Fillable Form 2027 Retail License Application (Town of Buena Vista)

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Form 2027 Retail License Application (Town of Buena Vista)

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1
DR 8404 (09/25/19)
COLORADO DEPARTMENT OF REVENUE
Liquor Enforcement Division
(303) 205-2300
Colorado Liquor
Retail License Application
New License
New-Concurrent
Transfer of Ownership
State Property Only
• All answers must be printed in black ink or typewritten
• Applicant must check the appropriate box(es)
• Applicant should obtain a copy of the Colorado Liquor and Beer Code: www.colorado.gov/enforcement/liquor
1. Applicant is applying as a/an Individual Limited Liability Company Association or Other
Corporation Partnership (includes Limited Liability and Husband and Wife Partnerships)
2. Applicant If an LLC, name of LLC; if partnership, at least 2 partner's names; if corporation, name of corporation FEIN Number
2a. Trade Name of Establishment (DBA) State Sales Tax Number Business Telephone
3. Address of Premises (specify exact location of premises, include suite/unit numbers)
City County State ZIP Code
4. Mailing Address (Number and Street) City or Town State ZIP Code
5. Email Address
6. If the premises currently has a liquor or beer license, you must answer the following questions
Present Trade Name of Establishment (DBA) Present State License Number Present Class of License Present Expiration Date
Section A Nonrefundable Application Fees Section B (Cont.) Liquor License Fees
Application Fee for New License ............................................$1,550.00
Application Fee for New License w/Concurrent Review ............$1,650.00
Application Fee for Transfer ...................................................$1,550.00
Lodging & Entertainment - L&E (County) ...........................................$500.00
Manager Registration - H & R ................................................................$75.00
Manager Registration - Tavern ............................................................... $75.00
Manager Registration - Lodging & Entertainment ................................$75.00
Manager Registration - Campus Liquor Complex ...............................$75.00
Master File Location Fee ........................$25.00 X ________ Total ________
Master File Background ...................... $250.00 X ________ Total ________
Optional Premises License (City) ......................................................... $500.00
Optional Premises License (County) ...................................................$500.00
Racetrack License (City) ....................................................................... $500.00
Racetrack License (County) .................................................................$500.00
Resort Complex License (City).............................................................$500.00
Resort Complex License (County) ....................................................... $500.00
Related Facility - Campus Liquor Complex (City) .............................. $160.00
Related Facility - Campus Liquor Complex (County) ........................ $160.00
Related Facility - Campus Liquor Complex (State) ............................ $160.00
Retail Gaming Tavern License (City) ...................................................$500.00
Retail Gaming Tavern License (County) .............................................. $500.00
Retail Liquor Store License--Additional (City) ......................................$227.50
Retail Liquor Store License--Additional (County) ................................$312.50
Retail Liquor Store (City) ....................................................................... $227.50
Retail Liquor Store (County) .................................................................$312.50
Tavern License (City) .......................................................................... $500.00
Tavern License (County) ....................................................................$500.00
Vintners Restaurant License (City) ......................................................$750.00
Vintners Restaurant License (County) .................................................$750.00
Section B Liquor License Fees
Add Optional Premises to H & R ......... $100.00 X ________ Total ________
Add Related Facility to Resort Complex $75.00 X ________ Total ________
Add Sidewalk Service Area.................................................................... $75.00
Arts License (City) ................................................................................ $308.75
Arts License (County) .......................................................................... $308.75
Beer and Wine License (City) .............................................................. $351.25
Beer and Wine License (County) ........................................................ $436.25
Brew Pub License (City) .................................................................... $750.00
Brew Pub License (County) ................................................................. $750.00
Campus Liquor Complex (City) ........................................................... $500.00
Campus Liquor Complex (County) ..................................................... $500.00
Campus Liquor Complex (State) ......................................................... $500.00
Club License (City) ............................................................................... $308.75
Club License (County) ........................................................................ $308.75
Distillery Pub License (City) ................................................................. $750.00
Distillery Pub License (County) ........................................................... $750.00
Hotel and Restaurant License (City) ................................................... $500.00
Hotel and Restaurant License (County) ............................................ $500.00
Hotel and Restaurant License w/one opt premises (City) ................. $600.00
Hotel and Restaurant License w/one opt premises (County) ............ $600.00
Liquor–Licensed Drugstore (City) ....................................................... $227.50
Liquor–Licensed Drugstore (County) ................................................. $312.50
Lodging & Entertainment - L&E (City) ................................................ $500.00
Questions? Visit: www.colorado.gov/enforcement/liquor for more information
Do not write in this space - For Department of Revenue use only
Liability Information
License Account Number Liability Date License Issued Through (Expiration Date)
Total
$
2
DR 8404 (09/25/19)
Application Documents Checklist and Worksheet
Instructions: This checklist should be utilized to assist applicants with ling all required documents for licensure.
