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 PRESENT LICENSE NUMBER Corporation ..................................... Individual Partnership ...................................... Limited Liability Company 2. Name of Licensee 3. Trade Name 4.Location Address City County ZIP SELECT THE APPROPRIATE SECTION BELOW AND PROCEED TO THE INSTRUCTIONS ON PAGE 2. Section A – Manager reg/change Section C 2012-750 (999) 2200-100 (999) Wholesale Branch House Permit (ea).... 100.00 Change Corp. or Trade Name Permit (ea) .50.00 2230-100 (999) Change Location Permit (ea).................. 150.00 Change, Alter or Modify Premises $150.00 x ______ Total Fee _________________ 2220-100 (999) Manager's Registration (Hotel & Restr.)..$75.00 Retail Warehouse Storage Permit (ea) $100.00 2280-100 (999) 1983-750 (999) 2210-100 (999) 2260-100 (999) • License Account No. ___________________________________ Addition of Optional Premises to Existing H/R $100.00 x ______ Total Fee _________________ 1988-100 (999) Addition of Related Facility to Resort Complex $75.00 x ______ Total Fee __________________ Manager's Registration (Tavern)..............$75.00 Change of Manager (Other Licenses) NO FEE Section B – Duplicate License • Liquor License No. _______________________________ 2270-100 (999) Duplicate License ...........................$50.00 DO NOT WRITE IN THIS SPACE – FOR DEPARTMENT OF REVENUE USE ONLY DATE LICENSE ISSUED -750 (999) -100 (999) LICENSE ACCOUNT NUMBER 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. PERIOD 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 STORAGE PERMIT Retail Warehouse Permit for: On–Premises Licensee (Taverns, Restaurants etc.) Off–Premises 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. CHANGE TRADE NAME OR CORPORATE NAME 6. Change of Trade Name or Corporation 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 ________________________ CHANGE OF LOCATION (a) Address of current premises ______________________________________________________________ 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. American LegalNet, Inc. www.FormsWorkFlow.com CHANGE OF MANAGER DR 8442 (09/24/09) Page 4 8. Change of Manager or to Register the Manager of a Tavern or a Hotel and Restaurant liquor license. (a) Change of Manager (attach Individual History DR 8404-I H/R and Tavern only) Former manager's name _________________________________________________________________ New manager's name ____________________________________________________________________ (b) Date of Employment _________________ Has manager ever managed a liquor licensed establishment?.................................................. Yes Does manager have a financial interest in any other liquor licensed establishment?............... Yes No No If yes, give name and location of establishment _______________________________________________ ________________________________________________________________________________________ 9. Modification of Premises, Addition of an Optional Premises, or Addition of Related Facility MODIFY PREMISES OR ADDITION OF OPTIONAL PREMISES OR RELATED FACILITY NOTE: Licensees may not modify or add to their licensed premises until approved by state and local authorities. (a) Describe change proposed _____________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ (b) If the modification is temporary, when will the proposed change: Start _________________ (mo/day/year) End _________________ (mo/day/year) NOTE: THE TOTAL STATE FEE FOR TEMPORARY MODIFICATION IS $300.00 (c) Will the proposed change result in the licensed premises now being located within 500 feet of any public or private school that meets compulsory education requirements of Colorado law, or the principal campus of any college, university or seminary? (If yes, explain in detail and describe any exemptions that apply) ............................................Yes No (d) Is the proposed change in compliance with local building and zoning laws? ............................Yes No (e) If this modification is for an additional Hotel and Restaurant Optional Premises or Resort Complex Related Facility, has the local authority authorized by resolution or ordinance the issuance of optional premises? ...................................................................................................................................................Yes No (f) Attach a diagram of the current licensed premises and a diagram of the proposed changes for the licensed premises. (g) Attach any existing lease that is revised due to the modification. OATH OF APPLICANT I declare under penalty of perjury in the second degree that I have read the foregoing application and all attachments thereto, and that all information therein is true, correct, and complete to the best of my knowledge. Signature Title Date REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY / COUNTY) The foregoing application has been examined and the premises, business conducted and character of the applicant is satisfactory, and we do report that such permit, if granted, will comply with the applicable provisions of Title 12, Articles 46 and 47, C.R.S., as amended. THEREFORE, THIS APPLICATION IS APPROVED. Local Licensing Authority (City or County) Signature Date filed with Local Authority Title Date REPORT OF STATE LICENSING AUTHORITY The foregoing has been examined and complies with the filing requirements of Title 12, Article 47, C.R.S., as amended. Signature Title Date American LegalNet, Inc. www.FormsWorkFlow.com