WLD-031 (7/06) FOR NEW LICENSES AND TRANSFER LICENSE AND/OR PERMIT APPLICATION FOR LIQUOR, COUNTY MALT BEVERAGE, LIMITED, WINERY OR MICROBREWERY Formerly Held by: To be completed by the City, Town or County Clerk: Date Filed: / Basic Fee: Add’l Dispensing Room Fee: Transfer Fee: Total License Fee Collected Publishing Fee Collect: / Annual Fee Applicant: $ $ . . Prorated Fee $ . $ . $ $ . . $ $ . Trade Name (dba): Premise: Number & Street City . State Zip County Mailing Address: Required Attachments Received: Advertising Dates(4): Hearing Date: / / Local Licensing Number: Number & Street or P.O. Box Yes City State Zip Business Telephone Number: ( Fax Number: 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. A copy must be immediately forwarded to: State of Wyoming Liquor Division 1520 E 5th Street Cheyenne WY 82002-0110 FILING FOR ) ) E-Mail Address: For the license term: Month FILING IN (CHOOSE ONLY ONE) CITY OF COUNTY OF FILING AS (CHOOSE ONLY ONE) INDIVIDUAL LLC PARTNERSHIP LLP CORPORATION LTD PARTNERSHIP ASSOCIATION ORGANIZATION Day Month Day Through: TYPE OF LICENSE OR PERMIT NEW TRANSFER LOCATION TRANSFER OWNERSHIP ( (CHOOSE ONLY ONE) RETAIL LIQUOR LICENSE on-premise only off-premise only combination on/off premise RESTAURANT LIQUOR LICENSE RESORT LIQUOR LICENSE COUNTY RETAIL or SPECIAL MALT BEVERAGE PERMIT VETERANS CLUB FRATERNAL CLUB GOLF CLUB SOCIAL CLUB MICROBREWERY WINERY BAR AND GRILL Year , Year To Assist the Liquor Division with scheduling inspections: DO YOU OPERATE? FULL TIME (e.g. Jan through Dec) SEASONAL/PART-TIME (specify months of operation) from _____________ to _____________ DAYS OF WEEK (e.g. Mon through Sat) HOURS OF OPERATION (e.g. 10a - 2a) LOCATED WITHIN 5 MILES OF CITY (County License only) 1. Location of License: (a) Give a description of the dispensing room and state where it is located in the building (e.g. 10x12 room in SE corner of 1st floor of building). If the building is not in existence, provide the location and an architect's drawing or suitable plans of the room and premises to be licensed: If Winery or Microbrewery, also list manufacturing facility. W.S. 12-4102(a)(i): (b) Do you have an additional dispensing room? YES NO If yes, provide description and location: (c) Provide the legal description and the zoning of the site where the applicant will conduct business: 2. Do you W.S. 12-4-103 (a) (iii): (1) OWN the building in which sales room is located? (2) LEASE the building in which sales room is located? YES (own) YES (lease) (A) DATE lease expires _______________________ located on page_____paragraph_____of lease document. (B) Provision for SALE of alcoholic or malt beverages located on page_____paragraph_____of lease document. NOTE: Attach a true copy of the lease to application. Lease MUST contain provision for SALE OF ALCOHOLIC or MALT BEVERAGES and be valid THROUGH the TERM OF THE LICENSE W.S. 12-4-103(a)(iii). 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 YES and the licensed room to carry on the licensed liquor business? NO American LegalNet, Inc. www.FormsWorkflow.com WLD-031 (7/06) 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 YES NO (a) Hold any interest in the license applied for? (b) Furnish by way of loan or any other money or financial assistance for purposes hereof in your business? YES NO (c) Furnish, give, rent or loan any equipment, fixtures, interior decorations or signs other than standard brewery or manufacturer's signs? YES NO (d) If you answered YES to any of the above, explain fully and submit any documents in connection therewith: 5. Does applicant have any interest or intent to acquire an interest in any other retail liquor license to be issued by this licensing authority? W.S. 12-4-103(b) YES NO If "YES", explain: 6. Is applicant a mayor, member of a city or town council, or member of the board of county commissioners within the YES jurisdiction of this licensing authority? W.S. 12-4-103(a)(i) NO 7. Is applicant employed by the State, City or Town, or County as a law enforcement officer, or hold office as a law enforcement YES NO officer through election? W.S. 12-4-103(a)(ii) RESTAURANT OR BAR AND GRILL LICENSE: Complete questions 8(a) and 8(b): YES NO 8. (a) Have you submitted a valid food service permit