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1 CITY OF DOUGLAS ONE DAY MALT BEVERAGE PERMIT APPLICATION Authorizes the sale of malt beverages only by any responsible person or organization. NO spirituous or fermented alcoholic products may be sold or offered with this permit. Wyoming State Law requires applicant to purchase all malt beverages to be sold from a licensed distributor, and requires applicant to collect and remit sales tax. A Temporary Business Operations application from the Department of Audit is attached and must be remitted to that department. For more information regarding licensed distributors, contact the Wyoming Liquor Division at [PHONE REDACTED], 6449, or 7233. For more information regarding sales tax, contact the Department of Audit/Excise Tax Division at [PHONE REDACTED] or visit http://revenue.wyo.gov . INFORMATION REGARDING APPLICANT: Full Name: WY Sales Tax License number: If you do not have a WY Sales Tax License number, a copy of the completed Temporary Business Operations form that will be submitted to the Wyoming Dept. of Audit must be attached. Address: City: State/Zip: Phone number: Cell: Organization Name (if applicable): Primary contact person: Phone number(s): (If different from applicant) INFORMATION REGARDING EVENT: Type of event to be held: Approximate # of people attending: Date permit will be used: Hours of permit: (am/pm) to (am/pm) Location/premise where permit will be used: Define Boundaries of permit area and attach a map and diagram showing enclosed consumption and dispensing areas): Security/control/supervision measures to be used in addition to required wrist bands (e.g. ID scanner; other means to check IDs; monitoring in place; limited number of entrance/exits; clear cups; etc.) NOTE that proof of alcohol server training certification is required for the permit holder. : Any person, organization, or licensee who is issued a permit hereunder, shall by operation of the issuance of the permit, indemnify and hold the City, its employees, agents and representatives, including members of the City Council in their representative capacities, harmless from any liability, loss or damage which may be incurred as a result of claims, demands, costs, or judgments arising out of, connected with, or concerning the issuance, use or existence of the permit. SIGNATURE OF APPLICANT DATE OF APPLICATION FOR OFFICE USE ONLY NOTE: DEPOSIT IS REFUNDED UPON CLEANING OF LOCATION Permit Fee Receipt # Date of Approval Deposit Fee (Required if City property) Date Received License # Issued Date verified with Public Works: By Date deposit refunded: By ---PAGE BREAK--- 2 STAFF COMMENTS & APPROVALS CITY ADMINISTRATOR ADMINISTRATIVE SERVICES DIRECTOR CITY CLERK CHIEF OF POLICE PUBLIC WORKS DIRECTOR COMMUNITY DEVELOPMENT/PLANNING DIRECTOR ---PAGE BREAK--- 3