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(7/23) RENEWAL OF LIQUOR LICENSE OR PERMIT APPLICATION FOR LIQUOR DIVISION USE ONLY Customer Trf from: Reviewer: Initials Date Agent: / / Mgr: / / To be completed by City / Town / County Clerk Local License License Fees Annual Fee: Date filed with clerk: Prorated Fee: Advertising Dates: (2 Consecutive Weeks Prior to Hearing) Transfer Fee: Publishing Fee: Public Hearing Date: Publishing Fee Direct Billed to Applicant: License Term: / / Through / / Month Day Year Month Day Year LICENSING AUTHORITY: Begin publishing As W.S. 12-4-104(d) specifies: NO LICENSING AUTHORITY SHALL APPROVE OR DENY THE APPLICATION UNTIL THE LIQUOR DIVISION HAS CERTIFIED THE APPLICATION IS COMPLETE. Applicant (Business Name): Doing Business As (DBA) / Trade Name: Building to be licensed / Building Address: (Address Number, and Suite or Unit Number, and Street or Road Name) City State Zip County Local Mailing Address: (Address Number or PO Box, and Suite or Unit Number, and Street or Road Name) City State Zip County Local Business Telephone Number: Fax Number: Business E-Mail Address: Business Primary Contact: First Name Last Name FILING IN (CHOOSE ONLY ONE) FILING AS (CHOOSE ONLY ONE) CITY / TOWN OF: INDIVIDUAL LP LLP LLLP PARTNERSHIP POLITICAL SUDIVISION COUNTY OF: CORPORATION (INC) ORGANIZATION LLC LC OTHER TYPE OF LICENSE OR PERMIT (CHOOSE ONLY ONE) RETAIL LIQUOR LICENSE RESTAURANT LIQUOR LICENSE MICROBREWERY PERMIT BAR AND GRILL LIQUOR LICENSE WINERY PERMIT PRIMARY BUSINESS TYPE RESORT LIQUOR LICENSE MANUFACTURER SATELLITE PERMIT (CHOOSE ONLY ONE) WINERY SATELLITE PERMIT ON-PREMISE BAR LIMITED RETAIL LIQUOR LICENSE (CLUB) COUNTY MALT BEVERAGE PERMIT OFF-PREMISE PACKAGE STORE VETERANS CLUB SPECIAL MALT BEVERAGE PERMIT FRATERNAL CLUB ON & OFF PREMISE BAR & PACKAGE STORE GOLF CLUB SOCIAL CLUB SPECIAL STATUTORY DESIGNATIONS (CHOOSE ONLY ONE) COMMERCIAL AIRPORT (W.S. 12-4-201(d)(iv) RESORT (W.S. 12-4-401(iv) / 12-5-201(f)) GOLF CLUB (W.S. 12-5-201(f)) GOLF CLUB-POLITICAL SUBDIVISION (W.S. 12-4-301(e) / 12-5-201(f)) GUEST RANCH (W.S. 12-5-201(f)) OPERATIONAL STATUS (To Assist the Liquor Division with scheduling inspections (W.S. 12-1-101(a)(xxi) / 12-2-301(c) / 12-4-103(a)(iv))) FULL TIME MONTHS OF OPERATION from to All Year (Jan-Dec) SEASONAL DAYS OF WEEK OF OPERATION: from to Every Day (Mon-Sun) NON-OPERATIONAL / PARKED HOURS OF OPERATION from to 24 Hours a Day ---PAGE BREAK--- (7/23) ALL APPLICANTS MUST COMPLETE QUESTIONS 1- 3 1. BUILDING OWNERSHIP: W.S. 12-4-103(a)(iii) Does the Applicant own or lease the licensed building? The Applicant OWNS the licensed building. YES (own) The Applicant LEASES the licensed building. YES (lease) The Lease is current and on file with the licensing authority and Liquor Division. YES NO If the building is leased and the lease is not current, please submit a copy of the lease and indicate: Lease term expiration date; located on Note: The lease term MUST continue at least through the term of the liquor license or permit (ii) Sales provision for alcoholic or malt beverages: located, on paragraph____________. Note: The lease MUST contain a provision for SALE OF ALCOHOLIC or MALT BEVERAGES. 2. LIQUOR BUSINESS CONTROL: W.S. 12-4-601(b) To operate the liquor business, has the business or license/permit been assigned, leased, transferred or contracted with any other person (entity) to operate and assert total or partial control of the license or permit or the licensed building? YES NO If the answer was YES to 2(a) above, explain fully and submit any documents in connection there within. 3. INTEREST IN LICENSE OR PERMIT: W.S. 12-5-401, 12-5-402, 12-5-403 Does any alcohol manufacturer, brewer, rectifier, wholesaler, or through a subsidiary affiliate, officer, director or member of any such firm: Hold any interest in the license/permit applied for? YES NO Furnish by way of loan or any other money or financial assistance for purposes hereof in the business? YES NO Furnish, give, rent or loan any equipment, fixtures, interior decorations or signs other than standard brewery or manufacturer's signs? YES NO If the answer was YES to any of the above, explain fully and submit any documents in connection there within. 