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HomeMy WebLinkAboutMontana Department of Revenue (8) ., 41" dibili-A, Montana Department of Revenue y a- a" Mike Kadas Steve Bullock Director Governor July 7, 2016 License Type: Montana Retail On-Premises Consumption Beer and Wine License License Number: 03-044-9228-301 Subject: Application for one Original New Montana Retail On-Premises Consumption Beer and Wine License Applicant: Town and County Supply Association Location Address: High Water Casino, 817 West Main Street, Laurel, Yellowstone County Montana NEW LICENSED PREMISE 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 Auaust 7. 2016,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. This is an application for a new premises, a premises not currently licensed for the consumption of alcohol. Building, health and fire approval will be required before department approval will be considered. 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:de-it-Lp;toe.t) k0E I] V E -Th-i Vickie Zincke , Li)), Compliance Specialist, Department of Revenue Liquor Licensing _ J U L 1 1 2016 PO Box 1712 I Helena MT 59604-1712 (406)444-0713 CITY OF LAUREL VZincke2@mt.gov End. Floor Plan and Application Pages Certificate of Service 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 _7 day of _July , 2016, 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 PO BOX 35010 BILLINGS MT 59107-5010 SLONGta CO.YELLOWSTONE.MT.GOV ADMINISTRATIVE ASSISTANT FIRE PREVENTION AND INVESTIGATION BUREAU 303 NORTH ROBERTS BOX 201415 HELENA MT 59620-1417 diswingley@mt.govOdkad ° dir J- ca Tam -- • pliance Technician RECF!`"e"" Section II JUN 6 2016 GENERAL INFORMATION IRs 0 Name of Entity or Person Applying Town and Country Supply Association (Sole Propr etor/Partnerships/Corp/LICALP e.g.Swanny's Bar LLC) Business Name Town and Country Supply Association Physical Address of Premises to be Ucensed 817 West Main Street Laurel 59044 Street Suite No City Zip Mailing Address P.O.Box 367 Laurel MT 59044 Street,Suite No City State Zip Business Cell Phone (406)628-6314 Phone (406)208.6448 Fax (406)628-7895 Email gaming©tandcsupply.00m FEIN 0 Check this box if you wish to receive annual 0 N/A(f sole renewals electronically / proprietor who will not require hired stow Uquor Ucense Number (write NEW"if new license application) 03-0449228,301 ATTORNEY INFORMATION 0 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 Business Phone Mailing Address Street;Suite No City State Zip Email Address The premises for licensing is located within: 111 the boundaries of an incorporated city/town a distance of five miles of an incorporated city/town r1 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 ID OWNERSHIP& MANAGEMENT INFORMATION The applicant is a:(See Information checkbtJordocumentsrequiredforeachownes 4r type) Owp : Individual(s)/Sole Proprietor(s) Are any individuals and/or partners � Ind ( General Partnership Joint Tenants with Rights of Survivorship onion? �- Limited Partnership X No 0 les �- Limited Liability Company p Limited Liability Partnership • Charitable or Non-Profit Organization qualified under 26 U.S.C.501(c)(3),(c)(4),(c)(8)or(c)(9) f Retirement home or nursing home(Gambling Only) (X. C Corporation [ Subchapter S Corporation IT: Publicly Held Corporation List all owners,partners,members,officers and/or directors of entity applying. Please indude 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(First,ML,Last) Robert J.Michael Title Secretary/Treasurer DOB C SSN or FEIN Number of Shares I Address 3731 Pioneer Road,Billings, MT 59105 Percentage of Ownership 0 Name(First,MI,Last) Marvin S. Bauwens Title Board Member DOB - SSN or FEIN - _Number of Shares 1 Address 167 Lower River Rd,Fromberg,MT 59029 Percentage of Ownership 0 % Name(Pint,MI.Last) Randy Reiter ,Title Board Member DOB -_- SSN or FEIN - Number of Shares 1 Address 608 27th Ave W., Laurel,MT 59044 Percentage of Ownership 0 Management Type: 1 Entity t Individual g Owner managed t Not known at this time Provide the following information