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WLD-28 (10/15) RENEWALS ONLY----- RENEWAL OF LICENSE AND/OR PERMIT APPLICATION FOR LIQUOR, WINERY OR MICROBREWERY NOTE TO APPLICANT: To be filed with the local licensing authority. (Hearing must be 30 days prior to expiration) To be completed by the City, Town or County Clerk: Date Filed: / / Annual Fee $ . $ . $ . Basic Fee Additional Disp Rm Fee Total Lic Fee Collected Publishing Fee Collected $ . Required Attachments Received Yes Advertising Dates(2 wks): Hearing Date: / / Local Licensing Number: For the license term: / / Month Day Year Through: / / Month Day Year A copy must be immediately forwarded to: State of Wyoming Liquor Division 6601 Campstool Rd. Cheyenne WY 82002-0110 FILING IN TYPE OF LICENSE OR PERMIT To Assist the Liquor Division with (CHOOSE ONLY ONE) scheduling inspections: CITY OF RETAIL LIQUOR LICENSE on-premise only (Bar) DO YOU OPERATE? COUNTY OF off-premise only (Package Store) combination on/off premise (Both) FULL TIME (e.g. Jan through Dec) RESTAURANT LIQUOR LICENSE FILING AS (CHOOSE ONLY ONE) RESORT LIQUOR LICENSE SEASONAL/PART-TIME INDIVIDUAL LLC PARTNERSHIP LLP CORPORATION COUNTY RETAIL or SPECIAL MALT BEVERAGE PERMIT (specify months of operation) LTD PARTNERSHIP ASSOCIATION VETERANS CLUB from to FRATERNAL CLUB ORGANIZATION GOLF CLUB DAYS OF WEEK (e.g. Mon through Sat) SOCIAL CLUB MICROBREWERY HOURS OF OPERATION (e.g. 10a - 2a) LOCATED WITHIN 5 MILES OF WINERY CITY (County License only) BAR AND GRILL Minimum Purchase Requirement: 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. RETAIL: 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: Have you purchased $500 in spirits, wines and/or malt beverages during the previous license term? YES NO W.S.12-4-103(c) TO BE COMPLETED BY APPLICANTS {Pursuant to W.S.12-4-102(a)} 1. Location of License: Give a description of the dispensing room and state where it is located in the building (e.g. 10 x 12 room in SE corner of 1st floor of building). If the building is not in existence, provide the location and 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 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: ---PAGE BREAK--- WLD-28 (10/15) 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? (If yes, submit a drawing of the changes in the dispensing room.) YES NO a) Do you anticipate any changes in the next twelve (12) months? YES NO ---PAGE BREAK--- WLD-28 (10/15) 3. Leases: If the premises are not owned by licensee, attach a copy of the lease agreement which shows that the right to occupy the premises continues through the term of the license and contains an agreement that alcoholic or malt beverages may be sold upon the leased premises. Please indicate the page and paragraph of lease that shows the date of expiration. W.S.12-4-103(a)(iii) a) DATE lease expires: located on page paragraph of lease document. b) Provision for SALE of alcohol or malt beverages located on page paragraph of lease document. 4. Restaurant and Bar and Grill Liquor Licenses Only: a) Gross sales figures and percentages of income derived from: Gross Sales: W.S.12-4-408(b) Food Sales: Liquor Sales: b) 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. If applicant is a Microbrewery: a) 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 b) Do you self distribute your products? YES NO c) Do you distribute your own products through an existing malt beverage wholesaler? YES NO 6. If applicant is an Individual(s) or Partnership: State the name, date of birth and residence of the applicant and of each applicant or partner, if the application is made by more than one individual or partnership. If the application is for a Club: State the name, date of birth and residence of each officer. True and Correct Name Date of Birth DO NOT LIST PO BOXES Residence Address, 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, complete in identical form, on a separate piece of paper and attach to this application.) 7. If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: State the name, date of birth and residence of 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. True and Correct Name Date of Birth DO NOT LIST PO BOXES Residence Address, 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 YES NO YES NO (If more information is required, complete in identical form, on a separate piece of paper and attach to this application.) VERIFICATION OF APPLICATION (Requires signatures by ALL Individuals, ALL Partners, ONE LLC Member, 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. Dated this day of Applicant THE STATE OF WYOMING COUNTY OF SS. Applicant Subscribed and sworn to before me by this day of Witness my hand and official seal. Notary Public or Person Authorized to Administer Oath My Commission expires: FOR LIQUOR DIVISION USE ONLY Reviewer Initials Date Agent: Chief: Acct: