HomeMy WebLinkAboutMT Department of Revenue (3) Montana Department of Revenue
As. 4�
�� -�
Mike Kadas {! . —II
I it Steve Bullock
Director i 1 4 Governor
j 1 AUG22015
August 20, 2015 Account ID: 6372042-003-ONP
CITY
OF D �L License Number: 03-044-9403-002
Subject: Application for Transfer of Ownership
Applicant: KRS Management LLC–Sole Member: K.0 Henry
DBA:The Palace Bar& Lanes
Location Address: 301, 303, 305 E Main Street, Laurel, Yellowstone County, Montana.
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 September 20. 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,
VA:t-ett-Ai^0e--t-)
Vickie Zincke
Compliance Specialist
Department of Revenue
Liquor Licensing
PO Box 1712
Helena MT 59604-1712
End. Floor Plan and Application Pages
Certificate of Service
c: Department of Labor& Industry
Montana Beer and Wine Distributors Association
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 20 day of August , 2015, 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
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
diswingleya mt.gov
i gi IAI
•
Sermon II
GENERAL INFORMATION
Name of Entity or
Person APPIY1011 ;: P$tb.t ,t._ :.- [—;
Ocie At*swamies Bur ail
Business Name ... -.
physical Ackkess-of
Premises to be
Licensed _+ ' .�; : . .40- sL� l .. as Sinrec • , :iNa rev
Mailing
Address Ev o 11 Faure I _air b /c(
Street,sate tie aty star 20
Business Cell
Oni
Phone (a to8—1731 Phone . /-7;173
Fax Email
FEIN Q Check:this bar if wish to receive annual
(3144/A {/safe propaet r who wit not require Mnd renewals electronically
serlD
Liquor license Number(write fir`x new *application).0 - 6! q54.0 3-00.
"takv av BION
ci Chedrthiskor andcomp below inibrMationifyouwishtohaveallcorrespondencesenttotheat y
who submitted this applicadon on yourbehalf
Attorney Name Business Phone
Mailing
Address
sweet,sae No aty State 211,
Email Address
The for licensing is located withhr
the boundaries of an incorporated dty/town
I5 a distance offfive inks.of an inoorporated.eity/town
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 / Courcy of c 4-11#110
2
Semon: In.
•*- OWNERSNI.P..&MANAGEMENT I A:i N
kar reqs‘edihrosdr _-re)e)
Ownership Aes ; P
• id ►t( ria) Jointlienents with hof rrtrarshipif f ?
0 General Partnership•
Partnership
►• ►
: UabOtyPartnership
O Charitable or Non-Prrrlit,Organiaatloin*ratified under 26 U.S.0 S014c)(3),CMX4),(e)(8)Or WO).• RetirramealsOrneernursIng home(Gambling Only)
CCorporatwn
ri
$obdilipterSCOreirnnion
•[:2 Ft110101Plivid Corporation
Ust.aHowner*p eu me s.oI& i / . ars ofrarldtV1101.0111.inesselochod•SUffiwindhddlinis
and FON for a Each lndividtial VOW below MUM submit OF*comploted firilefrigatiffis,INIMonalt
crin*ial history gatemons and Woes. thie.iiiilltionst shoat of paper if rientOOM For'aPillkann goat use a
multiple rattily eretuttire,attach aerilagnunehowingal errtlties aadkedl+Wduak.
Name(1104 NIL litii **pr.i '(ei"'
DOB '. SSN•.or • Number&Shares A 1
L� Cr'l l elra of ership r 9
Address ion �h�f rr: Fert
Name( .k4 testi
DOB . SSNorFEIN .Nur rofShares
Address . ... .. of Ownership
Name l f"a ) ..
DOS SSN or FEIN Number of Shares
Address Percentage of gip. %
Nlanag meat Type:
C Entity !a Indivaluel :mer managed C Not known at thistime
PetiVidOlha following information.foreach managementemployee.If spolgingasant,:hithrdeth
of the day-to=day opleadon for the business. Attach rnimagentent agement If appl able. Owls IndiVidual
listed below mustsubmit two torttplueldfingerprint muds,pemanolltr h ► endlbes.:
0 GarnblIM 0 Alooholte.Beverages 0 Both
Nameilitik:Ml,aast) ;.. . DOB SSWFEIN .
Addnrels 'Salary
I Gambling 0AloohoilcBevelragea O Both 1y1A
Name ph*,sork last) DOB SSN/FEIN
Address Salary . •
a
•
•
i
$e ti n:V. .
A. Does thes premises:
1. a.i4o � : . ave permanently Installed walls extending from floor to ceiling?
2. ONO ~ Have 6 un14u4 dearly,Wined address that Is not shared with another busineSs ,e,, :or
unit da ted)
3. Wits El Yes Have another business operatingout of the same premises?
4. niflo E3'lres Ham a Ill'external entrance entranCethat Isshag!•wftti another is erniseS forwilidte
gambling:operatoriiceree-bas been issued?
(q)r,.namns.afb l:^
S.
tEliffe Elites Stere a corral**Internet wall with anther premises to Which a gaming operator'
license hasbeen issued?if yespionalein and submit roper of th a flroor'plan*Matta dame of
opermor's/ownerst
6. alto Have a bar arid.*least twelve OZ.seats at•the or booths i dependent,of
gambling machines?
