HomeMy WebLinkAboutMontana Department of Revenue (6) ilk
Montana Department of Revenue
Mike Kadas i 1
Director
---- Steve Bullock
Governor
U Li JAN 1 2 2015 V 09-Jan-2015
Account ID: 6289939-005-ONP TY
`''
' Letter ID: L1402200704
License Type: Montana Retail On-Premises Consumption Beer and Wine with Catering
Endorsement License
License Number: 03-044-9315-302
RE: Application for Transfer of Ownership of Montana Retail Beer and Wine with Catering
Endorsement License for Dollar Bills, Ta, Travelcenters Of America, (formerly known as
Pelican Truck Plaza) 11360 1-90 Frontage Rd, Laurel, Yellowstone County, Montana
The above referenced application was received at the Department of Revenue, Liquor Control
Division. Notice is being provided to you to give you an opportunity to advise if the applicant
and premises meet a!! 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 February 08, 2015. 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 concerning this or any other matter, please feel free to contact me at
the number listed below.
Sincerely,
Cori Kerins
Compliance Specialist
PO Box 1712
Helena, MT 59624-1712
Phone: (406)444-0712
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 ( day of IA, 2014, 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
RIVERSTONE HEALTH
123 SOUTH 27TH STREET
BILLINGS MT 59101
YELLOWSTONE COUNTY
TREASURERS OFFICE
PO BOX 35010
BILLINGS MT 59107-5010
ADMINISTRATIVE ASSISTANT
FIRE PREVENTION AND INVESTIGATION BUREAU
303 NORTH ROBERTS BOX 201415
HELENA MT 59620-1417
alorenz@mt.00v
MID
Check the Appropriate Boxes to Designate the Purpose of this Application
Alcoholic Beverage Designate the Type of License
❑New Alcoholic Beverage License Application of Your Application:
ffi Existing Alcoholic Beverage License;Transfer of Ownership 0 On-Premises Beer
❑ Existing Alcoholic Beverage License;Licensee Structure Change: NI
On-Premises Beer and Wine
(Addition of shareholder,member or partner not previously qualified) ❑All-Beverage
❑Restaurant Beer and Wine
❑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.
CI New Gambling
❑Gambling Only-No Alcoholic Beverage License is required for Live Keno/Bingo.
General Information
Print or Type
Name of Entity Applying TA Operating Montana LLC
(Owning entity Sole Proprietor/PartnershipslCorp./LLC/LLP i.e.John's Bar LLC)
Business/Trade Name Dollar Bill's ,TA,TravelCenters of America
Business Address of Premises to be Licensed 11360 I-90 Frontage Road.Laurel.Montana 59044
(Street,Suite No.,Bulking No.,City,ST and Zip)
Mailing Address 24601 Center Ridge Road
(P.O.Box or Street,City,ST and Zip)
City Westlake State Ohio Zip 44145
Business Phone ( 617 ) 796-8157 Cell Phone ( )
Fax( 617 ) 969-4697 E Mail address jnynrmZ@ta-petro corn
Federal Tax I.D.Number
Alcohol Beverage License Number 03 - 044 - 9315 - 302
(N/A if not applicable)
Check this box If you wish all correspondence sent to the attorney who submitted this application on your behalf.
Are the premises for licensing located:
❑Within the boundaries of an incorporated city/town.(Liquor and Gambling Licensing)
DI Within a distance of five miles of an incorporated city/town.(Liquor Licensing)
❑ Within an unincorporated city/town or outside the boundaries of, and more than five miles distance from, any city/town
whether incorporated or unincorporated.(Liquor Licensing)
Laurel in the County of Yellowstone
City Name County Name
2
r
IIIIIIID
Ownership Information
A.The applicant is a: (See information checklist for documents required for each ownership type)
❑ Individual(s)/Sole Proprietor(s) Individuals and Partnerships may wish to apply
❑ Partnership as Joint Tenants with Rights of Survivorship
0 General 0 Limited (JTROS)or Tenants in Common(TENCOM).
FR Limited Liability Company Make certain each individual with right of
❑ Limited Liability Partnership survivorship or tenant in common is listed below.
❑ Charitable or Non-Profit Organization qualified
Under 26 U.S.C.501(c)(3),(cX4),(c)(8)or(c)(9) 0 JTROS or 0 TEN COM
❑ Retirement home or nursing home(Gambling Only)
❑ Corporation
❑ C Corporation
❑ Subchapter S j
❑ Publicly Held
In the spaces below, list all owners, partners,members,officers and/or directors.Each individual listed below must
submit 2 completed fingerprint cards,personalcriminal history statement and fees. Use additional sheet of paper if
necessary.For applicants that use a multiple entity structure,attach a diagram showing all entities and individuals.
Name(First, M.t., Last) Thomas M. O'Brien Title Director/President
Date of Birth Social Security No. _ Number of Shares_ N/A
Address 30622 Lake Road,Bay Village OH 44140 Percentage of Ownership 0
Name(First, M.1., Last) Andrew i Rehhnh Title Director/CFO/VP/Secretary
Date of Birth, Social Security No. _ 5 Number of Shares N/A
Address 18054 Spyglass Hill,Strongsville,OH 44136 Percentage of Ownership 0
Name(First, M.l., Last)TravelCenters of America Holding Company LLC Title Sole Member
Date of Birth_ Social Security No. - Number of Shares N/A
Address 24601 Center Ridge Road,Westlake,OH 44145 Percentage of Ownership 100%
®®
Management Information
A. Provide the following information for each management employee. If applying as an entity,include the manager
of the day-to-day operation for the business.Attach management agreement if applicable. Each individual listed
below must submit 2 completed fingerprint cards,personal/criminal history statement(s)and fee(s).
0 Gambling 0 Alcoholic Beverage II Both 0 N/A
Name TA Operating LLC Date of Birth_ Social Security No.
Address 24601 Center Ridge Road.Westlake.OH 44145 Phone 440-808-9100 Salary Mannn o, f/yr,
Name On site manager TBD Date of Birth Social Security No.
Address Phone Salary
3
011111110
Premises Information
A. Does the applicant's premises:(Use additional paper if necessary)
1. IXYes 0 No Have
permanently installed walls extending from floor to ceiling?
2. DA Yes 0 No Have a distinct address?
TA Operating LLC dba
3. raYes 0 No Share an address with another business? If Yes,name the business: TravelCenters of America
4. ❑Yes I10 No Have a public external entrance that is shared with another premises for which a gambling operator
license has been issued? If Yes,name the business:
5. ❑Yes IX No Share a common internal wall with another premises to which a gambling operator license has been
issued?If Yes,explain and submit copy of the floor plan and also name of operator/owners:
6. INYes 0 No Have a bar and at least 12 seats at the bar,tables or booths independent of gaming machines?
B. Describe where the premises is located:
• 1. Are the entrance doors of the premises proposed for licensing on the same street as,and within 600 feet of,the
entrance doors of a building occupied exclusively as a church, synagogue or other place of worship or school
(except a commercially operated or post secondary school)?
❑Yes $1 No
2. Is the premises located within 150 feet of another premises licensed for on-premises alcoholic beverage consumption?
(As defined in 23-5-629 MCA)
❑Yes IX No If yes,answer all the following questions and include name of premise licensed:
❑Yes 0 No Does the second premises already have a permit for placement of video gambling machines?
O Yes 0 No Is there a structural walkway between the two premises?
O Yes 0 No Is the second premises licensee affiliated with the applicant?
❑ Yes 0 No Is there an immediate family member related to the applicant within the ownership structure of the
second premises licensee?
❑Yes 0 No Do the two licensed premises share any common management personnel?
O Yes 0 No Would the applicant be considered a parent or subsidiary business entity to the second licensee?
❑Yes 0 No Does any person or entity within the ownership structure of the applicant share a commonality of business
interest with any other person cc entity within the ownership structure of the second licensee?
❑Yes 0 No Are there any contractual agreements or financing agreements between the applicant and the second
licensee?
❑Yes 0 No Are there any investors common to the applicant and the second licensee?
C. Is the premises within any defined zones:
1. ❑Yes 154 No Where the sale of alcoholic beverages is restricted by city or county zoning ordinance?
2. ❑Yes No Where gambling is restricted by city or county zoning ordinance?
D. Is the building ready for use for an alcoholic beverage business:IS Yes 0 No
1. ❑Yes DI No Is this a newly constructed premises?
If Yes,indicate an estimated date of occupancy
2. O Yes X No Is this a remodel of an existing premises?
If Yes, indicate an estimated date of completion
E.Is the premise operated under a concession agreement?
1. ❑Yes DI No If Yes,attach a copy of the concession agreement. Note: ARM 42.12.133 requires certain signage for a
premise operated under a concession agreement.
1/4
9
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41.11111.
Daolartdion and Authorization
ASSFORMAL LAR TION AND AUTHORPZAII N
FOREXAMINATION MD RELEASE OF INFORNIAITON
I. TA t LLC ,hereby dedsrs under the penally of few manor theissvOetion o OW
Noenses Rusted Pursuant hereto,that I am the or duly authorized'spmser re of the sashor;c
this eppI sties*We*I hese eseretried the laPolication,including any abcomparqing infonnitikm,and that;the responses
provided.Win are tine,correct and Complus.I undsmtend If this or aeaohmsnt(s)aor4aine.foN rte,t
arsrr
aubjediolhe criminal penMies of Section 45.7402,46-7-203 and 45.74011,Montane-Cede AnnObitail.Blur alletication
of arty p..or Osfshling noenriesIalletted:*Mod to this on.
I further authorize a full review,discideuni end•release to any duty reitherlmerd Ober,agent or employes of the hgtintana
DePertment of Jew*.' 'O edntrat Minion.*tans and all neon*concerning,rate that the Morena Deptehnent of
Justice properly dated**.relate to my qualifications for gambling and/or liquor licensor*,whether Me records are of a
public,private,or con ldusgel nature.
81GMTUEE 1.
MSTnit,L NAME Ai m J Rebh912 J
TI7LEIpo.S1'Tmpy Exec VP.CFO.Treasurer it Secretary
ar+y..
DATE Walt tw !
Thies must becomPiebod inlu ,.and all regdestbd;attachments must tEcompanyt
D"Y,dee 110 tla►Mot cf the fin will result Incomplete.
Inioniudion MaY Ropited DiehtSthe
inveedoelen of Your Ucene A,ppitsatlofi.
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