Renewal Of Liquor License Or Permit Application {WLD-28}

WLD-31 (5/17) RENEWAL OF LIQUOR LICENSE OR PERMIT APPLICATION To be completed by City/County Clerk License Fees Annual Fee: Prorated Fee: Transfer Fee: $___________._____ $___________._____ $___________._____ FOR LIQUOR DIVISION USE ONLY Customer #: Reviewer: Agent: Chief: Initials Date / / ________/________/________ / / Local License #:__________________________________ Date filed with clerk: Advertising Dates: (2 Weeks) _____________________&_____________________ Hearing Date: ________/________/________ Publishing Fee: $___________._____ Publishing Fee Direct Billed to Applicant: License Term: __ Month / Day /__ _________ Through __ Year Month / Day /_____________ Year LICENSING AUTHORITY: Begin publishing promptly. 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: __________________________________________________________________________________________ Trade/Business Name (dba): ___________________________________________________________________________ Building to be licensed/Building 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:______________________________________________________________________________________ Brief legal description and the zoning of the licensed building or site for licensed building: W.S. 12-4-102 (a) (vii) ___________________________________________________________________________________ MINIMUM PURCHASE Retail License Holders Only Have you purchased $2,000 in spirits, wines and/or malt beverages during the previous license term? YES NO Please submit invoices to clerk FILING IN (CHOOSE ONLY ONE) CITY OF:__________________ FILING AS (CHOOSE ONLY ONE) INDIVIDUAL PARTNERSHIP LP/LLP LLC CORPORATION LTD PARTNERSHIP ORGANIZATION OTHER _______________________ COUNTY OF:_______________ TYPE OF LICENSE OR PERMIT (CHOOSE ONLY ONE) RETAIL LIQUOR LICENSE ON-PREMISE ONLY (BAR) OFF-PREMISE ONLY (PACKAGE STORE) COMBINATION ON/OFF PREMISE (BOTH BAR & PACKAGE STORE) RESTAURANT LIQUOR LICENSE RESORT LIQUOR LICENSE BAR AND GRILL LIMITED RETAIL (CLUB) VETERANS CLUB FRATERNAL CLUB GOLF CLUB SOCIAL CLUB MICROBREWERY WINERY DISTILLERY SATELLITE WINERY SATELLITE COUNTY RETAIL or SPECIAL MALT BEVERAGE PERMIT SPECIAL DESIGNATIONS CONVENTION FACILITY CIVIC CENTER/EVENT CENTER/ PUBLIC AUDITORIUM GOLF CLUB GUEST RANCH RESORT WHEN DO YOU OPERATE? (To assist the Liquor Division with scheduling inspections) FULL TIME (e.g. Jan through Dec) (specify months of operation) from ___________ to ____________ SEASONAL/PART-TIME DAYS OF WEEK (e.g. Mon through Sat) from ___________ to ____________ NON-OPERATIONAL/PARKED HOURS OF OPERATION (e.g. 10a - 2a) from ___________ to ____________ ALL APPLICANTS MUST COMPLETE QUESTIONS 1- 6 1. BUILDING OWNERSHIP: Does the applicant? W.S. 12-4-103 (a) (iii) (1) OWN the licensed building? (2) LEASE the licensed building? (Lease must be through the term of the liquor license) (3) LEASE is current and on file with the licensing authority & Liquor Division. If lease is not current, please submit a copy of the lease and indicate: (A) When the lease expires, located on page_____paragraph_____of lease document. YES (own) YES (lease) YES NO American LegalNet, Inc. www.FormsWorkFlow.com (B) Where the Sales provision for alcoholic or malt beverages is located, on page_____paragraph_____of lease. (MUST contain a provision for SALE OF ALCOHOLIC or MALT BEVERAGES.) WLD-31 (5/17) 2. If the applicant is filing as an Individual or Partnership or as a Club: W.S. 12-4-102 (a) (ii) & (iii) Each individual or partner or officer must complete this section. 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? True and Correct Name Date of Birth YES NO YES YES NO YES YES NO YES NO YES NO YES NO YES NO NO (If more information is required, list on a separate piece of paper and attach to this application.) NO 3. If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: W.S. 12-4-102 (a) (iv) & (v) 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. DONOT LIST PO BOXES Residence Address No. & Street City, State & Zip Residence Phone Number No. of Years in Corp or LLC Have you been Convicted of a Felony Violation? Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? True and Correct Name Date of Birth % of Stock Held YES NO YES 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.) NO 4. Restaurant and Bar and Grill Liquor License Holders Only: (a) (b) Gross sales figures and percentages of income derived from: W.S.12-4-408(b) (Line 1 + Line 2 must = Line 3) (Line 1) Liquor Sales: (Line 2) Food Sales: (Line 3) Gross Sales: $___________(_______%) $___________(_______%) $___________(_______%) YES NO Did you attach a copy of your valid food service permit to this application. W.S.12-4-407(a), W.S.12-4-413(a) (c) Restaurant License Holders Only: Give a description of the dispensing room(s) and state where it is located in the building. W.S. 12-4-102(a)(i) (e.g. 10 x 12 room in SE corner of building): st 1 Room: ______________________________________________________________________________________________ nd 2 Room:______________________________________________________________________________________________ 5. Microbrewery License Holders Only: Did you produce over 50 barrels (1,550 gallons) but less than 50,000 barrels (1,550,000 gal