21 DR 8403 (03/19/09) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 COLORADO FERMENTED MALT BEVERAGE (3.2% BEER) LICENSE APPLICATION NEW LICENSE • • • • TRANSFER OF OWNERSHIP LICENSE RENEWAL ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPEWRITTEN APPLICANT MUST CHECK THE APPROPRIATE BOX(ES) LOCAL LICENSE FEE $ __________________________ APPLICANT SHOULD OBTAIN A COPY OF THE COLORADO LIQUOR AND BEER CODE (Call 303-370-2165) DO NOT WRITE IN THIS SPACE 1. Applicant is applying as a Corporation Partnership (includes Limited Liability and Husband and Wife Partnerships) Individual Limited Liability Company Association or Other 2. Applicant(s) If an LLC, name of LLC; if partnership, at least 2 partners' names; if corporation, name of corporation Fein Number 2a. Trade Name of Establishment (DBA) State Sales Tax No. Business Telephone 3. Address of Premises (specify exact location of premises) City County State ZIP Code 4. Mailing Address (Number and Street) City or Town State ZIP Code 5. If the premises currently have a liquor or beer license, you MUST answer the following questions: Present State License No. Present Class of License Present Expiration Date Present Trade Name of Establishment (DBA) LIAB SECTION A NONREFUNDABLE APPLICATION FEES LIAB 2300 Application Fee for New License 2121 Retail 3.2% Beer On-Premises (City) $ 96.25 2302 Application Fee for New License w/Concurrent Review 2124 Retail 3.2% Beer On-Premises (County) $ 117.50 $ 1,125.00 2122 Retail 3.2% Beer Off-Premises (City) $ 96.25 Application Fee for Transfer $ 1,025.00 2125 Retail 3.2% Beer Off-Premises (County) $ 117.50 2123 Retail 3.2% Beer On/Off Premises (City) $ 96.25 2126 Retail 3.2% Beer On/Off Premises (County) $ 117.50 2310 $ 1,025.00 SECTION B 3.2% BEER LICENSE FEES 2370 Master File Location Fee ...... $ 25.00 x ______ Total ________ 2375 Master File Background ........ $ 250.00 x ______ Total ________ DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY LIABILITY INFORMATION County Industry Type City License Account Number Liability Date FROM City County 2180-100 (999) 2190-100 (999) Cash Fund New License Cash Fund Transfer License 2300-100 (999) 2310-100 (999) 3 3 3210987654321098765432121098765432109876543210987654321 21098765432109876543212109876543210987654321098765432 3210987654321098765432121098765432109876543210987654321 21098765432109876543212109876543210987654321098765432 3210987654321098765432121098765432109876543210987654321 21098765432109876543212109876543210987654321098765432 21098765432109876543212109876543210987654321098765432 3210987654321098765432121098765432109876543210987654321 3210987654321098765432121098765432109876543210987654321 1 3 1 State _____-750 (999) License Issued Through (Expiration Date) TO TOTAL • American LegalNet, Inc. www.FormsWorkFlow.com DR 8403 (03/19/09) Page 2 APPLICATION DOCUMENTS CHECKLIST AND WORKSHEET Instructions: This check list should be utilized to assist applicants with filing all required documents for licensure. All documents must be properly signed and correspond with the name of the applicant exactly. All documents must be typed or legibly printed. Upon final State approval the license will be mailed to the local licensing authority. Application fees are nonrefundable. ITEMS SUBMITTED, PLEASE CHECK ALL APPROPRIATE BOXES COMPLETED OR DOCUMENTS SUBMITTED I. APPLICANT INFORMATION A. Applicant/Licensee identified. B. State sales tax license number listed or applied for at time of application. C. License type or other transaction identified. D. Return originals to local authority. E. Additional information may be required by the local licensing authority. II. DIAGRAM OF THE PREMISES A. No larger than 8 1/2" X 11". B. Dimensions included (doesn't have to be to scale). Exterior areas should show control (fences, walls, etc.). C. Separate diagram for each floor (if multiple levels). D. Kitchen - identified if Hotel and Restaurant. III. PROOF OF PROPERTY POSSESSION A. Deed in name of the Applicant ONLY (or) B. Lease in the name of the Applicant ONLY. C. Lease Assignment in the name of the Applicant (ONLY) with proper consent from the Landlord and acceptance by the Applicant. D. Other Agreement if not deed or lease. IV. BACKGROUND INFORMATION AND FINANCIAL DOCUMENTS A. Individual History Record(s) (Form DR 8404-I). B. Fingerprints taken and submitted to local authority. (State authority for master file applicants.) C. Purchase agreement, stock transfer agreement, and or authorization to transfer license. D. List of all notes and loans. V. CORPORATE APPLICANT INFORMATION (If Applicable) A. Certificate of Incorporation (and/or) B. Certificate of Good Standing if incorporated more than 2 years ago. C. Certificate of Authorization if foreign corporation. D. List of officers, directors and stockholders of parent corporation (designate 1 person as "principal officer"). VI. PARTNERSHIP APPLICANT INFORMATION (If Applicable) A. Partnership Agreement (general or limited). Not needed if husband and wife. VII. LIMITED LIABILITY COMPANY APPLICANT INFORMATION (If Applicable) A. Copy of articles of organization (date stamped by Colorado Secretary of State's Office). B. Copy of operating agreement. C. Certificate of Authority (if foreign company). VIII. MANAGER REGISTRATION FOR HOTEL AND RESTAURANT, TAVERN LICENSES WHEN INCLUDED WITH THIS APPLICATION A. $75.00 fee. B. Individual History Record (DR 8404-I). American LegalNet, Inc. www.FormsWorkFlow.com DR 8403 (03/19/09) Page 3 Yes No 6. Is the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockholders or directors if a corporation) or manager under the age of twenty-one years? 7. Has the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockholders or directors if a corporation) or manager ever (in Colorado or any other state); (a) been denied an alcohol beverage license? (b) had an alcohol beverage license suspended or revoked? (c) had interest in another entity that had an alcohol beverage license suspended or revoked? If you answered yes to 7a, b or c, explain in detail on a separate sheet. 