upon application? W.S. 12-4-407(a) W.S. 12-4-413(a) (b) Was your dispensing room for alcoholic and/or malt beverages in existence and open for consumption purposes prior to February 1, 1979? W.S. 12-4-410(b) YES NO N/A RESORT LICENSE: Complete questions 9(a) through 9(c): 9. (a) Is the actual valuation of the resort complex 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 (b) Does the resort complex 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 (c) Does the resort complex include motel or hotel accommodations with at least one hundred (100) sleeping rooms? W.S. 12-4-401(b)(iii) YES NO MICROBREWERY AND/OR WINERY LICENSE: Complete questions 10 through 11: YES NO 9. Is premise to be co-existent with a retail, restaurant, resort or bar and grill liquor license? W.S. 12-4-412(b)(iii) If "YES", please specify type: Microbrewery Winery Retail Restaurant Resort 11. (a) Do you self distribute your products? (b) Do you distribute your products through an existing malt beverage wholesaler? Bar and Grill: YES YES NO NO ORGANIZATION AND/OR CLUB LICENSE: Complete questions 12 through 15 as applicable: 12. FRATERNAL CLUBS W.S. 12-1-101(a)(iii)(B) (a) The name and address of the grand lodge or national organization is: (b) Does lodge or fraternal organization hold a charter from a national organization or national grand lodge? YES NO (c) Has the fraternal organization been actively operating in at least thirty-six (36) states? YES (d) Has the fraternal organization been actively in existence for at least twenty (20) years? YES NO NO 13. VETERANS CLUBS W.S. 12-1-101(a)(iii)(A): (a) The name and address of the National Veterans organization is: (b) Has the Veteran's organization been chartered by the Congress of the United States for patriotic, fraternal or YES NO benevolent purposes? (c) Is the membership of the Veteran's organization comprised only of Veterans and its duly organized auxiliary? YES NO American LegalNet, Inc. www.FormsWorkflow.com WLD-031 (7/06) 14. SOCIAL CLUBS W.S. 12-1-101(a)(iii)(E): (a) Do you have more than one hundred (100) bona fide members who are residents of the county in which the club is YES NO located? (b) Is the club incorporated and operating solely as a nonprofit organization under the laws of this state? YES NO (c) Is the club qualified as a tax exempt organization under the Internal Revenue Service? YES NO (d) Has the club been in continuous operation for a period of not less than one (1) year? YES NO (e) 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 (1) full year in dues? YES NO (f) Does the club hold quarterly meetings and have an actively engaged membership carrying out the objectives of the club? YES NO (g) Have you filed a true copy of your bylaws with the local licensing authority and the Wyoming Liquor Division? YES NO (h) Has at least fifty one percent (51%) of the membership signed a petition indicating a desire to secure a Limited YES NO Retail Liquor License (THE PETITION MUST BE ATTACHED TO APPLICATION) ? (i) 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 15. GOLF CLUBS W.S. 12-1-101(a)(iii)(D): (a) Do you have more than fifty (50) bona fide members? (b) Do you own, maintain, or operate a bona fide golf course together with clubhouse? YES YES NO NO 16. (a) If applicant is an Individual or Partnership: State the name, date of birth and residence of each applicant or partner, if the application if made by more than one individual or by a partnership. If the application is for a Club: State the name, date of birth and residence of each officer. NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO Residence Phone Number NO YES NO YES Residence Address No. & Street City, State & Zip Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES True and Correct Name Date of Birth Have you been Convicted of a Felony Violation? YES NO YES DONOT LIST PO BOXES Have you been a DOMICILED resident for at least 1 year and not claimed residence in any other state in the last year? YES NO NO (If more information is required, list on a separate piece of paper and attach to this application.) (b) If the applicant is a Corporation, Limited Liability Company, Limited Liability Partnership or Limited Partnership: State the name, date of birth and residence