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Home My WebLink AboutMontana Department of Revenue (2)Montana Department of Revenue pL~C~L~~dL~ -,- Dan Bucks Brian Schweitzer Director SAY 3 0 ~$ Governor May 29, Zoos CITY OF LAUREL RE: Application for Issuance of One-Original (NEW) Montana Retail Off- Premises Consumption Beer/Wine License No. 03-999-9143-303, CVS/PHARMACY #5305, 307 South East 4t" Street, Laurel, Yellowstone County, Montana NEWLY LICENSED PREMISES 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 if 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. This is an application for a new premises; a premises not currently licensed for the sal® of alcohol. Building, health and fire approval will be required before departmen# approval will be considered. If any agency determines deficiencies exist that should be considered in the issuance of this license, please advise this office in writing by June 30, 2008. 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. 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, please call (406) 444-7927. Sincerely, - Susan M. Gardipee Compliance Specialist Department of Revenue Liquor Licensing P O Box 1712 Helena MT 59624-1712 c: Annette Rinehart, Department of Labor ~ Industry Customer Service (406) 444-6900 ~,. TDD (406) 444-2830 ~ www.mt.gov/revenue CERTIFICATE OF SERVICE I certify that on this 29 day of Maw , 2008, 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 MIKE ATKINSON 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 O BOX 35010 BILLINGS MT 59107-5010 ADMINISTRATIVE ASSISTANT FIRE PREVENTION AND INVESTIGATION BUREAU 303 NORTH ROBERTS BOX 201417 ~~~~~ - HELENA MT 59620-1417 - Department o1 VENUE Off-Premises Liquor License Application Section 1:~'EihtltytTrans'actlon Check appropriate boxes 1. Business Entity 2. Transaction ^ Individual (one person) 1~ New License ^ Gorporation ^ Transfer of Locatlon -License # ~ Other -- I..LC ^ Corporate Structure Change -License # Attach additional pages if more space is needed ~;.~~ ,,r Instruction for completing applicant name. Z If Individual, list individual's name. ~ If Corporation, provide current corporate statement or list of officers, directors and shareholders and Certificate of Existence/ Authority. Y If Other.. . - If more than one individual ,list names of all below. - If partnership, list partnership name below then, individual partners' names and provide copy of the partnerships Certificate of Limited Partnership, Certificate of Fact or Certificate of Registration. - If LLC, list LLC name below then, all members' names and provide a copy of the Certificate of Fact. 1. Name of Applicant(s) CV a ~ Business Telephone No. ~ D 6a~ -87y Fax No. ~ o --''7og Federal Tax LD. No. gyp- Yol$ ) ~9S 2. Name of Person Managing Business 3. Provided Personal History 8~ R lease of Information forms for each individual, partner, 10% stockholder, member or manager. ^ Yes ~ No ~'Tu C oI2~Q~ 4. Business/Trade Name ~-~ ha~~ ci.C ~S 3b$ (doing business as... Assumed business name must be filed with the Secretary of State's Office) Melling Address Li ce ~N ~~ - '~olp7 ~~/~ Ci/5 -~~ City, State, Zip i'V ooN ac '~ ~ 4a. Address of premises to be licensed, if different than mailing address. Give Exact Location of Premises, including a street and number. Physical Address - O ~ ~~ J'1`" City, State, Zip 1-.cx~~rc ~o 5. Is your location within an incorporated city/town7l~ Yes ^ No 6. Are the premises within any defined zones where the sale C~g,es is prohibited by city/county ordinances? ^ Yes ^ No 7. Is your premises proposed for licensing operated as a ^ Grocery Store If grocery store -attach copy of inventory (Form G-1) `~prugstore If drug store -attach copy of pharmaceutical license 8. Do you riow or will you own the building proposed for licensing? ^ Yes '~ Na C{-o ev~~l If No, please provide a current or proposed lease or rental agreement. If Yes provide acceptable proof of ownership. 