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HomeMy WebLinkAboutMT Department of Revenue - Pizza Hut Montana D venue 0006, Dan Bucks 2011 Bria Schweitzer Director _ OCT � 3 [C Governor October 28, 2011 CITY OF LAUREL RE: Application for Transfer of Ownership Montana Retail On- Premises Consumption Beer and Wine License of Montana On- Premises Consumption Beer and Wine License No. 03 -044- 9179 -301, PIZZA HUT, 119 4 Street South East, 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 any agency determines deficiencies exist that should be considered in the issuance of this license, please advise this office in writing by November 29, 2011. 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. In addition, if we receive a written protest against the issuance of this license, a public hearing will be scheduled. If no response is received, it will be assumed there are no problems that would affect the issuance of a license. If you have any questions, please call (406) 444 -3505. Sincere L / Jessica Burbank Compliance Specialist Department of Revenue Liquor Licensing PO Box 1712 Helena MT 59624 -1712 c: Department of Labor & Industry Montana Beer and Wine Wholesaler Association revenue.mt.gov • Toll free 1- 866 - 859 -2254 (in Helena, 444 -6900) A TDD (406) 444 -2830 CERTIFICATE OF SERVICE I certify that on this day of /b , 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(a�mt.gov ' C Check the Appropriate Boxes to Designate the Purpose of this Application Alcoholic Beverage Designate the Type of License New Alcoholic Beverage License of Your Application: © g Application D Existing Alcohoic Beverage License; Transfer of Ownership Application On- Premises Beer Existing Alcohohc Beverage License; Corporate Structure Change 13 On- Premises Beer/Wine 0 Existing Alcoholic Beverage License; Transfer of Location Application mil- Beverage f Existing Alcoholic Beverage License; Death of Licensee Restaurant Beer/Wine 0 Resort License Gambling An ownership interest in a licensed gambling operation may not transfer an interest in the operation to a stranger to the license until a new gambling license application reflecting the proposed transfer is submitted to the department and the department approves the transfer. An ownership interest in a licensed gambling operation may not be transferred to another owner or group of owners of an interest or interests in the same licensed gambling operation without submitting an amended gambling license application to the department and obtaining department approval. O New Gambling 0 New Gambling • No Akohollc Beverage Ucense is Required for Live Keno/Bingo. 1:3 Amended Gambling Ucense Application (Note: No fee is required for this application) O Existing Gambling License Change Among Existing 0 Existing Gambling License Deletion of Owner(s) Corporate Shareholder(s) 0 Existing Gambling Location Change Application 0 Existing Gambling License Change Among Existing 0 Existing Gambling License Type Change Application Partners or LLC/LLP Members 0 Other (Explain) Section 1 General Information Print or Type Name of Applicant HMII LLC (Oning entity such as Sole Proprietor /Partnerships/CorpJLLC/LLP) Business/Trade Name Pizza Hut G (An assumed business name must be filed with the Secretary of State and verification provided.) Mailing Address 3020 N Cypress, Suite 100; Wichita, KS 67226 (P.O. Box or Street) Address of Premises to be Licensed 119 4th Street S.E. (Street, Suite No., Building No.) City Laurel State MT Z Business Phone ( 316 )634 -1190 Cell Phone ( ) Fax ( 316 ) 6341662 Federal Tax I.D. Number OV , 0 Check if applied for but not yet received. Alcohol Beverage License Number 03 _ 044 _9179 b I _ 301 (WA if not applicable) Are the premises for licensing located: i3 Within the boundaries of an incorporated city/town (Gambling Licensing.) 0 Within a distance of five miles of an incorporated city/town (Alcoholic Beverage Licensing.) O Within an unincorporated city/town or outside the boundaries of and more than five miles distance from any city /town whether incorporated or unincorporated (Alcoholic Beverage Licensing.) Laurel in County of Yellowstone City Name County Name 2 L 4uso I Check the Appropriate Boxes to Designate the Purpose of this Application Alcoholic Beverage Designate the Type of License Q C C ,p New Alcoholic Beverage License Application f Your Application: {u E3 Existing Alcoholic Beverage License; Transfer of Ownership Application On- Premises Beer El Existing Alcoholic Beverage License; Corporate Structure CSfnIe2 0 7011 El On- Premises Beer/Anne Q Existing Alcoholic Beverage License; Transfer of L All- Beverage Q Existing Alcoholic Beverage License; Death of Licen 7 I ROL DIt�ISlO Restaurant Beer/Anne D Resort License Gambling An ownership interest in a licensed gambling operation may not transfer an interest in the operation to a stranger to the license until a new gambling license application reflecting the proposed transfer is submitted to the department and the department approves the transfer. An ownership interest in a licensed gambling operation may not be transferred to another owner or group of owners of an interest or interests in the same licensed gambling operation without submitting an amended gambling license application to the department and obtaining department approval. 0 New Gambling 0 New Gambling - No Alcoholic Beverage License is Required for Live Keno/Bingo. QAmended Gambling License Application (Note: No fee is required for this application) 0 Existing Gambling License Change Among Existing 0 Existing Gambling License Deletion of Owner(s) Corporate Shareholder(s) 0 Existing Gambling Location Change Application 0 Existing Gambling License Change Among Existing 0 Existing Gambling License Type Change Application Partners or LLC /LLP Members 0 Other (Explain) Section 1 General Information Print or Type Name of Applicant HMII LLC (Owning entity such as Sole Proprietor /Partnerships/Corp. /LLC/LLP) Business/Trade Name n/a (An assumed business name must be filed with the Secretary of State and verification provided.) Mailing Address 3020 N Cypress, Suite 100; Wichita, KS 67226 (P.O. Box or Street) Address of Premises to be Licensed 119 4th Street S.E. ty Laurel (Street, Suite No., Building No.) c State MT Zi Business Phone ( 316 )634 -1190 Cell Phone ( ) Fax ( 316 ) 634 -1662 Federal Tax I.D. Numbe V(4 0 Check if applied for but not yet received. Alcohol Beverage License Number 03 _044 _9179 OK-- _ 301 (NIA if not applicable) Are the premises for licensing located: El Within the boundaries of an incorporated city/town (Gambling Licensing.) 