for sash management employee. If applying as an entity;include the manager of the day-to-day operation for the business. Attach management apeement if applicable. Each Individual listed below must submit two completed fingerprint cards,personal/criminal history statements and fees. 0 Gambling 0 Alcoholic Beverages M Both 0 N/A Name(First,MI,Last) Wesley D. Burley DOB SSN/FEIN' ---- Address 6309 Bear Paw Dr S Salary 183,000.00 ❑ Gambling 0 Alcoholic Beverages N Both ❑ N/A Name(First,MI,Last) Cathy Culp DOB ? _ SSN/FEIN: Address PO Box 372,Laurel, MT 59044 ;celery 60,000.00 3 Section V PREMISES INFORMATION A. Does the applicant's premises: 1. a No n Yes Have permanently installed walls extending from floor to ceiling? 2. fl No SI Yes Have a unique,clearly defined address that is not shared with another business(i.e.,suite or unit designated) 3. gir No J Yes Have another business operating out of the same premises? (e yes,name of the business) 4. g No IG Yes Have a public external entrance that is shared with another premises for which a gambling operator license has been issued? (►f yes,name of business): 5. I :No gl 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. (T No IR 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. or No 0 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?(except a commercially operated or post-secondary school) 2. No p:Yes Is the premises located within 150 feet of another premises licensed for on-premises �r alcoholic beverage consumption?(as defined in 23-5-629 MCA) ' I. Name of second location: 4 3. U No E`Yes Does the second premises already have a permit for placement of video gambling machines? 4. h No h Yes Is there a structural walkway between the two premises? le 5. ET No p'Yes Is the second premises licensee affiliated with the applicant?(if yes,please explain) 6. fl No CI Yes Is there an immediate family member related to the applicant within the ownership structure of the second premises licensee? 7. a No ri Yes Do the two licensed premises share any common management personnel? '' =8. 0 No EY Yes Would the applicant be considered a parent or subsidiary business entity to the second • licensee? kc 9. CI No cy,Yes Does any person or entity within the ownership structure of the applicant share a _. f commonality of business interest with any other person or entity within the ownership structure of the second licensee? 10.R No Q Yes Are there any contractual agreements or financing agreements between the applicant 1and the second licensee? '<:.' 11. la No a 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. fid No a Yes Sale of alcoholic beverages is restricted by city or county zoning ordinance? 2. I No p Yes Gambling is restricted by city of county zoning ordinance? D. Is the premises: 1. R No p Yes Ready for use 2. p;No EE Yes Newly constructed premises?(if yes,indicate an estimated dote of completion) 9/1/2016 3. gir No DT Yes Remodel of an existing premises?(e yes,indicate an estimated date of completion) 4. g No Q Yes Operated under a concession agreement?(ryes,attach a copy of the concession agreement Nota ARM 42.12.133 requires certain*nage fore premises operated undera concession agreement) 9 Section VIII DECLARATION AND AUTHORIZATION I� Wesley D. Burley , 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,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 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 itik26/441/4 Print Full Name WesleY D• Buffy Title/Position General Manager Date 5/5/2018 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. Additional Information may be required during the review of your license application. 12 • E 4 i IA r O i II p_ -_-- I. p s .m1 �� n 111.1 I rt.11 i DE 1 14-Er, II 1.4 , ---- II 1r_E17 Fi Fl L,. mli i —fl al 01 1 0 0 Iiii;CI itligi f, 1 E Iii 4 _901 4 % % 1.CI i 1 4 %, 0 i t 4 AAA lkik� .&&&�&•-�� 0A : Dim Du 3 I , IMP xr.10 a 14, O 0 Q O 1 rc i 0 PRELIMINARY , . pp RATIVE I N g Arwrw-arc rwrr ceaw na.... ..,rrr.r�....� !I t- TOWN AND COUNTRY coranffr oma. GARAGE BUILDING