All documents must be properly signed and correspond with the name of the applicant exactly. All documents must be typed
or legibly printed. Upon nal State approval the license will be mailed to the local licensing authority. Application fees are
nonrefundable. Questions? Visit: www.colorado.gov/enforcement/liquor for more information
Items submitted, please check all appropriate boxes completed or documents submitted
I. Applicant information
A. Applicant/Licensee identied
B. State sales tax license number listed or applied for at time of application
C. License type or other transaction identied
D. Return originals to local authority (additional items may be required by the local licensing authority)
E. All sections of the application need to be completed
II. Diagram of the premises
A. No larger than 8 1/2" X 11"
B. Dimensions included (does not have to be to scale). Exterior areas should show type of control (fences,
walls, entry/exit points, etc.)
C. Separate diagram for each oor (if multiple levels)
D. Kitchen - identied if Hotel and Restaurant
E. Bold/Outlined Licensed Premises
III. Proof of property possession (One Year Needed)
A. Deed in name of the applicant (or) (matching question #2) date stamped / led with County Clerk
B. Lease in the name of the applicant (or) (matching question #2)
C.
Lease assignment in the name of the applicant with proper consent from the landlord and acceptance by the applicant
D. Other agreement if not deed or lease. (matching question #2)
IV. Background information (DR 8404-I) and nancial documents
A. Complete DR 8404-I for each principal (individuals with more than 10% ownership, ofcers, directors,
partners, members)
B. Fingerprints taken and submitted to the appropriate Local Licensing Authority through an approved state
vendor. Do not complete ngerprint cards prior to submitting your application.
The Vendors are as follows:
IdentoGO – https://uenroll.identogo.com/
Phone: 844-539-5539 (toll-free)
IdentoGO FAQs: https://www.colorado.gov/pacific/cbi/identification-faqs
Colorado Fingerprinting – http://www.coloradongerprinting.com
Appointment Scheduling Website: http://www.coloradongerprinting.com/cabs/
Phone: 720-292-2722 Toll Free: 833-224-2227
C. Purchase agreement, stock transfer agreement, and/or authorization to transfer license
D. List of all notes and loans (Copies to also be attached)
V. Sole proprietor/husband and wife partnership (if applicable)
A. Form DR 4679
B. Copy of State issued Driver’s License or Colorado Identication Card for each applicant
VI. Corporate applicant information (if applicable)
A. Certicate of Incorporation
B. Certicate of Good Standing
C. Certicate of Authorization if foreign corporation (out of state applicants only)
VII. Partnership applicant information (if applicable)
A. Partnership Agreement (general or limited).
B. Certicate of Good Standing
VIII. Limited Liability Company applicant information (if applicable)
A. Copy of articles of organization
B. Certicate of Good Standing
C. Copy of Operating Agreement (if applicable)
D. Certicate of Authority if foreign LLC (out of state applicants only)
IX. Manager registration for Hotel and Restaurant, Tavern, Lodging & Entertainment, and Campus Liquor
Complex licenses when included with this application
A. $75.00 fee
B. Individual History Record (DR 8404-I)
C. If owner is managing, no fee required
3
DR 8404 (09/25/19)
Name Type of License Account Number
7. Is the applicant (including any of the partners if a partnership; members or managers if a limited liability company; or ofcers,
stockholders or directors if a corporation) or managers under the age of twenty-one years?
Yes No
8. Has the applicant (including any of the partners if a partnership; members or managers if a limited liability company; or ofcers,
stockholders or directors if a corporation) or managers ever (in Colorado or any other state):
a. Been denied an alcohol beverage license?
b. Had an alcohol beverage license suspended or revoked?
c. Had interest in another entity that had an alcohol beverage license suspended or revoked?
If you answered yes to 8a, b or c, explain in detail on a separate sheet.
9. Has a liquor license application (same license class), that was located within 500 feet of the proposed premises, been denied within the
preceding two years? If "yes", explain in detail. ______________________________________________________________________
10. Are the premises to be licensed within 500 feet, of any public or private school that meets compulsory education requirements of
Colorado law, or the principal campus of any college, university or seminary?
Waiver by local ordinance?
Other: ________________
or
11. Is your Liquor Licensed Drugstore (LLDS) or Retail Liquor Store (RLS) within 1500 feet of another retail liquor license for off-premises
sales in a jurisdiction with a population of greater than (>) 10,0000? NOTE: The distance shall be determined by a radius measurement
that begins at the principal doorway of the LLDS/RLS premises for which the application is being made and ends at the principal door-
way of the Licensed LLDS/RLS.
12. Is your Liquor Licensed Drugstore (LLDS) or Retail Liquor Store (RLS) within 3000 feet of another retail liquor license for off-premises
sales in a jurisdiction with a population of less than (<) 10,0000? NOTE: The distance shall be determined by a radius measurement
that begins at the principal doorway of the LLDS/RLS premises for which the application is being made and ends at the principal
doorway of the Licensed LLDS/RLS.
13 a. For additional Retail Liquor Store only. Was your Retail Liquor Store License issued on or before January 1, 2016?
13 b. Are you a Colorado resident?
