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HomeMy WebLinkAboutMontana Department of Revenue (4) Montana Departmentof Revenue 1. t; \'� � Dan Bucks s l ; I Brian Schweitzer J � Director ff 1 MAY 2 5 2012 J Governor May 22, 2012 CITY OF LAUREL RE: Application for Corporate Structure Change of Montana Retail Off - Premises Consumption Beer and Wine License No. 03- 999 - 9143 -303, CVS PHARMACY #5305, 307 South East 4th 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 us that 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 y agency determines deficiencies exist that should be considered in the issuance of this license, please advise this office in writing by June 21, 2012. 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 and we are notified the issues have been resolved. If no response is received, 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. Sincerely, ce•Ca•--- W14:41//4126Q Susan M. Gardipee Compliance Specialist Department of Revenue Liquor Licensing P 0 Box 1712 Helena MT 59624 -1712 Telephone (406) 444 -7927 sugardipeeamt.aov c: Department of Labor & Industry Montana Beer and Wine Wholesaler Association revenue.mt.gov A Toll free 1- 866 - 859 -2254 (in Helena, 444 -6900) • TDD (406) 444-2830 CERTIFICATE OF SERVICE I certify that on this ci 3 day of h 2012, 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 0 BOX 35010 BILLINGS MT 59107 -5010 ADMINISTRATIVE ASSISTANT FIRE PREVENTION AND INVESTIGATION BUREAU 303 NORTH ROBERTS BOX 201415 HELENA MT 59620 -1417 alorenzamt.gov MONTANA n,,ar Rev 05 11 REVENUE r RECEIVED Montana Retail Off - Premises Consumption Beer and Wine License Application DEC 1 9 2011 Section 1 - General Information Dept. cm rievvnu Liquor Licensing 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. Name ofApplicant(s) Montana CVS Pharmacy, LLC FEIN/09I4 - Contact Person Cathy Tardie Trade Name of Business CVS /pharmacy 145305 Physical Address of Premises to be Licensed 3U SC y N ` 54,0- 0- (Street Address, City(State) 90"7/1/ Is the physical address located within t e city limits r county area? (please circle one). Mailing Address One CVS Drive, MD #23062A, Woonsocket, RI 02895 (Street or PO Box, Address, City, State and Zip Code) Telephone 401- 770 -3355 Fax 401- 216 -3782 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: El New License Office Use Only Amount Paid $ $ 100.00 One -time Off - Premises Processing Fee (non- refundable) A Owed $ New mount 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 in 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 \ \3 17 see ction 3 — Corporate Statement All entities exceptsole 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 FID #- Sole Member: CVS Pharmacy, Inc. Address One CVS Dative, Woonsocket, RI 02895 Date of Birth Actual Number of Shares and % of Ownership 100% 2 Shareholder, Member or Partner Name FID Sole Shareholder: CVS Caremark Corporation Address One CVS Drive, Woonsocket, RI 02895 Date of Birth Actual Number of Shares and % of Ownership 1002 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 See Corporate Officer List Attached Liquor License Committee: Thomas S. Moffatt — One CVS Drive, Woonsocket, RI 02895 — Preside Linda M. Ciabron — One CVS Drive, Woonsocket, RI 02895 — Assistant Secretary 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? ® 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 EEKio 4. Do you own or are you purchasing the building proposed for licensing? ❑ Yes li lo ; � Section 5 — Manager Information , 1 Name of the person managing the business e 101 5.. Is this person a shareholder, member or partner? ❑ Yes Q4 o 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 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 declare under penalty of false swearing that the information provided on this application and its attachments are true, correct and complete. fi gt ie;m41M1. /F a 3 �Uj� Linda M. Ciibron Assistant Secretary Sig ature Date 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 rage 1 of STATE OF MONTANA Pharmacist in Charge: Department of Labor and Industry CARL RAY WALLILA Board of Pharmacy Endorsement: This verifies the below named is currently licensed as a TECHNICIAN UTILIZATION PLAN Community Pharmacy DISPENSER OF DANGEROUS DRUGS License #: 1254 Active Expires: 11/3012012 MONTANA CVS PHARMACY LLC DBA CVS PHARMACY #5305 307 SOUTHEAST 4TH ST LAUREL, MT 59044 To use license as a Wall License, cut off excess paper and affix the above to wall for display. To use the license as a Pocket Card, cut to the size of a business card or drivers license. (either single or double-wide to fold), laminate if desired. Remember to renew online if possible. Benefits of renewing online include: The ability to change an address (for most professionals) The ability to print license(s) the same day as the renewal The ability to print multiple licenses including one for a pocket card if desired The ability to print in color (if you have a color printer) The ability to print additional licenses for no additional charge up to 60 days following your renewal date. To renew online: http: / /UcenseRenewal.mtgov s;7 If you paid with a credit card or electronic check, this charge will appear on your statement as MT.GOV PURCHASE. Date Paid: November 02, 2011 Reference Number: bsdrnwa11305163823246901 Licensee: MONTANA CVS PHARMACY LLC License Type: Community Pharmacy License Number: 1254 License Renewal Fee: $425.00 https: // app. mt. gov /cgi- bin/renewal /renewal.cgi? action = download& sessionid= bsdrnwa11305163823246901 11 /2/2011 , 40 1 1 I a p i. 1. 1 5 o ill m sr. LA. g . 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