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WLD-28 (1/16) RENEWAL OF LIQUOR LICENSE OR PERMIT APPLICATION To be completed by the City, Town or County Clerk: Date Filed With Clerk: / / Annual Fee Prorated Fee Basic Fee: $ . $ . Add’l Dispensing Room Fee: $ . $ . Transfer Fee: $ . Total License Fee Collected $ . $ . Publishing Fee Collected: $ . Publishing Fee Amount: Advertising Dates (2 wks): Hearing Date: / / LICENSE TERM: «Begin_Date» Through: «End_Date» A copy must be immediately forwarded to: State of Wyoming Liquor Division 6601 Campstool Rd. Cheyenne WY 82002-0110 Applicant: Trade Name (dba): Premise Address: Number & Street City State Zip County Mailing Address: Number & Street or P.O. Box City State Zip Business Telephone Number: Fax Number: E-Mail Address: 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. FILING IN TYPE OF LICENSE OR PERMIT To Assist the Liquor Division with (CHOOSE ONLY ONE) scheduling inspections: City of Douglas RETAIL LIQUOR LICENSE WHEN DO YOU OPERATE? ON-PREMISE ONLY (BAR) OFF-PREMISE ONLY (PACKAGE STORE) NON-OPERATIONAL/PARKED FILING AS (CHOOSE ONLY ONE) COMBINATION ON/OFF PREMISE (BOTH BAR & PACKAGE STORE) FULL TIME (e.g. Jan through Dec) INDIVIDUAL LLC RESTAURANT LIQUOR LICENSE PARTNERSHIP LLP RESORT LIQUOR LICENSE SEASONAL/PART-TIME CORPORATION BAR AND GRILL LTD PARTNERSHIP LIMITED RETAIL (CLUB) (specify months of operation) ASSOCIATION FRATERNAL CLUB ORGANIZATION VETERANS CLUB from to SOCIAL CLUB GOLF CLUB DAYS OF WEEK (e.g. Mon through Sat) MICROBREWERY WINERY DISTILLERY SATELLITE HOURS OF OPERATION (e.g. 10a - 2a) WINERY SATELLITE COUNTY RETAIL or SPECIAL MALT BEVERAGE PERMIT Minimum Purchase Requirement: RETAIL LICENSE HOLDERS: Have you purchased $2,000 in spirits, wines and/or malt beverages during the previous license term? YES NO RESTAURANT, RESORT, CLUB, COUNTY MALT, OR BAR AND GRILL LICENSE HOLDERS: Have you purchased $500 in spirits, wines and/or malt beverages during the previous license term? YES NO W.S.12-4-103(c) 1. DISPENSING ROOM DESCRIPTION WITH DIMENSIONS: Give a description with dimensions of the dispensing room and state where it is located within the building (e.g. 10 x 12 room in SE corner of building). If the building is not in existence, also provide an architect's drawing or suitable plans of the room and premises to be licensed: W.S. 12-4-102(a)(i) If Winery or Microbrewery, also list the manufacturing facility.(e.g. MFG: 10’ X 12’ room in SW portion of bldg.) Do you have an additional dispensing room? YES NO If yes, provide description and location: Provide the legal description and the zoning of the site where the applicant will conduct business: 2. Have there been any changes in the physical location of the dispensing room since the last application was filed? YES If YES, please submit a drawing of the new dispensing room. NO Do you anticipate any changes in the next twelve (12) months? YES If YES, please submit a drawing of the new dispensing room. NO 3. BUILDING OWNERSHIP: Does the applicant? W.S. 12-4-103 (iii): OWN the building in which sales room is located? YES (own) LEASE the building in which sales room is located? YES (lease) DATE lease expires located on page_____paragraph_____of lease document. Provision for SALE of alcoholic or malt beverages located on page_____paragraph_____of lease. ---PAGE BREAK--- WLD-28 (1/16) NOTE: Please submit a copy of the lease with the application. W.S. 12-2-103(a)(iii) requires the lease be valid THROUGH the TERM OF THE LICENSE and MUST contain a provision for SALE OF ALCOHOLIC or MALT BEVERAGES. 4. Restaurant and Bar and Grill Liquor License Holders Only: (Line 1) Liquor Sales: Gross sales figures and percentages of income derived from: (Line 2) Food Sales: W.S.12-4-408(b) (Line 1 + Line 2 must = Line 3) (Line 3) Gross Sales: Did you attach a copy of your valid food service permit to this application. YES NO W.S.12-4-407(a), W.S.12-4-413(a) 5. Microbrewery License Holders Only: Did you produce over 50 barrels (1,550 gallons) but less than 50,000 barrels (1,550,000 gallons) during the previous license term? W.S.12-1-101(a)(xix) YES NO Do you self distribute your products? W.S. 12-2-201(a) YES NO (Requires additional licensing with the Liquor Division) Do you distribute your own products through an existing malt beverage wholesaler? YES NO W.S. 12-2-201(g)(i) (Requires additional licensing with the Liquor Division) 6. Social Club License Holders Only: Have you filed a detailed statement of your activities during the year with an itemized statement of amounts expended? W.S. 12-1-101(a)(ii)(E) YES NO 7. If the applicant is filing as an Individual or Partnership or as a Club: Each individual or partner or officer must complete this section. True and Correct Name Date of Birth DONOT LIST PO BOXES Residence Address No. & Street City, State & Zip 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 of a Felony Violation? Have you been Convicted of a 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 (If more information is required, list on a separate piece of paper and attach to this application.) 8. If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: Each stockholder holding, either jointly or severally, ten percent (10%) or more of the outstanding and issued capital stock of the corporation, limited liability company, limited liability partnership, or limited partnership, and every officer, and every director must complete this section. True and Correct Name Date of Birth DONOT LIST PO BOXES Residence Address No. & Street City, State & Zip Residence Phone Number No. of Years in Corp or LLC % of Stock Held Have you been Convicted of a Felony Violation? Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES NO YES NO YES NO YES NO YES NO (If more information is required, list on a separate piece of paper and attach to this application.) 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 Before Me, (specify) (Printed name of Notary or other officer authorized to administer oaths) a Notary Public, Officer authorized to administer oaths in and for State of Wyoming, personally appeared he/she being first duly sworn (Insert Names) by me upon his oath, says that the facts alleged in the foregoing instrument are true. (Seal) My Commission expires: Witness my hand and official seal: FOR LIQUOR DIVISION USE ONLY Reviewer Initials Date Agent: Chief: ---PAGE BREAK--- WLD-28 (1/16) Acct.: (Notary Public or other officer authorized to administer oaths) Title Dated: