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Home My WebLink AboutMT Department of Revenue Montana Department of Rev- nue >- Dan Bucks Brian Schweitzer Director OCT 8 2010 Governor October 7, 2010 CITY OF LAUREL RE: Application for Issuance of One Original (NEW) Montana Retail Off - Premises Consumption Beer and Wine License No. 03- 999 - 9523 -303, FASTLANE C- STORE, 815 East Main Street, Laurel, Yellowstone County, Montana NEWLY LICENSED PREMISES The above referenced (NEW) application was received at the Department of Revenue, Liquor Licensing. Notice is being provided to you to give you an opportunity to advise if the applicant and premises meet all the laws and ordinances your office is responsible for regulating. We will be happy to provide any additional information that is needed. Local laws are not enforced through the alcoholic beverage licensing process; however, if there are local laws affected by this application, compliance with those laws may influence the final determination to issue the license. This is a (NEW) application for a premises not currently licensed for the sale of alcohol. Building, health and fire approval will be required before department approval will be considered. If any agency determines deficiencies exist that should be considered in the issuance of this license, please advise this office in writing by November 6, 2010. If we receive a determination of a local deficiency, the license application process cannot be completed until the issue is cleared up at the local level. I would be happy to assist you if you have any questions. Please contact me at the address, phone number or e-mail listed below. Sincerely, rn4i Susan M. Gardipee Compliance Specialist Department of Revenue Liquor Licensing P 0 Box 1712 Helena MT 59624 -1712 Telephone (406) 444 -7927 sugardipee c: Department of Labor & Industry Montana Beer and Wine Wholesaler Association revenue.mt.gov • Toll free 1- 866 - 859 -2254 (in Helena, 444 -6900) • TDD (406) 444 -2830 CERTIFICATE OF SERVICE I certify that on this 7 day of October , 2010, a true and correct copy of the foregoing has been served by placing same in the United States mail, postage prepaid, and addressed as follows: LAUREL CITY COUNCIL PO BOX 10 LAUREL MT 59044 LAUREL CITY ATTORNEY PO BOX 10 LAUREL MT 59044 LAUREL POLICE CHIEF MIKE ATKINSON PO BOX 10 LAUREL MT 59044 LAUREL CITY BUILDING INSPECTOR PO BOX 10 LAUREL MT 59044 YELLOWSTONE COUNTY SANITARIAN BOX 35033 BILLINGS MT 59107 YELLOWSTONE COUNTY TREASURERS OFFICE P O BOX 35010 BILLINGS MT 59107 -5010 ADMINISTRATIVE ASSISTANT FIRE PREVENTION AND INVESTIGATION BUREAU 303 NORTH ROBERTS BOX 201415 HELENA MT 59620 -1417 Y?/1 Return to: tono REV F M UE SEP 1 3 2010 One-Stop Licensing Montana Department of Revenue PO Box 8003 = DEPARTMENT OF REVENUE Helena, MT 59604 -8003 Off-Pre WARPS LICENSING Liquor License Application I Section 1: Entity/Transaction I Check appropriate boxes: 1. Business Entity 2. Transaction 3. License Type /Fee ❑ Individual (one person) JET' New License ler Processing Fee - $100.00 (All) ❑ Corporation ❑ Transfer of Location - License # ❑ Off - Premises Beer - $200.00 id Other ),j4_, ❑ Off- Premises Wine - $200.00 ❑ Corporate Structure Change - License # 11( Off- Premises Beer/Wine - $400.00 Attach additional pages if more space is needed Section 2: General Information I Instruction for completing applicant name. Y If Individual, list individual's name. ➢ If Corporation, provide current corporate statement or list of officers, directors and shareholders and Certificate of Existence/ Authority. > If Other... - If more than one individual , list names of all below. - If partnership, list partnership name below then, individual partners' names and provide copy of the partnerships Certificate of Limited Partnership, Certificate of Fact or Certificate of Registration. - If LLC, list LLC name below then, all members' names and provide a copy of the Certificate of Fact. 1. Name of Applicant(s) �� 54 (0 144._ C 5 .+b( - Business Telephone No(4 )b - . -Lao ' Fax No.6100 6 a.8 - Zo 4 Federal Tax I.D. No.. 2. Name of Person Managing Business " I ( P L. ��r.) 3. Provided Personal History & Release of Information forms for each individual, partner, 10% stockholder, member or manager. 4. B Yes ❑No (1 1 usiness!Trade Name c# 6 n F ( t 6.. (doing business as... Assumedb name must be filed with the Secretary of State's Office) � Mailing Address /V /, A , cY e b r i e City, State, Zip 1,.., - & TPl,, r `]` ..,596 a4 4a. Address of premises to be licensed, if different than mailing address. Give Exact Location of Premises, including a street and number. /^ / ,�y� ( ``- Physical Address l'" Pa ST IZ Z n S + ee City, State, Zip � Qla.,\ ' .I my , . fa 5i 5. Is your location within an incorporated city/town? Yes ❑ No 6. Are the premises within any defined zones whey the sale of alcoholic beverages is prohibited by city /county ordinances? ❑ Yes X No COrk v t e il � re- 7. Is your premises proposed for licensing operated as a ❑GGrocery Store If groce store - attach copy of inventory (Form G -1) ❑ Drugstore If drug store - attach copy of pharmaceutical license 8. Do you now or will you own the building proposed for licensing? ❑ Yes No If No, please provide a current or proposed lease or rental agreement. If Yes provide acceptable proof of ownership. 