B. DescribllloSerethe premised*Wted' .
1. ilifSe E1 yes Are the entrance doors of the premises proposed:for licensing on the same street ase-
and
s,and within 600 feet of,the entrance doors of a building occupied eadusivey as a chur'ch,.
synagogue or other place of worship or school?Asmara rommercitrifyypoOtal foraasrqrscandoey
sdwarl
2, s Is thepremises located with n 150 feetiof.another premises licensed for on-premises
alcoholicbeverage Conslur t?lasda led 74,562sMCA
,.„: Name of second loam
:s... C No Elia Doesthe second p'already have a permft!or placement of video gambling.
I. eriaahine>i
A. .0 Ho .ayes Is therea structural walkwaybetween the t p.�?
. ,5. :also .glias is the second premises licensee affiliateded withthe:applicant?” sez pa
6. 1:11416 Ayes Is there an Immediate:family member related to the applicant within the ownership
'. structure of the second premises licensee?
`: 7. a No hies Do the two licensed premises share any common management personnel?
8. ONO : Yes would the applkent be considered a parent or sObsidiw;y business entity to the second
licensee?
9. Olio ayes Does any person or entity within the ownership structure of the applicant share a
t • commonality of business interest with any other Person or entity within the ownership
structure of the second licensee?
. 10 pm) D V s Are there any con noctUal agreerrrents or financing agreements between the applicant
t t
and the seidnsee?
ti 11.D'No CY= Are there any investors common to theappliamtandthe second: e?
G. is the within**ciffolIoa**deliiiarla
1. . *Yes Salebt af+rohafic aevereges lst restricted ty city:orcaunty soningordinance?
2. i `. Vets Gantbibteis restricted by dry of county awing ordinance?
D. *Om , -
1. i _ _,2Ready:for use
I ,, . mi,Yes Newly constructed premises?(gm an Istlatotod dote fcondi**Remodel Of an**lingprembes?_0fwarndaareasstewa.ddates"foonpa l
4. f','' :
�- : Operated ender+`r`QFpr1Ql:iMlrlrJ^ab;otroofreopy�d+t ►'
Keen AIM OLIZIS3 rinsOrarsinakisranssalarli lonseriss operated aader•: n I
9
SectfonVIII .
Docimignoto MIDI AYTHORIZO1310til
.ciedan t under thepenalty Of Man swda�g:that i am-
the applcan#.arduly ' • representative of the entity making this witIleation with*l/taremined the
application Witalintattyacisonipanying biformation,Information1 andthatthe respansesprovided herein are true,correct and
complete.I u nderstand tf this applicatiOnor a t+ent(SI false ice,I;am subject to the criminal
penalties of Montana Cede.Annotated 45.7201,4 403 end 455-7108;.and/or revocftlOri.of any alcoholic-
beverages or$ambling licensesgranted pursuant to this 'a
I further authorize a full reviav4 dittletureond*lease to:any duly at#►or ed gfficen agent elltPkneto'f#te
Montana Department otiustice,Gambling C.ontrol Divisn,of any andall records concerning me that:the Montana
Department.Of**cos.overly determines relate to my;qualifications f r gaMbling anger Ilquor litensurei
whether:the records are of-a public,:private,or cotidential natio*.
Print Full Fuli Name , /
Ilde/POSitiOn , 0,/
Misapplication must be:aomplated in fu l cad a Il requestedla meats must accompany
`Delay deviator the return of the appy wilt result if incomplete.
Ad mtlyhe required
dorm bra review:of+your 0cen*spun.
•
12
r
•
i M!)a iti: �a e4
•'';::4‘.:''i'": :
c 444-;:.%C �;.p;r xy. �.y n� ry �»�� 5" r'}el
.y ti ,. ti yy sdi5rt€ns' fr ar f 4 F Y',u3!ra s�.. i • i f p },
r ^S y ' eta: T .y q �-s' • -.s, Rt t, o {
� i '��S ���� '• ,7�. ` F •
��� r ms h'y�ye Vi ' e,�"' t i.
'tet' {e"y9 w y�P r 'S.,A • b' ,amu r s •.,1';
'1 � S ' s
,-.-Z..
4 +.g�rc :r.''',.:,•.-.."'...:rQ
-syL'kh�Yf { 'Y'�"YP x++. k,k SYa t �"q ^+'�".v �di 3" !:,`.:j.r Kms'?
�x sr, yid L �� ,t; .{ d
gig++ :-..6
i� try ' ° 6 x a ?� �� fvu,.> y
4 4 � y ?>r Ss- ` F k k
°fft -.AA,a�r�r� "F�i3 : �`-�^- Y++1�`2 � � � �" �} 3y`F -.,���� , u ...��::
I
•. . r,.a � , , w ,'y � ,.� �����.v�-�.�c-yam' 4 ,.E cZ m r
w x bra. _ rY *s i y i 4; ?l..x r -' SIF 1 ��t b.. t.x�"°�tt i1•1+x. , ` - - G.
,- wr . �.,4••,,,,,, �,�w'sf'e' .r ct ,i,' ��:'•rfr5 kx r I t^ r
;t.
i•Y
kS
•
�,3k
oti, , . _.
..06
•
. wp
�_V
. w.
(
.,, . •
•,,.,,,,•.
_w
ti
Y
tO
I
. •+ '
4-
1
•
0 is I0 0.2, . •:
•
9 ..• 42 +70.4061.QO
r o O.. r. r d • O 'w O'r. O..
�..�� - '
c. n �. :g..' �a
ti (% -
•
�� Qb
- . .tiii• ''''''""'"'r.
•
4
`j" 1-4.___ lgo, tett e. Jg`. i `— At,c_s
•
ci 3c' 3 ° : . • Vie..,)► )1 ,