of 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. NO YES NO YES NO % of Stock Held NO YES NO YES No. of Years in Corp or LLC NO YES NO YES Date of Birth Residence Phone Number Have you been Convicted of a Violation Relating to Alcoholic Liquor or Malt Beverages? YES NO YES True and Correct Name Residence Address No. & Street City, State & Zip Have you been Convicted of a Felony Violation? YES NO YES DONOT LIST PO BOXES NO (If more information is required, list on a separate piece of paper and attach to this application.) American LegalNet, Inc. www.FormsWorkflow.com WLD-031 (7/06) OATH OR VERIFICATION (Requires signatures by ALL Individuals, ALL Partners, TWO (2) LLC Members, or TWO (2) Corporate Officers/Directors, or TWO (2) 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) a Notary Public, Officer authorized (Printed name of Notary or other officer authorized to administer oaths) to administer oaths in and for__________________________________________________County, State of Wyoming, personally appeared ________________________________________________________name he/she being first duly sworn by me upon his oath, says that the (Insert Names) facts alleged in the foregoing instrument are true. (Seal) 1.__________________________________________________ 2.__________________________________________________ 3.__________________________________________________ My Commission expires: _____________________ 4.__________________________________________________ Witness my hand and official seal: __________________________________________ (Notary Public or other officer authorized to administer oaths) Title ______________________________________ Dated: ______________________________________ REQUIRED ATTACHMENTS: (1) Attach any lease agreements W.S. 12-4-103(a)(iii). (2) If building is not in existence, an architect's drawing or suitable plans of the room and premises to be licensed must be attached W.S. 12-4-102(a)(i). (3) A statement indicating the financial condition and financial stability of new applicant W.S. 12-4-102(a)(v). (4) Restaurant or Bar and Grill Liquor License Applications must attach a copy of their CURRENT and valid food service permit W.S. 12-4-407(a) or W.S.12-4-413(a). (1) Check or bank draft as payment for the application and for publishing the notice of application. W.S. 12-4-104(a). Direct billing is permissible. (2) If transfer, a form of assignment from current licensee, allowing transfer W.S. 12-4-601(b). NOTE: Federal law requires you to pay a SPECIAL OCCUPATIONAL TAX (federal tax stamp) before you begin business and before July 1 each year thereafter. If you have not paid this tax, contact: BUREAU OF ATF JOHN WELD PECK FEDERAL BLDG RM 6525 550 MAIN ST CINCINNATI OH 45202-3263 1-800-937-8864 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 promptly 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 four (4) 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. HEARING REQUIREMENTS W.S. 12-4-104(b): Any license or permit authorized under this title shall not be issued, renewed or transferred until on or after the date set in the notice for hearing protests. If a renewal hearing, the hearing shall be held no later than thirty (30) days preceding the expiration date of the license or permit. A license or permit shall not be issued, renewed or transferred if the licensing authority finds from evidence presented at the hearing: (i) (ii) (iii) (iv) (v) The welfare of the people residing in the vicinity of the proposed license or permit premises shall be adversely and seriously affected; The purpose of this title shall not be carried out by the issuance, renewal or transfer of the license or permit; The number, type and location of existing licenses or permits meets the needs of the vicinity under consideration; The desires of the residents of the county, city or town will no be met or satisfied by the issuance, renewal or transfer of the license or permit; or Any other reasonable restrictions or standards which may be imposed by the licensing authority shall not be carried out by the issuance, renewal or transfer of the license or permit. FOR LIQUOR DIVISION USE ONLY Reviewer Initials Date Clerk: Agent: Acct.: American LegalNet, Inc. www.FormsWorkflow.com