4. RETAIL LIQUOR LICENSE-COUNTY LOCATIONS ONLY: W.S. 12-4-201(f)(ii) Is the licensed building within five miles of an incorporated town or city? YES NO 5. RETAIL LIQUOR LICENSE-COMMERCIAL SERVICE AIRPORTS ONLY: W.S. 12-4-201(m) Will food and beverage services be contracted or subcontracted? YES NO 1. If YES to is a copy of the current food and beverage contract on file with the licensing authority and Liquor Division? YES NO 2. If NO to please attach a copy of the current contract. 6. RESTAURANT LIQUOR LICENSE ONLY: W.S. 12-4-407(a) / W.S. 12-4-408 Gross sales figures and percentages of income derived from: (Line 1) Liquor Sales: (Line 2) Food Sales: (Line 1 + Line 2 must = Line 3) (Line 3) Gross Sales: Is a copy of the valid food service permit or the approved permit application attached? YES NO 7. BAR AND GRILL LICENSE LIQUOR LICENSE ONLY: W.S. 12-4-413(a) / W.S. 12-4-413(h),(j),(k) Gross sales figures and percentages of income derived from: (Line 1 + Line 2 + Line 3 must = Line 4) (Line 1) Liquor Sales: (Line 2) Food Sales: (Line 3) Entertainment Sales: (Line 4) Gross Sales: Is a copy of the valid food service permit or the approved permit application attached? YES NO 8. MICROBREWERY PERMIT ONLY: PRODUCTION AND WHOLESALE DISTRIBUTION Did the microbrewery at this location produce at least 50 barrels (1,550 gallons) but less than 50,000 barrels 550,000 gallons) during the previous license term? (W.S. 12-1-101(a)(xix)) YES NO Are microbrewery products from this location being distributed to other alcohol retailers in Wyoming? (W.S. 12-2-201(a)) YES NO If YES, a wholesale malt beverage license from the Liquor Division will be required. ---PAGE BREAK--- (7/23) 9. RESORT LIQUOR LICENSE: W.S. 12-4-401 through W.S. 12-4-403(b) Does the resort complex: Have an actual valuation of at least one million dollars, or have committed or expended at least one million dollars ($1,000,000.00) on the complex, excluding the value of the land? W.S. 12-4-401(b)(i) YES NO Include a restaurant and a convention facility; a convention facility that will seat at least one hundred (100) persons? W.S. 12-4-401(b)(ii) YES NO Include motel, hotel or privately owned condominium, town house or home accommodations approved for short term occupancy with at least one hundred (100) sleeping rooms? W.S. 12-4-401(b)(iii) YES NO If no on question have a ski resort facility open to the general public in which has been committed or expended not less than 10 million dollars ($10,000,000.00)? W.S. 12-4-401(b)(iv YES NO Will food and beverage services be contracted or subcontracted? W.S. 12-4-403(b) YES NO 1. If YES to is a copy of the current food and beverage contract on file with the licensing authority and Liquor Division? YES NO 2. If NO to please attach a copy of the current contract. 10. LIMITED RETAIL (CLUB) LIQUOR LICENSE: FRATERNAL CLUBS W.S. 12-1-101(a)(iii)(B) Has the fraternal organization been actively operating in at least thirty-six (36) states? YES NO Has the fraternal organization been actively in existence for at least twenty (20) years? YES NO 11. LIMITED RETAIL (CLUB) LIQUOR LICENSE: VETERANS CLUBS W.S. 12-1-101(a)(iii)(A) Does the Veteran’s organization hold a charter by the Congress of the United States? YES NO Is the membership of the Veteran's organization comprised only of Veterans and its duly organized auxiliary? YES NO 12. LIMITED RETAIL (CLUB) LIQUOR LICENSE: GOLF CLUBS W.S. 12-1-101(a)(iii)(D) / W.S. 12-4-301(e) Does the golf club have more than fifty (50) bona fide members? YES NO Does the Applicant, maintain, or operate a bona fide golf course together with a clubhouse? YES NO Is the Applicant a Political Subdivision of the state that owns, maintains, or operates this golf course YES NO 1. Will food and beverage services be contracted or subcontracted? W.S. 12-4-301(e) YES NO 2. If YES to is a copy of the current food and beverage contract on file with the licensing authority and Liquor Division? YES NO 3. If NO to please attach a copy of the current contract. 