9. Is the building ready for occupancy? ❑ Yes ' No If No, indicate estimated date of occupancy: / / f r:l �/ 0 10. Will you be remodeling or constructing the premises? yi( Yes ❑ No If Yes, indicate estimated date of completion: /q// 51/ 0 (Date) 11. Submit copy of current floor plan of licensed premises. Floor plan must include external dimensions and general layout on an 81/2" x 11" sheet of paper. Identify trade name of premises, address and date. 12. Please send a copy of your bank signature card. 21 518 Section 3: Temporary Authority The undersigned, requests authority to operate pending final approval of the license. Temporary authority may be granted to an applicant by the Department of Revenue if the current premises has been licensed in the past year for the sale of alcohol and no building, health, or fire deficiencies exist. The undersigned agrees that during the period of temporary operating authority, the applicant shall be responsible for all beer and wine purchased pursuant to Section 16 -3 -243, MCA (the seven -day credit limitation). I realize temporary authority will be immediately revoked if my employees or I violate any provisions of Title 16, MCA or the departments rules. Temporary authority cannot be granted for a transfer of location. I would like temporary authority issued on (Date) Section 4: Notice To Applicants In order for your application to be considered complete you must include all associated or related documents as indicated by your specific circumstance in the accompanying check sheet. Processing a license application takes approximately two (2) to three (3) months based upon the Department's determination of receipt of a complete application, if no deficiencies are received. You will be notified when a decision regarding the application has been made. I Section 5: Declaration and Affidavit This application must be signed by the applicant or by a duly authorized representative of the entity submitting this application. The person who signs this application attests that the information contained in the application is correct and complete. Montana law says "Upon proof that an applicant made a false statement in any part of the original application, in any part of an annual renewal application, or in any hearing conducted pursuant to an application, the application for the license may be denied, and if issued, the license may be revoked." (Section 16- 4-402, Montan , des Annotated) �i; — v 9 1 a Ito Signature Date nr te_ 1 > . Imo S (Kg rune (- Printed Name Title Section 6: Corporate Statement (includes Corporations, LLC's, LLP's and Partnerships) The stockholders /members/partners are: Name Address Social Security Date of Birth Number of T Number Shares • ottgre 4.1 Lea Total Shares: Officers and Directors of the Corporation are: Name Address Title Ai ,I * lamas l �■� rw Pres ; vdvit. r_ L, Fs l .5-2 c.1 Tf.e4 $ offprem00 Revised 05-06 22 Form G -1 Rev. 5/97 Grocery Inventory Section 16-4- 115(1), MCA states a retail license to sell beer or table wine in the original package for off - premises consump- tion only may be issued to a qualified applicant whose premises proposed for licensing is operated as a bona fide grocery store or a drug store licensed as a pharmacy. ARM 42.12.126(2) "The retail inventory of $3,000 will be used as a basis for determining whether an establishment qualifies as a "bona fide grocery store ". The retail inventory of at least $3,000 must be maintained at all times. The retail inventory must include at least three different types of items in each of the following food groups; meats, vegetables, fruits, bakery items, dairy products and household supplies. For example, three different types of items in the dairy products group would be a cheese, a milk and a butter, but skim milk, chocolate milk and whole milk would not be considered as three different types of items in the dairy products group." List three different types of food items you carry within each category listed below. Under Total Inventory state the total dol- lar retail inventory maintained in these above six food groups. Three Food Types Meats V c? cGirt/lc -r-� x �• Vegetables Fruits i fJ�� -�� ( � p � ir�� Bakery Items ('-,� .)/z,n Dairy Products 69-19vt..- Household its {/ .024 7!'i .pt d .0 -4J ��P�r�.t�• h a.�. /-° Total Inventory of Above Food Groups $ (Y')o,G !certif this inventory to be correct. 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