Permit Application And Report Of Changes {DR 8442}

DR 8442 (09/24/09) Page 1 COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION DENVER, COLORADO 80261 (303)-205-2300 FOR DEPARTMENT USE ONLY PERMIT APPLICATION AND REPORT OF CHANGES CURRENT LICENSE NUMBER ____________________________ ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPEWRITTEN LOCAL LICENSE FEE $ _________________________________ APPLICANT SHOULD OBTAIN A COLORADO LIQUOR & BEER CODE BOOK TO ORDER CALL (303) 370-2165 1. Applicant is a Corporation ..................................... Partnership ...................................... 2. Name of Licensee Individual Limited Liability Company 3. Trade Name PRESENT LICENSE NUMBER 4.Location Address City County ZIP SELECT THE APPROPRIATE SECTION BELOW AND PROCEED TO THE INSTRUCTIONS ON PAGE 2. Section A ­ Manager reg/change 2210-100 (999) 2200-100 (999) 2260-100 (999) 2012-750 (999) Manager's Registration (Tavern)..............$75.00 Change of Manager (Other Licenses) NO FEE 2230-100 (999) 2280-100 (999) Section B ­ Duplicate License 2220-100 (999) · Liquor License No. _______________________________ 2270-100 (999) Duplicate License ...........................$50.00 1988-100 (999) Change Location Permit (ea).................. 150.00 Change, Alter or Modify Premises $150.00 x ______ Total Fee _________________ Addition of Optional Premises to Existing H/R $100.00 x ______ Total Fee _________________ Addition of Related Facility to Resort Complex $75.00 x ______ Total Fee __________________ Section C Retail Warehouse Storage Permit (ea) $100.00 Wholesale Branch House Permit (ea).... 100.00 Change Corp. or Trade Name Permit (ea) .50.00 · License Account No. ___________________________________ 1983-750 (999) Manager's Registration (Hotel & Restr.)..$75.00 DO NOT WRITE IN THIS SPACE ­ FOR DEPARTMENT OF REVENUE USE ONLY DATE LICENSE ISSUED LICENSE ACCOUNT NUMBER PERIOD -750 (999) -100 (999) The State may convert your check to a one time electronic banking transaction. Your bank account may be debited as early as the same day received by the State. If converted, your check will not be returned. If your check is rejected due to insufficient or uncollected funds, the Department of Revenue may collect the payment amount directly from your bank account electronically. TOTAL AMOUNT DUE $ American LegalNet, Inc. www.FormsWorkFlow.com .00 DR 8442 (09/24/09) Page 2 INSTRUCTION SHEET FOR ALL SECTIONS, COMPLETE QUESTIONS 1-4 LOCATED ON PAGE 1 Section A To Register or Change Managers, check the appropriate box in section A and complete question 8 on page 4. Proceed to the Oath of Applicant for signature (Please note: Hotel, Restaurant, and Tavern licensees are required to register their managers). Section B For a Duplicate license, be sure to include the liquor license number in section B on page 1 and proceed to page 4 for Oath of Applicant signature. Section C Check the appropriate box in section C and proceed below. 1) For a Retail Warehouse Storage Permit, go to page 3 complete question 5 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 2) For a Wholesale Branch House Permit, go to page 3 and complete question 5 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 3) To Change Trade Name or Corporation Name, go to page 3 and complete question 6 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 4) To modify Premise, go to page 4 and complete question 9. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 5) For Optional Premises or Related Facilities go to page 4 and complete question 9. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 6) To Change Location, go to page 3 and complete question 7. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. American LegalNet, Inc. www.FormsWorkFlow.com DR 8442 (09/24/09) Page 3 5. Retail Warehouse Storage Permit or a Wholesalers Branch House Permit Retail Warehouse Permit for: STORAGE PERMIT On­Premises Licensee (Taverns, Restaurants etc.) Off­Premises Licensee (Liquor stores) Wholesalers Branch House Permit Address of storage premise: __________________________________________________________________ City _______________________, County ________________________________, Zip __________________ Attach a deed/ lease or rental agreement for the storage premises. Attach a detailed diagram of the storage premises. 6. Change of Trade Name or Corporation Name CHANGE TRADE NAME OR CORPORATE NAME Change of Trade name / DBA only Corporate Name Change (Attach the following supporting documents) 1. Certificate of Amendment filed with the Secretary of State, or 2. Statement of Change filed with the Secretary of State, and 3. Minutes of Corporate meeting, Limited Liability Members meeting, Partnership agreement. Old Trade Name New Trade Name Old Corporate Name New Corporate Name 7. Change of Location NOTE TO RETAIL LICENSEES: An application to change location has a local application fee of $750 payable to your local licensing authority. You may only change location within the same jurisdiction as the original license that was issued. Pursuant to 12-47311 (1) C.R.S. Your application must be on file with the local authority thirty (30) days before a public hearing can be held. Date filed with Local Authority _______________________ Date of Hearing ________________________ (a) Address of current premises ______________________________________________________________ CHANGE OF LOCATION City ________________________ County _______________________________ Zip ___________________ (b) Address of proposed New Premises (Attach copy of the deed or lease that establishes possession of the premises by the licensee) Address ______________________________________________________________________________ City ________________________ County _______________________________ Zip ___________________ (c) New mailing address if applicable. Address ______________________________________________________________________________ City ________________________ County _____________________ State ________ Zip _____________ (d) Attach detailed diagram of the premises showing where the alcohol beverages will be stored, served, possessed or consumed. Include kitchen area(s) for hotel and restaurants.