra/
STATEMENT OF OWNER OF PREMISES

Required in connection with Alcoholic Beverage Laws of Maryland. (Not required if licensee has a lease on
the entire building in which the facility is located for not less than the term of the renewal license, May 1999
- April 2000) lf this section is not completed, the attached Statement of Licensee must be completed.

I/\/\/E HEREBY CERTIFY that lAffE are the owner(s) of the property known ?s 3700 Rossrnoor B1vd.
(i r 'etr eFri ng, Md,. named in the aforegoing renewal application made by ruaryle,d
Clubhouse Seivices, Inc. tO the BOard Of LiCenSe COmmiSSiOnerS.
Under the Alcoholic Beverage Laws of Maryland: That lAtVe assent to the granting of the license
applied for, that lAlVe hereby authorize the State Comptroller, his duly authorized deputies, inspectors and
clerks, the Board of License Commissioners for Montgomery County, its duly authorized agents and
employees, and any peace officers of said county to inspect and search, without warrant, the premises
upon which the business is to be conducted, at any and all hours.

.. .24/---
Witness:
(Residence) l/2-L/'
Date. 3- /s-- y'? (Owner) i-tntcc trustee or Facilities
Comm.
(Residence) qzo.r p^ocmnnr R'rrrrr - S s. Mrr 2oQ06

Extract from Section 16-501 of Article 28 of the Annotated Code of Maryland: lf any signed statement,
affidavit or oath required under the provisions of this Act shall contain any false statement, the offender
shall be deemed guilty of perjury, and upon indictment and conviction thereof, shall be subject to the
penalties provided by law for that crime.
 ELECTION OF OFFICERS FORM
CORPORATE MINUTES

l, Robert E. Sullivan hereby certify that the following

(Name)

named individuals are the present officers of Marvland Clubhouse Serviees----Ine-

(Corp. Name)

President Robert E. Sullivan

(Name)

Vice-President Marilyn Geor:g

(Name)

Secretary Elizabeth A. LrHeureux

(Name)

Treasurer
(Name)

?re s ii eii
Title
 AFFIDAVIT OF STATE TAX OBLIGATTONS

lA//e hereby agree to keep current all state and local tax obligations

including, but not limited to, state sales and use taxes, withholding taxes, and ad-

missions taxes.

MD STATE SALES TAX ACCOUNT NUMBER: OJ-OL/O 6/0

dL-?* r!
Signature of Licensee
oo.'

Robert E. Sullivan
Marvland Clubhouse Services. lnt:.
Printed Name of Licensee

March 15, L999

Date

State of Maryland i 1,1aryland

: SS:
County of Montgomery : Montgcmery

Subscirbed and sworn to before me, a Notary Public, this 154 day of

ila r ch 1 999.

Public Elizabeth A. LtHeureux

expires on 8- 1-200 1

(Seal)
 RATIO AFFIDAVIT
BEER. WINE & LIQUOR LICENSE. CLASS B. ON SATE ONLY
HOTEURESTAURANT . HOTEUMOTEL

lryehereby attest, under the penalty of perjury, that the gross receipts from the sale of alcoholic
beverages in the hotelirestaurant - hotel/motel for the twelve month period immediately preceding the
application for renewal did not exceed the gross receipts from the sale of food.

(s of Applicant)
Ted Barton
Food Service Director
(Title)

State of Maryland Maryland

SS:

County of Montgomery Montgomery

This certifies thai on the 2 day of Mqtnlr 1999. be:c'e :^e

subscriber. a Notary of the State of Maryland, personally appeared, Ted B:'rton

the applicant named in this food to alcoholic beverage ratio statement, and made oath in due form of law
that the matters and facts contained in said statement are true and correct.

Witness my Hand and Seal:

(sEAL)

Public Elizabeth A.
}leureux
L r

My Commission explres on B-0 1-200 1

 foSt oil-PREltIsE SSN: 229-08-soBJ
rssued: 06/23/1998 Expires: 06/15/2001
rD #: 87931{7 D.o.B.: 05/18/1962

IIARCIA GROI,E

1421s-302 CRAllo PRE RoAD

SILVER SPRII{G, ItD 20906

ilD E)(PIRRII0II IS: 06/15/2002

filliar Perez, ?1362, AB

ftPs' the TIPS (Training for

lntemention
successful completion of
Thiscard indicates
PruceduteS) PNgratu
For more uJorudon co:t"tt'
'-rIrL^
Healh Comilrnic3tlons
Suite I7U0
I l0l Wilson
Bouleraro
 o
Leisure World of Maryland Corporation
3701 Rossmoor Boulet'ard' Silver Spring, Marylattd 20906 !.: n{-3ol)598-1An

March 15, L999

Board of License Comilissi-oners

l-6650 Crabbs Branch WaY
Rockville, Md.20855
Gentlemen:
Enclosed ia Maryland Clubhouse Services, Inc. application for
renewal of our Alcoholic Beverage License and the $50.00 processing
fee. Also included is the Statement of owner of Premises, Election
of Corporate Officers form, Affidavit of State Tax obligations,
Ratio Affidavit and copy of Alcohol Awareness Cerlification.
These documents fuIfill our obligation for applicatj-on for rere;al-.

S incereli',

flJ)rL
Robert E. Sui-:-,'a:
General Ya:a;e:

RES/pmp