8. Has a 3.2 beer license for the premises to be licensed been denied within the preceding one year? If "yes," explain in detail. 9. Has a liquor or beer license ever been issued to the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockholders or directors if a corporation)? If yes, identify the name of the business and list any current or former financial interest in said business including any loans to or from a licensee. Yes No Yes No 10. Does the Applicant, as listed on line 2 of this application, have legal possession of the premises by virtue of ownership, lease or other arrangement? Ownership Lease Other (Explain in Detail) a. If leased, list name of landlord and tenant, and date of expiration, EXACTLY as they appear on the lease: Landlord Tenant Yes No Yes No Expires Attach a diagram and outline or designate the area to be licensed (including dimensions) which shows the bars, brewery, walls, partitions, entrances, exits and what each room shall be utilized for in this business. This diagram should be no larger than 8 1/2" X 11". (Doesn't have to be to scale) 11. Who, besides the owners listed in this application (including persons, firms, partnerships, corporations, limited liability companies), will loan or give money, inventory, furniture or equipment to or for use in this business; or who will receive money from this business. Attach a separate sheet if necessary. Name Date of Birth FEIN or SSN Interest Attach copies of all notes and security instruments, and any written agreement, or details of any oral agreement, by which any person (including partnerships, corporations, limited liability companies, etc.) will share in the profit or gross proceeds of this establishment, and any agreement relating to the business which is contingent or conditional in any way by volume, profit, sales, giving of advice or consultation. Date of Birth 12. Name of Manager for all on and on/off applicants. _________________________________________________________ Yes No 13. Does this manager act as the manager of, or have a financial interest in, any other liquor licensed establishment in the State of Colorado? If yes, provide name, type of license and account number. 14. Tax Distraint Information. Does the applicant or any other person listed on this application and including its partners, officers, directors, stockholders, members (LLC) or managing members (LLC) and any other persons with a 10% or greater financial interest in the applicant currently have an outstanding tax distraint issued to them by the Colorado Department of Revenue? If yes, provide an explanation and include copies of any payment agreements. Yes No American LegalNet, Inc. www.FormsWorkFlow.com DR 8403 (03/19/09) Page 4 15. If applicant is a corporation, partnership, association or a limited liability company, applicant must list ALL OFFICERS, DIRECTORS, GENERAL PARTNERS, AND MANAGING MEMBERS. In addition applicant must list any stockholders, partners, or members with OWNERSHIP OF 10% OR MORE IN THE APPLICANT. ALL PERSONS LISTED BELOW must also attach form DR 8404-I (Individual History Record), and submit finger print cards to their local licensing authority. Name Home Address, City & State Date of Birth Position % Owned* * If total ownership percentage disclosed here does not total 100%, applicant must check this box Applicant affirms that no individual, other than those disclosed herein, owns 10% or more of the applicant Additional Documents to be submitted by type of entity CORPORATION Cert. of Incorp. PARTNERSHIP Partnership Agreement (General or Limited) LIMITED LIABILITY COMPANY ASSOCIATION OR OTHER Cert. of Good Standing (if more than 2 yrs. old) Articles of Organization Cert. of Auth. (if a foreign corp.) Husband and Wife partnership (no written agreement) Cert. of Authority (if foreign company) Operating Agrmt. Attach copy of agreements creating association or relationship between the parties Registered Agent (if applicable) Address for Service OATH OF APPLICANT I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my knowledge. I also acknowledge that it is my responsibility and the responsibility of my agents and employees to comply with the provisions of the Colorado Liquor or Beer Code which affect my license. Authorized Signature Title Date REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY/COUNTY) Date application filed with local authority Date of local authority hearing (for new license applicants; cannot be less than 30 days from date of application 12-47-311 (1)) C.R.S. THE LOCAL LICENSING AUTHORITY HEREBY AFFIRMS: That each person required to file DR 8404-I (Individual History Record) has: Yes No Been fingerprinted ......................................................................................................................................................................................... Been subject to background investigation, including NCIC/CCIC check for outstanding warrants ............................................................... That the local authority has conducted, or intends to conduct, an inspection of the proposed premises to ensure that the applicant is in compliance with, and aware of, liquor code provisions affecting their class of license ....................................................................................... (Check One) Date of Inspection or Anticipated Date _____________________________________ Upon approval of state licensing authority. The foregoing application has been examined; and the premises, business to be conducted, and character of the applicant are satisfactory. We do report that such license, if granted, will meet the reasonable requirements of the neighborhood and the desires of the adult inhabitants, and will comply with the provisions of Title 12, Article 46 or 47, C.R.S. THEREFORE, THIS APPLICATION IS APPROVED. Local Licensing Authority for Telephone Number TOWN, CITY COUNTY Signature Title Date Signature (attest) Title Date American LegalNet, Inc. www.FormsWorkFlow.com