0 Within a distance of five miles of an incorporated city/town (Alcoholic Beverage Licensing.) 0 Within an unincorporated city/town or outside the boundaries of and more than five miles distance from any city/town whether incorporated or unincorporated (Alcoholic Beverage Licensing.) La urel in County of Yellowstone City Name County Name 2 C. Provide the information requested below for each: Check appropriate box (Use additional paper if necessary) • Individual /Sole Proprietor ❑ Person(s) holding an option to purchase the business ® General or ❑ Limited Partnership or any interest in the business © Limited Liability Company (Member of...) ❑ Other ❑ Officer of a Corporation ❑ Check this box if ownership in the alcoholic beverage ❑ Director of a Corporation license is also held as Joint Tenants with Rights of Survivorship (JTROS) or Tenants in Common (TEN Shareholder of a Corporation COM) and make certain each individual with rights of ❑ Shareholder owning 5% or more of the stock of a survivorship or common are listed below. • publicly traded corporation ❑ JTROS or ❑ TEN COM O Person(s) and/or committee managing the gambling activity under a 26 U.S.C. 501 (c)(3), (cx4),)(8) or (c) (19) organization Name (First, M.I., Last)Hal W. McCoy 11 Td I e SoIe member Date of Birth 7/22/1967 Social Security No. Number of Shares Address33 Mission; Wichita, Kansas 67206 Percentage of Ownership 100% Name (First, M.I., Last) Title Date of Birth Social Security No. Number of Shares Address Percentage of Ownership Name (First, M.1., Last) Title Date of Birth Social Security No. Number of Shares Address Percentage of Ownership Note: Each individual fisted above must submit with this application a Personal/Criminal History Statement (Form 10) and a completed Fingerprint Card and fee. Use additional sheet of paper if necessary. I hereby request smoking exception and affirm that 60% of the revenue generated by this business will be from the sale of alcoholic beverages and/or gambling. ❑Yes I do not request smoking exception. El No D. Charitable, Religious, Veterans' or Fraternal Organization If the applicant is a charitable, religious, veterans' or fratemal organization, complete the following information. If not applicable indicate: ® N/A Date qualified for exemption under 26 U.S.C. 501 (c)(3), (c)(4), (cX8) or (cx19): Month Day Year Date local charter issued or post organized: Month Day Year Has national organization been in existence for a period of five years prior to January 1, 1949? 0 Yes © No Provide Address of National Headquarters: Street Address City State Zip A copy of your organization or post charter must accompany this application. Location of Gambling Premises: Street Address City State Zip How many days, per year, is gambling conducted at this location? Days 4 C. Is the premises within any defined zones: 1. Where the sale of alcoholic beverages is restricted by city or county zoning ordinance? Yes El No 2. Where gambling is restricted by city or county zoning ordinance? D Yes d No D. Is the building ready for use for an alcoholic beverage business: ®YesD No 1. Is this a newly constructed premises? IIYes Ed No If Yes, indicate an estimated date of occupancy 2. Is this a remodel of an existing premises? El Yes El No If Yes, indicate an estimated date of completion E. Submit a copy of the floor plan area to be licensed, using approximate dimensional measurements, including external dimensions and general layout - on an 8 -1/2" x 11" sheet of paper and number of tables and chairs indicated. If you are applying for a restaurant beer and wine license, be sure the floor plan has the service bar area clearly designated thereon. Note: On the floor plan you will need to clearly mark the areas where alcohol will be served, stored and consumed. The floor plan must contain outside dimensions, the name of the establishment, physical address, alcoholic beverage license number (if applicable) and date of submittal. 13 • Section VII Declaration and Authorization APPLICANT'S FORMAL DECLARATION AND AUTHORIZATION FOR EXAMINATION AND RELEASE OF INFORMATION 1, Hal W. McCoy II , hereby declare under the penalty of law and/or the revocation of any licenses granted pursuant hereto, that 1 am the applicant or duly authorized representative of the firm or corporation making this application and that I have examined the application, including any accompanying Information, and that the responses provided herein are true, correct and complete. I understand if this application or attachment(s) contains false information, I am subject to the criminal penalties of Section 45 -7- 202, 45-7 -203 and 45 -7 -208, Montana Code Annotated, and /or revocation of any alcoholic beverage or gambling licenses granted pursuant to this application. further authorize a full review, disclosure and release to any duly authorized officer, agent or employee of the Montana Department of Justice, Gambling Control Division, of any and all records concerning me that the Montana Department of Justice properly determines relate to my qualifications for gambling and /or liquor licensure, whether the records are of a public, private, or confidential nature. SIGNATURE ' PRINT FULL NAME Hal W. McCoyll TITLE /POSITION Member DATE 114 i This application must be completed in full, and all requested attachments must accompany it. Delay, denial or the retum of the application will result if incomplete. 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