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Home My WebLink AboutMontana Department of Revenue - Fowl Play Spoz:r p r� Montana Department of Revenueill v N Mike Kadas Steve Bullock Director Governor May 29, 2015 Account ID: 6456790-003 License Number: 03-044-9195-001 Subject: Application for All Alcoholic Beverages License No. 03-044-9195-001 Applicant: Fowl Play, LLC—Sole Member: Joseph M Holetz Location Address: LBM OF LAUREL 220 South 1st Avenue, Laurel, Yellowstone County, Montana TRANSFER OF OWNERSHIP We need your help to determine if the above applicant and location comply with all laws and ordinances administered by your office. We ask that you please advise us by June 30, 2015 if there is a compliance issue. If we do not hear from you concerning a compliance issue, we will assume the laws and ordinances have been met. We would be happy to provide you with any additional information to determine compliance. It is important for you to understand that local laws are not enforced through the alcoholic beverage licensing process but several factors can influence the issuance of a license or prevent processing of the application: • Compliance with local laws may influence our final decision; and • Notification of a local deficiency I will be happy to assist you if you have questions. Please contact me at the address, telephone number or e-mail below. Sincerely, r--.7-77-7-777-7-7---. r.,,', 1 Vickie Zincke , I i ��nYL� li U �' i 11 11 Compliance Specialist Department of Revenue n Liquor Licensing JU�� 1 2015 _I PO Box 1712 Helena MT 59604-1712 Phone: (406)4440 13E�iLEP`�- Vzincke2Cc�mt.gov _ End. Floor Plan and Application Pages Certificate of Service I revenue.mt.gov A Toll free 1-866-859-2254(in Helena,444-6900) A TDD(406)444-2830 CERTIFICATE OF SERVICE I certify that on this Zq day of2015, a true and correct copy of the foregoing has been served by placing same in the Unit 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 SHERRY LONG 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 dswingley@mt.gov Section II GENERAL INFORMATION Name of Entity or Person Applying Fowl Play,LIC (Sole Proprietor/Partnerships/Corp/LLS/UP e.g.Swanny's Bar CLC) Business Name LBM of Laurel Physical Address of Premises to be Licensed 220 S 1st Avenue Laurel Mt 59044 Street Suite No City Zip Mailing Address 220 S 1st Avenue Laurel Mt 59044 Street Suite No City State Zip Business Cell Phone (e)628.8241 Phone (612)860-9269 Fax (000)000-0000 Email jholelzONfelknefitness.com FEIN NI Check this box if you wish to receive annual 0 N/A(if sole proprietor who will not require hired renewals electronically staff) Liquor License Number (write"NEW'if new license application) ATTORNEY INFORMATION ® Check this box and complete below information if you wish to have all correspondence sent to the attorney who submitted this application on your behalf Attorney Name see attached authority Business Phone Mailing Address Street Suite No City State Zip Email Address bobapeiot@rnan.com The premises for licensing is located within: the boundaries of an incorporated city/town 6 a distance of five miles of an incorporated city/town A an unincorporated city/town or outside the boundaries of,and more than five miles distance from any city/ town whether incorporated or unincorporated City of Laurel county of Yellowstone 2 • Section III OWNERSHIP&MANAGEMENT INFORMATION The applicant is a:(See Infos ation deet t)lar*moments required for each omen*type) Ownership Type: E Individual(s)/Sole Proprietor(s) Are any individuals and/or partners (- General Partnership Joint Tenants with Rights of Survivorship(JTROS)T ✓ Limited Partnership kI No 0 Yes Limited Liability Company ✓ Limited Liability Partnership F. Charitable or Non-Profit Organization qualified under 26 U.S.C.501(c)(3),(c)(4),(c)(8)or(c)(9) E Retirement home or nursing home(Gambling Only) E C Corporation r Subchapter S Corporation IT Publicly Held Corporation list all owners,partners,members,officers and/or directors of entity applying. Please induce SSN for Individuals and FEIN for entities. Each individual listed below must submit two completed fingerprint cards, personal/ criminal history statements 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(Fm._MI,Last) Joseph M.HoletZ Title Sole Member DOB SSN or FEIN _Number of Shares all Address 7991 ,v ddnley St N.E. Percentage of Ownership 100 96 Name(First,MI,Last) Title DOB SSN or FEIN Number of Shares Address Percentage of Ownership Name(First,MI,Last) Title DOB SSN or FEIN Number of Shares Address Percentage of Ownership Management Type: r Entity G Individual R Owner managed I* Not known at this time Provide the following information for each management employee. If applying as an entity,indude the manager of the day-to-day operation for the business. Attach management agreement if applicable. Each individual listed below must submit two completed fingerprint cards,personal/criminal history statements and fees. ❑ Gambling 0 Alcoholic Beverages ® Both 0 N/A Name(First MI,Last) owner(sole member) DOB SSN/FEIN Address Salary ❑ Gambling 0 Alcoholic Beverages 0 Both 0 N/A Name(First,MI,Last) DOB SSN/FEIN Address Salary 3 • Section V PREMISES INFORMATION A. Does the applicant's premises: 1. Q No el Yes Have permanently installed walls extending from floor to ceiling? 