13. LIMITED RETAIL (CLUB) LIQUOR LICENSE: SOCIAL CLUBS W.S. 12-1-101(a)(iii)(E) / W.S. 12-4-301(b) Does the club have more than one hundred (100) bona fide members who are residents of the county in which the club is located? YES NO Is the social club incorporated and operating solely as a nonprofit organization under the laws of this state? YES NO Is the club qualified as a tax-exempt organization under the Internal Revenue Service? YES NO Has the club been in continuous operation for a period of not less than one year? YES NO Has the club received twenty-five dollars ($25.00) from each bona fide member as recorded by the secretary of the club and are club members at the time of this application in good standing by having paid at least one full year in dues? YES NO Does the club hold quarterly meetings and have an actively engaged membership carrying out the objectives of the club? YES NO Is a true copy of the club bylaws on file with the licensing authority and Liquor Division? YES NO 1. If NO to please attach a current copy the club bylaws. Is a detailed statement with itemized expenditures of the club’s activities during the last year attached? YES NO 14. If the Applicant is Filing As an Individual, Partnership, Political Subdivision, Organization or Other: W.S. 12-4-102(a)(ii) & (iii) Each individual, partner or club officer must complete all of the information below. (If more information is required, list on a separate piece of paper and attach to this application.) True and Correct Name Date of Birth Residence Address No. & Street City, State & Zip DO NOT LIST PO BOXES Residence Phone Number Have you been a DOMICILED resident for at least 1 year and not claimed residence in any other state in the last year? Have you been convicted within the previous 10 years of: a Felony Violation Relating to Alcoholic Liquor or Malt Beverages? any Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO ---PAGE BREAK--- (7/23) 15. If the Applicant is Filing As a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: W.S. 12-4-102(a)(iv) & Each stockholder holding, either jointly or severally, ten percent (10%) or more of the outstanding and issued capital stock or ownership of the corporation, limited liability company, limited liability partnership, or limited partnership. Each Officer, Director or LLC member must complete all of the information below. (If more information is required, list on a separate piece of paper and attach to this application) True and Correct Name Date of Birth Residence Address No. & Street City, State & Zip DO NOT LIST PO BOXES Residence Phone Number No. of Years in Corp or LLC % of Corporate Stock or Ownership Held Have you been convicted within the previous 10 years of: a Felony Violation Relating to Alcoholic Liquor or Malt Beverages? any Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO REQUIRED ATTACHMENTS: A copy of any lease agreements. W.S. 12-4-103(a)(iii) Bar & Grill and Restaurant liquor license Applicants: attach a copy of the current Food Service Permit or the approved permit application for the Applicant and for the licensed building location. 12-4-413(a) / W.S. 12-4-407(a) If food and beverage services will be contracted or subcontracted attach a copy of the contract or lease agreement W.S. 12-4-201(m) / W.S. 12-4-301(e) / W.S. 12-4-403(b) OATH OR VERIFICATION Requires signatures by ALL Individuals, ALL Partners, ONE LLC Member, or TWO Corporate Officers or Directors except that if all the stock of the corporation is owned by ONE individual then that individual may sign and verify the application upon his oath, or TWO Club Officers. W.S. 12-4-102(b) Under penalty of perjury, and the possible revocation or cancellation of the license, I swear the above stated facts, are true and accurate. STATE OF WYOMING ) ) SS. COUNTY OF ) Signed and sworn to before me on this day of that the facts alleged in the foregoing instrument are true by the following: 1) (Signature) (Printed Name) Title 2) (Signature) (Printed Name) Title 3) (Signature) (Printed Name) Title 4) (Signature) (Printed Name) Title 5) (Signature) (Printed Name) Title Witness my hand and official seal: Signature of Notary Public (SEAL) My commission