WLD-31 (1/16) NEW OR TRANSFER LIQUOR LICENSE OR PERMIT APPLICATION To be completed by the City/Town or County Clerk: Date Filed With Clerk: Basic Fee: Add'l Dispensing Room Fee: Transfer Fee: Total License Fee Collected Publishing Fee Collected: Publishing Direct Billed: Advertising Dates (2 wks): Hearing Date: LICENSE TERM: Month Formerly Held by:__________________________________ Applicant: / / Annual Fee $ . $ . $ $ $ . . . Prorated Fee $ . $ . Trade Name (dba): Premise Address: Number & Street $ . City State Zip County Mailing Address: Number & Street or P.O. Box / / Day / / Year City State Zip Business Telephone Number: ( Fax Number: ( ) ) Through: Month / Day / Year E-Mail Address: A copy must be immediately forwarded to: State of Wyoming Liquor Division 6601 Campstool Rd. Cheyenne WY 82002-0110 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. TYPE OF LICENSE OR PERMIT (CHOOSE ONLY ONE) To Assist the Liquor Division with scheduling inspections: WHEN DO YOU OPERATE? NON-OPERATIONAL/PARKED FULL TIME (e.g. Jan through Dec) SEASONAL/PART-TIME (specify months of operation) from ___________ to _____________ DAYS OF WEEK (e.g. Mon through Sat) FILING FOR NEW TRANSFER LOCATION TRANSFER OWNERSHIP FILING IN (CHOOSE ONLY ONE) CITY OF COUNTY OF FILING AS (CHOOSE ONLY ONE) INDIVIDUAL PARTNERSHIP CORPORATION LTD PARTNERSHIP ASSOCIATION ORGANIZATION LLC LLP 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 HOURS OF OPERATION (e.g. 10a - 2a) 1. DISPENSING ROOM DESCRIPTION WITH DIMENSIONS: (a) Give a description with dimensions of the dispensing room and state where it is located within the building (e.g. 10 x 12 room in SE corner of building). Please provide a drawing of the establishment that includes the dispensing room: W.S. 12-4-102(a)(i) (b) If Winery or Microbrewery, also list the manufacturing facility.(e.g. MFG: 10' X 12' room in SW portion of bldg.) MFG: (c) Do you have an additional dispensing room? YES NO If yes, provide description and location: (d) Provide the legal description and the zoning of the site where the applicant will conduct business: 2. BUILDING OWNERSHIP: Does the applicant? 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. NOTE: Please submit a copy of the lease with the application. W.S. 12-2-103(a)(iii) requires the lease be valid THROUGH the TERM OF THE LICENSE and MUST contain a provision for SALE OF ALCOHOLIC or MALT BEVERAGES. American LegalNet, Inc. www.FormsWorkFlow.com WLD-31 (1/16) 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 and the licensed room to carry on the licensed liquor business? YES NO 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 (a) Hold any interest in the license applied for? business? YES YES YES NO NO NO (b) Furnish by way of loan or any other money or financial assistance for purposes hereof in your (c) Furnish, give, rent or loan any equipment, fixtures, interior decorations or signs other than standard brewery or manufacturer's signs? therewith: 5. Does the applicant have any interest or intent to acquire an interest in any other liquor license issued by this licensing authority? W.S. 12-4-103(b) YES If "YES", explain: (d) If you answered YES to any of the above, explain fully and submit any documents in connection NO 6. Is the applicant a mayor, member of a city or town council, or member of the board of county commissioners within the jurisdiction of this licensing authority? W.S. 12-4-103(a)(i) YES NO 7. Is the applicant employed by the State, City or Town, or County as a law enforcement officer, or hold office as a law enforcement officer through election? W.S. 12-4-103(a)(ii) YES NO RESTAURANT OR BAR AND GRILL LICENSE: 8. Have you submitted a valid food service permit? W.S. 12-4-407(a)/W.S. 12-4-413(a) YES NO RESORT LICENSE: 9. Does the resort complex: (a) Have an actual valuation of 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 (b) 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 NO (c) Include motel, hotel or privately owned condominium, town house or home accommodations approved for short term occupancy with at least one hundred (100) sleeping rooms? W.S. 12-4-401(b)(iii) YES NO (d) If no on question (c), have a ski resort facility open to the general public in which you have committed or expended at least one million dollars ($1,000,000.00)? W.S. 12-4-401(b)(iv) YES NO MICROBREWERY LICENSE: 10. Will the license be held in conjunction with another liquor license? W.S. 12-4-412(b)(iii) (a) If "YES", please specify type: 11. RETAIL RESTAURANT RESORT BAR AND GRILL MICROBREWERY WINERY YES NO YES NO (a) Do you self distribute your products? W.S. 12-2-201(a) (Requires additional licensing with the Liquor Division) (b) Do you distribute your products through an existing malt beverage wholesaler? W.S. 12-2-201(g)(i) (Requires additional licensing with the Liquor Division) YES NO WINERY LICENSE: 12. Will the license be held in conjunction with another liquor license? W.S. 12-4-412(b)(iii) (a) If "YES", please specify type: RETAIL RESTAURANT RESORT BAR AND GRILL MICROBREWERY WINERY YES NO LIMITED RETAIL (CLUB) LICENSE: 13. FRATERNAL CLUBS W.S. 12-1-101(a)(iii)(B) (a) Has the fraternal organization been actively operating in at least th