2. No Iii Yes Have a unique,dearly defined address that is not shared with another business(i.e.,suite or unit designated) 3. Pi No (l0 Yes Have another business operating out of the same premises? (*yes,name of the business) 4. ffi No r Yes Have a public external entrance that is shared with another premises for which a gambling operator license has been issued? (If yes,name of business): 5. ii No IQ Yes 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's/owners: 6. (a No j Yes Have a bar and at least twelve (12) seats at the bar, tables or booths independent of gambling machines? B. Describe where the premises is located: 1. MINo Il Yes 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?(e>.epta.commerdallyopMated orvostseconda y school) 2. p No pg Yes Is the premises located within 150 feet of another premises licensed for on-premises ,. alcoholic beverage consumption?(as defined in 23-5429 m4) ..::**.,1,110/10001"1- Name of second location: J QImotive and Ludcv UI's 3. 0-No Yes Does the second premises already have a permit for placement of video gambling machines? 4. iiiii No R Yes Is there a structural walkway between the two premises? tc.. 5. pp No A Yes Is the second premises licensee affiliated with the applicant?(eyes,please explain) Ai 6. or No EYes Is there an immediate family member related to the applicant within the ownership structure of the second premises licensee? 7. NI No F Yes Do the two licensed premises share any common management personnel? 8. If No D Yves Would the applicant be considered a parent or subsidiary business entity to the second licensee? 9. Pir No la Yes Does any person or entity within the ownership structure of the applicant share a commonality of business interest with any other person or entity within the ownership structure of the second licensee? 10.pg No Ir Yes Are there any contractual agreements or financing agreements between the applicant and the second licensee? . 11.IR No 17 Yes Are there any investors common to the applicant and the second licensee? C. Is the premises within any of the following defined zones where: 1. Ih No P'Yes Sale of alcoholic beverages is restricted by city or county zoning ordinance.? 2. gr No rr Yes Gambling is restricted by city of county zoning ordinance? D. Is the premises: 1. r No pg Yes Ready for use 2. pg No JZ Yes Newly constructed premises?(eyes,indicate an estimated date of completion) 3. lif No Q Yes Remodel of an existing premises?(if yes,indicate an estimated date of completion) 4. Of No C Yes Operated under a concession agreement?(f yes,attach a copy of the concession agreement. Note:ARM 42.12.133 requires aertah*nage fora premises operated under a concession agreement) 9 Section VIII DECLARATION AND AUTHORIZATION i, Sasee4 At_ `/a[._tL , declare under the penalty of false swearing that I am the applicant or duly authorized representative of the entity making this application and that I have examined the application,induding 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 Montana Code Annotated 45-7-202, 45-7-203 and 45-7-208, and/or revocation of any alcoholic beverages or gambling licenses granted pursuant to this application. I further authorize a full review,disdosure and release to any duly authorized officer,agent or employee of the Montana Department ofJustice,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 772' sxr- Print Full Name J r,ce L r1 i c.L►a-t N o1 e L Title/Position p pe r a-4-o f Date H - 7 - o l5 This application must be completed in full,and all requested attachments must accompany it. Delay,denial or the return of the application will result if incomplete. IIS Additional information may be required during the review of your license application. 12 v•. N. / . ■ i / r f k o ;\ & qt _ 4 A t 4 tl _ t is :2 ° t tbg r—.-- 1.7-7 t......= ,la 4.. .1%,1 -t• '5 N k. , . I 1 , + RECEIVED B • i J MAY 1 4?0j3 .‘,.. -*‘, ........., . , _...... 1 I ) lar*— -4•• fI 1 %., Wit; ( .1 l ) ( 1 1 if1J ti " \ ( f I ) Z \-\.• t ) ( f z X .c I , • iitA vt t y y le' I A