Full Text
WLD-31 (1/16) NEW OR TRANSFER 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 Direct Billed: Advertising Dates (2 wks): Hearing Date: / / 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 Formerly Held 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 FOR TYPE OF LICENSE OR PERMIT To Assist the Liquor Division with (CHOOSE ONLY ONE) scheduling inspections: NEW TRANSFER LOCATION RETAIL LIQUOR LICENSE WHEN DO YOU OPERATE? TRANSFER OWNERSHIP ON-PREMISE ONLY (BAR) OFF-PREMISE ONLY (PACKAGE STORE) NON-OPERATIONAL/PARKED COMBINATION ON/OFF PREMISE (BOTH BAR & PACKAGE STORE) FILING IN (CHOOSE ONLY ONE) FULL TIME (e.g. Jan through Dec) RESTAURANT LIQUOR LICENSE CITY OF RESORT LIQUOR LICENSE SEASONAL/PART-TIME BAR AND GRILL COUNTY OF LIMITED RETAIL (CLUB) (specify months of operation) VETERANS CLUB FILING AS (CHOOSE ONLY ONE) FRATERNAL CLUB from to GOLF CLUB INDIVIDUAL LLC SOCIAL CLUB DAYS OF WEEK (e.g. Mon through Sat) PARTNERSHIP LLP MICROBREWERY CORPORATION WINERY LTD PARTNERSHIP DISTILLERY SATELLITE HOURS OF OPERATION (e.g. 10a - 2a) ASSOCIATION WINERY SATELLITE ORGANIZATION COUNTY RETAIL or SPECIAL MALT BEVERAGE PERMIT 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). Please provide a drawing of the establishment that includes the dispensing room: 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.) MFG: 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. 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. 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. ---PAGE BREAK--- WLD-31 (1/16) 3. Have you already assigned, leased, transferred or do you intend to assign, lease, transfer, contract or in any other manner agree with any person or firm other than yourself as licensee to operate and assert control or partial control of the license and the licensed room to carry on the licensed liquor business? YES NO 4. Does any manufacturer, brewer, rectifier, wholesaler, or through a subsidiary affiliate, officer, director or member of any such firm: W.S. 12-5-401, 12-5-402, 12-5-403 Hold any interest in the license applied for? YES NO Furnish by way of loan or any other money or financial assistance for purposes hereof in your 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 you answered YES to any of the above, explain fully and submit any documents in connection therewith: 5. Does the applicant have any interest or intent to acquire an interest in any other liquor license issued by this licensing authority? W.S. 12-4-103(b) YES NO If "YES", explain: 6. Is the applicant a mayor, member of a city or town council, or member of the board of county commissioners within the jurisdiction of this licensing authority? W.S. 12-4-103(a)(i) YES NO 7. Is the applicant employed by the State, City or Town, or County as a law enforcement officer, or hold office as a law enforcement officer through election? W.S. 12-4-103(a)(ii) YES NO RESTAURANT OR BAR AND GRILL LICENSE: 8. Have you submitted a valid food service permit? W.S. 12-4-407(a)/W.S. 12-4-413(a) YES NO RESORT LICENSE: 9. Does the resort complex: Have an actual valuation of at least one million dollars, or have you 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 which 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 you have committed or expended at least one million dollars ($1,000,000.00)? W.S. 12-4-401(b)(iv) YES NO MICROBREWERY LICENSE: 10. Will the license be held in conjunction with another liquor license? W.S. 12-4-412(b)(iii) YES NO If "YES", please specify type: RETAIL RESTAURANT RESORT BAR AND GRILL MICROBREWERY WINERY 11. 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 products through an existing malt beverage wholesaler? W.S. 12-2-201(g)(i) (Requires additional licensing with the Liquor Division) YES NO WINERY LICENSE: 12. Will the license be held in conjunction with another liquor license? W.S. 12-4-412(b)(iii) YES NO If "YES", please specify type: RETAIL RESTAURANT RESORT BAR AND GRILL MICROBREWERY WINERY LIMITED RETAIL (CLUB) LICENSE: 13. 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 LIMITED RETAIL (CLUB) LICENSE: 14. 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 ---PAGE BREAK--- WLD-31 (1/16) LIMITED RETAIL (CLUB) LICENSE: 15. SOCIAL CLUBS W.S. 12-1-101(a)(iii)(E): Do you 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 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 Have you filed a true copy of your bylaws with the local licensing authority and the Wyoming Liquor Division? YES NO Has at least fifty one percent (51%) of the membership signed a petition indicating a desire to secure a Limited Retail Liquor License? (THE PETITION MUST BE ATTACHED TO APPLICATION) YES NO Have you filed with the licensing authority and the Wyoming Liquor Division a detailed statement of your activities during the preceding year which were undertaken or furthered in pursuit of the objectives of the club, along with an itemized statement expended for such activities? YES NO LIMITED RETAIL (CLUB) LICENSE: 16. GOLF CLUBS W.S. 12-1-101(a)(iii)(D): Do you have more than fifty (50) bona fide members? YES NO Do you own, maintain, or operate a bona fide golf course together with clubhouse? YES NO 17. If applicant is filing as an Individual or Partnership: W. S. 12-4-102 (ii) & (iii) Each individual or partner must complete this section. If the applicant is filing as a Club: Each 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 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.) If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: W.S. 12-4-102 (iv) & 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 YES NO YES NO ---PAGE BREAK--- WLD-31 (1/16) YES NO YES NO (If more information is required, list on a separate piece of paper and attach to this application.) ---PAGE BREAK--- WLD-31 (1/16) 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: (Notary Public or other officer authorized to administer oaths) Title Dated: REQUIRED ATTACHMENTS: A statement indicating the financial condition and financial stability of the applicant W.S. 12-4-102 (vi). Include a drawing of the dispensing room W.S. 12-5-201 Attach any lease agreements W.S. 12-4-103 (iii). Include a copy of the CURRENT food service permit for Restaurant or Bar & Grill Liquor License applicants W.S. 12-4-407 or 12-4-413 If transferring a license from one ownership to another, a form of assignment from the current licensee to the new applicant authorizing the transfer W.S. 12-4-601 ADVERTISING REQUIREMENTS W.S. 12-4-104(a): When an application for a license, permit, renewal or any transfer of location or ownership thereof has been filed with a licensing authority, the clerk shall prepare a notice of application, place the notice conspicuously upon the premises shown by the application as the proposed place of sale and public the notice in a newspaper of local circulation once a week for two consecutive weeks. The notice shall state that a named applicant has applied for a license, permit, renewal or transfer thereof, and that protests against the issuance, renewal, or transfer of the license or permit will be heard at a designated meeting of the licensing authority. FOR LIQUOR DIVISION USE ONLY Reviewer Initials Date Agent: Chief: Acct.: