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Home My WebLink AboutMT Department of Revenue (2) Montana Depa - -R nue ,' w . i 4 i Dan Bucks n A 1 8 2011 Brian Schweitzer Director }J t1 _J Governor August 17, 2011 _ CITY Y OF LAUREL RE: Application of Issuance of One Original (NEW) Montana Retail Off - Premises Consumption Beer and Wine Licenses 1. No. 03- 999 - 9134 -303, CONO MART SUPER STORE #2, 411 Highway 212 South, Laurel, Yellowstone County, Montana 2. No. 03- 999 -9479 -303, CONO MART SUPER STORE #3, 519 West Main Street, Laurel, Yellowstone County, Montana The above referenced 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. If anv agency determines deficiencies exist that should be considered in the issuance of this license, please advise this office in writing by September 15, 2011. If we receive a determination of a local deficiency, the license application process cannot be completed until we are notified the issue is cleared up at the local level. If no response is received by your agency, it will be assumed there are no problems that would affect the issuance of a license. 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. Sin rely, , , ry i .iik,k,/,„ur Susan M. Gardipee Compliance Specialist Department of Revenue Liquor Licensing P O Box 1712 Helena MT 59624 -1712 Telephone (406) 444 -7927 sugardigee 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 17 day of August , 2011, 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 RICK MUSSON 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 alorenz @mt.gov i • RECEIVED AUG 0 4 2011 MONTANA Rev 05 11 AILEVEN Dept. of Kevenue Vquor Ucensing Montana Retail Off- Premises Consumption Beer and Wine License Application Section 1 - General Information Note: If the a p p l i c a n t i s an i n d i v i d u a l , l i s t t h e i n d i v i d u a l ' s name below. If the applcant is a partnership, limited liability partnership (LLP), corporation or limited liability company (LLC), list the business entity name below. Name ofApplicant(s)61J1 &at ano, FEIN /SSN Contact Person BFp DU& Trade Name of Business l A)Qk' t re 2 Physical Address of Premises to be Licensed Olt NLOt4 2)2 6. u i0 (Street Address, City, State) Is the physical address located within th ci li mrts r county area? (please circle one). Mailing Address PO E t) LgJl 0U � 1Q1 -O l --J (Street or PO Box, Address, Giy,y, State and Zip Code) Telephone 400 - (ps 5101 Fax 406-09-02105 Section 2 - Type of Transaction and Fees (This license must be renewed on an annual basis. The fees are $200.00 for beer, $200.00 for wine and $400.00 for beer and wine.) Please check the box that applies to the type of application you are completing and include the fee for the type of license you are applying for: l'/ New License omce Use Only Amount Paid $ $ 100.00 One -time Off - Premises Processing Fee (non-refundable Amount owed g fdbl ( ) New Lice Nu mber $ 200.00 Beer License Fee $ 200.00 Wine License Fee Account Number $ 400.00 Beer and Wine License Fee $ 29.25 Background Check Processing Fee for each individual (non - refundable) ❑ Transfer of Location ❑ Corporate Structure Change $ 100.00 Transfer of Location or Corporate Structure Change Processing Fee (non - refundable) $ 29.25 Background Check Processing Fee for each individual (non - refundable) Current License Number 01 r 17 • Section 3 — Corporate Statement All entities except sole proprietors and individuals please complete the following information for all shareholders, members or partners (please attach additional pages if necessary). Please Print 1 Shareholder, Member or Partner Name SS Address la 1191111 41 11/1k D to of Bi Actual Number of Shares.and % of Ownership 2 Shareholder, Member or Partner Name SSN Address Date of Birth Actual Number of Shares and % of Ownership 3 Shareholder, Member or Partner Name SSN Address Date of Birth Actual Number of Shares and % of Ownership 4 Shareholder, Member or Partner Name SSN Address Date of Birth Actual Number of Shares and % of Ownership Officers and Directors Name Address Title 18 Section 4 — Questions 1. Is this premises proposed for licensing going to be operated as a ❑ Grocery Store? ❑ Drugstore? 2. Is the building complete and ready for use? 131 ❑ No If "No" please provide expected date of completion 3. Is the location to be licensed within a zone or area where the sale of alcoholic beverages is not allowed byci — county, or tribal ordinances? ❑ Yes No 4. Do you own or are you purchasing the building proposed for licensing? ❑Yes 6/No Section 5 — Manager Information \ Name of the person managing the business [QA'lti i2 lAlhihn %' Is this person a shareholder, member or partner? I? Yes ❑ No If you answered "No" please include your management agreement with this application and enter the date of hire Section 6 — Temporary Operating Authority Temporary Operating Authority can be requested if the current premises was previously licensed in the last year for the sale of alcohol, and no budding, health or fire deficiencies exist. Please be aware that Temporary Operating Authority will be revoked if you or your employees violate any provisions of Montana Code Annotated or Administrative Rules of Montana. Please provide the expected date that Temporary Operating Authority will begin f (` Section 7 — Declaration and Affidavit This application needs to be signed by all individuals, partners or members. In the case of a corporate applicant, it may be signed by one shareholder or officer with authority to sign. I e de lare under penalty of false swearing that the information provided on this application and its ttach are true, j ect and complete. ..._ Vizpi �, f W�,.40 ter ignature D Printed Name Title Signature Date Printed Name Title Signature Date Printed Name Title Mail completed application and all necessary documents to: Montana Department of Revenue Liquor Control Division PO Box 1712 Helena, MT 59624 -1712 Questions? Call us toll free at 1- 866 - 859 -2254 (in Helena, 444- 6900), or Fax (406) 444 -0722. 19 • MONTANA G -1 Rev 01 11 Grocery Inventory A retail license to sell beer or table wine in the original package for off - premises consumption may only 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, Montana Code Annotated (MCA), 16-4 - 115(1). A "bona fide grocery store" is defined in Administrative Rules of Montana, (ARM), 42.12.106 (2). A retail inventory of $3,000 will be used as a basis to determine whether your establishment qualifies as a "bona fide grocery store" and must be maintained at all times and have available at least three different types of items in each of the food categories below. Please list the three different types of food and household items from your retail inventory that you must sell for consumption off- premises. (Example of three food types in the meat category are: canned tuna, bologna or beef jerky; examples in the vegetables category are: canned peas, fresh lettuce or frozen corn.) Meats 1 Al20/ 2Q LangELEILIE Vegetables PAP UPI £Jjrn &mud No V,Q k 0 Fruits Conaivi pPi2nh Gary of p21Z4'' Bakery Items ODfl tics Pri Qt,' I e ' , C ip • Dairy Products Newsp l ( 4L 7 Household Supplies / 5)(0 Pa. X Y Poi (W� f j n I Please enter the retail inventory dollar amount of your grocery inventory. $ 35") 1 i I certify the retail inventory to be true, correct and complete. C no Mari- G Slue Busin r Trade Name County c_stri :26er Date e pri- Signature MONTANA F -1 Floor Plan Exterior Dimensions and General Layout Design Rev 01 11 We will accept a prepared design layout on a 8 -1/2" x 11" sheet of paper that includes the business trade name, location address and date, or you may use this form to draw your floor plan design. 50 t 1 PLIMPB 112 PRA lQS' 1 ,tOPS N C 000e. COOLEE .� Tai ila TL - oo_ e 0 Co m Ml - ( 3�rr 2 Busines Trade Name iiii Hwy 212. S. L.a e ! f1T S414 Address 7 /21/i 1 Date RECEIVE[ AUG 0 4 2011 MONTANA • A& Rev 05 11 Manua IVU Dept. of Revenue Liquor Licensing Montana Retail Off- Premises Consumption Beer and Wine License Application Section 1— General Information Note: If the applicant is an individual, list the individual's name below. If the applicant is a partnership, limited liability partnership (LLP), corporation or limited liability company (LLC), list the business entity name below. I ' Name of Applicant(s) th t,1l (.40:33 L FEIN /SSN Contact Person &OphIlIU/ I Trade Name of Business (,gyp b' 314 &war ,t3 4t,g Physical Address of Premises to be Licensed SO W {-1 i( LollorpA N t 1 ffiD1 (Street Address, City, State) Is the physical address (V �� )1� located within the or county area? (please circle one). , Mailing Address 1'' P �71r� ( f �1�� t�` (Street or PO Box, Address, Ofty State and Zip Code) Telephone - IOLv'- (p51- 5161 Fax 4019- 1 - 0719?) Section 2 — Type of Transaction and Fees (This license must be renewed on an annual basis. The fees are $200.00 for beer, $200.00 for wine and $400.00 for beer and wine.) Please check the box that applies to the type of application you are completing and include the fee for the type of license you are applying for: Office Use Only New License Amount Paid $ $ 100.00 One -time Off - Premises Processing Fee (non-refundable Amount Owed $ g d ( ) New License Number $ 200.00 Beer License Fee Account Number $ 200.00 Wine License Fee $ 400.00 Beer and Wine License Fee $ 29.25 Background Check Processing Fee for each individual (non - refundable) ❑ Transfer of Location ❑ Corporate Structure Change $ 100.00 Transfer of Location or Corporate Structure Change Processing Fee (non - refundable) $ 29.25 Background Check Processing Fee for each individual (non - refundable) Current License Number 6" nG 17 Section 3 — Corporate Statement All entities except sole proprietors and individuals please complete the following information for all shareholders, members or partners (please attach additional pages if necessary). Please Print 1 Shareholder, Member or Partner Name SSN 0Onr S (A )ha m1rQ Addr s — -- — — _ Date o i h Actual Numb and % of Ownership 2 Shareholder, Member or Partner Name SSN Address Date of Birth Actual Number of Shares and % of Ownership 3 Shareholder, Member or Partner Name SSN Address Date of Birth Actual Number of Shares and % of Ownership 4 Shareholder, Member or Partner Name SSN Address Date of Birth . Actual Number of Shares and % of Ownership Officers and Directors Name Address Title 18 • Section 4 — Questions 1. Is this premises proposed for licensing going to be operated as a ❑ Grocery Store? ❑ Drugstore? 2. Is the building complete and ready for use? I Yes ❑ No If "No" please provide expected date of completion 3. Is the location to be licensed within a zone or area where the sale of alcoholic beverages is not__ _ allowed by city, county, or tribal ordinances? ❑ Yes dNo 4. Do you own or are you purchasing the building proposed for licensing? ❑ Yes Is No Section 5 — Manager Information 1 Name of the person managing the business 1>o/11 j9 h) kr (p) Is this pejson a shareholder, member or partner? ® Yes ❑ No If you answered "No" please include your management agreement with this application and enter the date of hire Section 6 — Temporary Operating Authority Temporary Operating Authority can be requested if the current premises was previously licensed in the last year for the sale of alcohol, and no building, health or fire deficiencies exist. Please be aware that Temporary Operating Authority will be revoked if you or your employees violate any provisions of Montana Code Annotated or Administrative Rules of Montana. Please provide the expected date that Temporary Operating Authority will begin Oh 1) Section 7 — Declaration and Affidavit This application needs to be signed by all individuals, partners or members. In the case of a corporate applicant, it may be signed by one shareholder or officer with authority to sign. I/We = are under penalty of false swearing that the information provided on this application and its al = - ents are true, ect and complete. G , ` / ^ • "AVM 4e.` Signature D. e Printed Name Title Signature Date Printed Name Title Signature Date Printed Name Title Mail completed application and all necessary documents to: Montana Department of Revenue Liquor Control Division PO Box 1712 Helena, MT 59624 -1712 Questions? Call us toll free at 1- 866 - 859 -2254 (in Helena, 444 - 6900), or Fax (406) 444 -0722. 19 MONTANA G -1 Rev 01 11 Grocery Inventory A retail license to sell beer or table wine in the original package for off - premises consumption may only 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, Montana Code Annotated (MCA), 16-4- 115(1). A "bona fide grocery store" is defined in Administrative Rules of Montana, (ARM), 42.12.106 (2). A retail inventory of $3,000 will be used as a basis to determine whether your establishment qualifies as a "bona fide grocery store" and must be maintained at all times and have available at least three different types of items in each of the food categories below. Please list the three different types of food and household items from your retail inventory that you must sell for consumption off -premises. (Example of three food types in the meat category are: canned tuna, bologna or beef jerky; examples in the vegetables category are: canned peas, fresh lettuce or frozen com.) Meats da (7fI(pd LP WAT/h 'v t„ QJ Vegetables canned cArf t2af apd ppa Y iV JaA' Y P Fruits Canoed p0 laud p4'ci&h Bakery Items Y?,1, 21 Cook As Dairy Products I�I� y ur4 L SRC i v Jt11[. Household Supplies PO Rai ! 6 ( y'1+ Please enter the retail inventory dollar amount of your grocery inventory. $2a ) I certify the retail inventory to be true, correct and complete. NT* ORA L Q gI re Businessade Name County 126111 Date, ture MONTANA F -1 Floor Plan Exterior Dimensions and General Layout Design Rev 01 11 We will accept a prepared design layout on a 8 -1/2" x 11" sheet of paper that includes the business trade name, location address and date, or you may use this form to draw your floor plan design. gir 419 eaeTEES Qt*- Dtmoz e OD C (2- r L MX ) Business Tra Name 50 Cc) I4air L jiri 4 K 5044 Address Date