9. Is the building ready for occupancy? ~ Yes ^ No I If No, indicate estimated date of occupancy: ~ ~. l`r ewe! i7 TJ ~y E~ 10. Will you be remodeling or constructing the premises? ^ Yes 537 No If Yes, indicate estimated date of completion: (Date) 11. Submit copy of current floor plan of licensed premises. Floor plan must include external dimensions and general layout on an 8'1;' x 11" sheet of paper. Identify trade name of premises, address and date. 12. Please send a copy of your bank signature card. 518 Return ta: One-Stop Licensing Montana Department of Revenue PO Box 8003 Helena, MT 59604-8003 ...) -.~'S~' 3. License Type /Fee ~( Processing Fee - $100.D0 (All) ^ Off-Premises Beer - $200.00 Off-Premises Wine - $200.D0 Off-Premises BeerMline - $400.00 Section 3; 7erriporary.Autho.rity - r The undersigned, requests authority to operate pending final approval of the license. Temporary authority may be granted to an applicant by the Department of Revenue if the current premises has been licensed in the past year for the sale of alcohol and no building, health, or fire deficiencies exist. Pursuant to ARM 42.12.122. The undersigned agrees that during the period of temporary operating authority, the applicant shall be responsible for all beer and wine purchased pursuant to Section 16-3-243, MGA (the seven- day credit limitation). I realize temporary authority will be immediately revoked if my employees or I violate any provisions of Title 16, MGA or the departments rules. Temporary authority cannot be granted for a transfer of location. I would like temporary authority issued on (Date) ..Section 4: Notice 7o=Applicants • '' ` ' In order for your application to be considered complete you must include all associated or related documents as indicated by your specific circumstance in the accompanying check sheet. Processing a license application takes approximately two (2) to three (3) months based upon the Department's determination of receipt of a complete application, if no deficiencies are received. You Will be notified when a decision regarding the application has been made. vn and gfftdavt#,;;, Section 5: • Declaratl " , ' •• This application must be signed by the applicant or by a duly authorized representative of the entity submitting this application. The person who signs this application attests that the information contained in the application is correct and complete, Montana law says "Upon proof that an applicant made a false statement in any part of the original application, in any part of an annual renewal application, or in any hearing conducted pursuant to an application, the application for the license may be denied, and if issued, the license may be r oke ." (section 16-4~2, M ana C es Annotated) ( Signature ~jn g ~, Cirnbran Date Assistant Secretary Printed Name Title 5ectiion 6: Co.rporate•Staterrent (include's'Corpora'tion"s,,l„L"LC's;~f_LP'srajad~.P~'itnarsrips). The stockhalderslmembers/partners are: p.~~ Name Address Social Security Number Date of.l~fih "~~_.. ~y S Cn. r Yrl a.r Cor rntf i of ~N2 Ct/5 A~ ~~ D ~ ~ as /C t) ~7a CSoI$ /~crnber Wr~GNS~' an- a a owvv~r ~a Total Shares: ---/1+- Officers and Directors of the Corporation are: Name Address Title offprem00 Revised 05-06 State of Montana Board of Pharmacy CER~IED PHARMACY CER`~I~ICATE pursuant to the provisions o#'Title 3?, Chapter 7, Montana Code Annotated and sub,}ect to alE other applicabte laws, nEles and conditions thereof, I1~I o~T`~'A1r~A CV S PHAI~AC Y ~~ ~ d~a C~~~'~-IARA~~ X5305 3~? Southeast ~~' Street, Laurel, Montana 590~~ Na-ing made appficRtion in due form, and having a Montana registered pf-artnacist-in-charge of the pharmacy operations of such glace, the said pharmacy is hereby licensed as a Co~FV1UNITY Hader t#~e iayvs oi'the State of ~7ontaga. Lieer~se Ntunber: I25~ lssued: March 31, X008 Exec ve Director A m LT1 N m m 01 N m ~, a, N m ~D v D m m c~, m m m w C n ~I'~ II r w. n urc h ~• ~ .~'Sw~l. ~~ 17id1GSi'OI~E*.~ ~1~~ ~~ , ~S~~RW ym C yp~ ~ ~ eJ ~ ~@} ~ ~~ ~ y~Ly^q~ a m~ ~a ~Tr ~ r cr GI e7 ~ ~ • ~ P = V a a m`a L ~ .. . S¢ ~ r r ~#Nd~ P