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APPLICATION FOR RENEWAL OF ALCOHOLTC BEVERAGE LICENSE
NOTE: This application must be filed between 211197 and 3/31/97 with the Office of the Eoard of
License Commissioners for Montgomery County, 16650 Crabbs Branch Way, Rockville, .

Maryland, othenrvise Licensees filing late applications during the month of Apritfrray
be fined an amount not to exceed $50 for each day the application is late.
{-A

For the Use of: (Circle One) lndividual Partnership Unincorp. Assn.

Class of Current License: L Current License *:CBW ACAO/

Circle Beer Wine
One: Beer & Wine

Circle One: On Sale Only Off Sale Only OnlOff 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.
Pre s ident
a. Robert E" Sullivan 620 Ashton Rd. Ashton. Md. 2A861 (301) t-7L-6sso
(Name & Title) (Home Address/Zip Code) (Home Telephone #)
Vice President
b. Marilyn Goers 7732 Derwood Rd. Derwood Md- 20855 r 301 ) Rgg- ?7 R7
(Name & Title) (Home Address/Zip Code) (Home Telephone #)
Secretary
c. ElizjLbeth LrHeureux 14112 Chadwick T.p" Rockrrille, Mrl ?0R51 (?01) R:l-gtq7
(Name & Title) (Home Address/Zip Code) (Home Telephone #)

(2) Name of Corporation (lF APPLICABLE). Maryland Clubhorrse Serwi ces , rne .

(3) Trade Name: u/R

(Business Telephone #)
(4) Stockholders: C/O LEISURE WORLD COMMUNITY CORP. TRUSTEE

a. Name/Address Wallace V. Cunnen 3701 Rossmoor Blvd. S. S. MdShares Owned: t

c/0
LETSURE WORLD COIO,IUNITY CORP.
Name/AddrBSS Rohert .T. Kennprly ?70.1 Rns",n^or Rl.,,d S S, MdShafes Owned: I
c/o t TirQrlDF woRLD COI\O4UNITY CORP " " "
b.

Name/Add6gss John'j""-"HTh"es 3701 Rossmoor BIvd. S. S, l{d. Shares Owned: 1

d Name/Add[eSS r.ei sr.r'e Worl!--LouldatioJr 3701 Rosuno-or-B-hzd-Shares Owned: 4o7

S"S. Md.
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(5) Address of Licensed Premises' 370!-Ros smoor Blvd " S, S ' Md ' 20906
'lA/r/e hereby certify that the facts and information set forth in the application upon which the present
license was issued are unchanged: YES ( x ) No ( ) lf no, EXPLAIN on a separate piece of
paper

(7) Answer YES or NO: lf answer is YES, EXPLAIN on a separate piece of paper During the current
Ircense year, has the applicant(s) been convicted of any of the following:

(a) Violation of Liquor Laws Nrr (b) Violation of Gambling Laws No

(c) Commission of a Felony (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 ( ) NO (x):

If YES, EXPLAIN:

(9) What financial interest does the applicant(s) have in the business conducted under the present
license?Applicantisasubq.1d@ge!re!!agentforfeeownerof
licensed propertY,
(10) ls any other person or corporation in any way financially interested in the license applied for. or rn
the business to be conducted thereunder?
LI\rCC as Trustee owns fee to licensed premises"

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

NOTE: IF FILED AS A CORPORATE APPLICATION THE PRESIDENT OR VICE PRESIDENT

MUST ALSO SIGN UNDER SECTION (dI IN ADDITION TO SIGNING AS AN APPLICANT
UNDER SECTION (al. (b). OR (cl.

(a
(Signature of

Marilyn Qeorg

(Signature of Appl icant)

abeth L'Heureux

(Signature of President or Vice President)

Rob-ert E. Sullivan, President

THESE SIGNATURES MUST ALL BE NOTARIZED ON THE NEXT PAGE

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STATE OF MARYLAND/COUNTY OF - MolEeoMsRJ : ss:

THIS CERTIFIES that on this day of February 1997, before the subscriber, a
of -Uth-
Notary Public of the State v,'yl ancr , personally appeared Roberr Sillivan
Pre s i dent
Marilyn Georg, Vice PleS. , Elizabeth L'Heureux. Secy.
the applicant(s) named in this renewal application, and made oath in due form of law that the matters and
facts coniained in said application are true and correct.

WITNESS my hand and official seal.

(Seal)
Public Elizabeth A" L'Heureux

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 1997
- April 1998) lf this section is not completed, the attached Statement of Licensee must be completed.

IA/VE HEREBYCERT|FYthatlM/Earetheowner(s) of thepropertyknown?S 37oo possrcnnr Blvd.

Si Md.
1r'er Soring , named in the aforegoing renewal application made by Maryland
Clubhouse Ser. f nc. to the Board of License Commissioners.
ffirageLawsofMaryland;ThatlMeassenttothegrantingofthelicense
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 premrses
upon which the business is to be conducted, at any and all hours.

/.
{f#,//
wrtness. cttz* fownerlJz-<-Lk
(Residence)
C.P.*i/
r ^^ HurE
Date: g-/7- ?7
-="
(Owner). LWCC Trrrs l-ee of Comm tr'a n i I i r'i o q
(Residence) 3701 Rossmoor Blvd. S. S. Md. 20906

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.
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ELECTION OF OFFICERS FORM
CORPORATE MINUTES

l, Rohprr Tl Qrr-l-l i-r-- hereby certify that the following

(Name)

narned individuals are the present officers s1 Maryland Clubhouse Services , rnc.
(Corp. Name)

President Rnherr tr Srrl'lirz-qn

(Name)

Vice-President
Marilyn Georg
(Name)

Secretary Elizabeth A. L'Heurerrx

(Name)

Treasurer
(Name)

Signature of Applicant Robert E " Sullivan

Pres ident
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RATIO AFFIDAVIT
BEER. WINE & LIQUOR LICENSE. CLASS B. ON SALE ONLY
HOTEURESTAURANT - HOTEUMOTEL

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

Ted Barton
Food Service Director
(Title)

State of Maryland
. 55.

County of Montgomery

This certifies that on the 17th day of Februarlr 1997, before the
subscriber, a Notary of the State of Maryland, personally appeared, Ted Barton
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)

t/rl/t/ ts/a) &P,kc ilhr7

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AFFIDAVIT OF STATE TAX OBLIGATIONS

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.

Signature of Licensee
Robert E. Sullivan, Pres.
Maryland Clubhouse Services, Inc.
Printed Name of Licensee

February 17, 1997

Date

State of Maryland Maryland

: SS:
County of Montgomery Montgomery

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

February 1 997.

Public Elizabeth A. L 'Heureux

My Cornnission expires 8-1-L99q

(Seal)
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