14. Has a liquor or beer license ever been issued to the applicant (including any of the partners, if a partnership; members or manager if a
Limited Liability Company; or ofcers, stockholders or directors if a corporation)? If yes, identify the name of the business and list any
current nancial interest in said business including any loans to or from a licensee.
15. Does the applicant, as listed on line 2 of this application, have legal possession of the premises by ownership, lease or other
arrangement?
Ownership Lease Other (Explain in Detail) _______________________________________________________________________
a. If leased, list name of landlord and tenant, and date of expiration, exactly as they appear on the lease:
Landlord Tenant Expires
b. Is a percentage of alcohol sales included as compensation to the landlord? If yes, complete question 16.
c. Attach a diagram that designates the area to be licensed in black bold outline (including dimensions) which shows the bars, brewery, walls,
partitions, entrances, exits and what each room shall be utilized for in this business. This diagram should be no larger than 8 1/2" X 11".
16. Who, besides the owners listed in this application (including persons, rms, partnerships, corporations, limited liability companies) will loan or give money,
inventory, furniture or equipment to or for use in this business; or who will receive money from this business? Attach a separate sheet if necessary.
Last Name First Name Date of Birth FEIN or SSN Interest/Percentage
Last Name First Name Date of Birth FEIN or SSN Interest/Percentage
Attach copies of all notes and security instruments and any written agreement or details of any oral agreement, by which any person (including
partnerships, corporations, limited liability companies, etc.) will share in the prot or gross proceeds of this establishment, and any agreement
relating to the business which is contingent or conditional in any way by volume, prot, sales, giving of advice or consultation.
17. Optional Premises or Hotel and Restaurant Licenses with Optional Premises:
Has a local ordinance or resolution authorizing optional premises been adopted?
Number of additional Optional Premise areas requested. (See license fee chart)
18. For the addition of a Sidewalk Service Area per Regulation 47-302(A)(4), include a diagram of the service area and documentation received from
the local governing body authorizing use of the sidewalk. Documentation may include but is not limited to a statement of use, permit, easement, or
other legal permissions.
19. Liquor Licensed Drugstore (LLDS) applicants, answer the following:
a. Is there a pharmacy, licensed by the Colorado Board of Pharmacy, located within the applicant's LLDS premise?
If "yes" a copy of license must be attached.
4
DR 8404 (09/25/19)
Name Type of License Account Number
20. Club Liquor License applicants answer the following: Attach a copy of applicable documentation
a. Is the applicant organization operated solely for a national, social, fraternal, patriotic, political or athletic purpose and not for pecuniary gain?
b. Is the applicant organization a regularly chartered branch, lodge or chapter of a national organization which is operated solely for the
object of a patriotic or fraternal organization or society, but not for pecuniary gain?
c. How long has the club been incorporated?
d. Has applicant occupied an establishment for three years (three years required) that was operated solely for the reasons stated above?
21. Brew-Pub, Distillery Pub or Vintner's Restaurant applicants answer the following:
a. Has the applicant received or applied for a Federal Permit? (Copy of permit or application must be attached)
22. Campus Liquor Complex applicants answer the following:
a. Is the applicant an institution of higher education?
Yes No
b. Is the applicant a person who contracts with the institution of higher education to provide food services?
If "yes" please provide a copy of the contract with the institution of higher education to provide food services.
23. For all on-premises applicants.
a. Hotel and Restaurant, Lodging and Entertainment, Tavern License and Campus Liquor Complex, the Registered Manager must also submit an
Individual History Record
- DR 8404-I and ngerprint submitted to approved State Vendor through the Vendor's website. See application checklist, Section IV, for details.
b. For all Liquor Licensed Drugstores (LLDS) the Permitted Manager must also submit an Manager Permit Application
- DR 8000 and ngerprints.
Last Name of Manager First Name of Manager
24. Does this manager act as the manager of, or have a nancial interest in, any other liquor licensed establishment in the State of
Colorado? If yes, provide name, type of license and account number.
25. Related Facility - Campus Liquor Complex applicants answer the following:
a. Is the related facility located within the boundaries of the Campus Liquor Complex?
If yes, please provide a map of the geographical location within the Campus Liquor Complex.
If no, this license type is not available for issues outside the geographical location of the Campus Liquor Complex.
b. Designated Manager for Related Facility- Campus Liquor Complex
Yes No
Last Name of Manager First Name of Manager
26. Tax Information.
a. Has the applicant, including its manager, partners, ofcer, directors, stockholders, members (LLC), managing members (LLC), or any
other person with a 10% or greater nancial interest in the applicant, been found in nal order of a tax agency to be delinquent in the
payment of any state or local taxes, penalties, or interest related to a business?
b. Has the applicant, including its manager, partners, ofcer, directors, stockholders, members (LLC), managing members (LLC), or any
other person with a 10% or greater nancial interest in the applicant failed to pay any fees or surcharges imposed pursuant to section
44-3-503, C.R.S.?
Yes No
27. If applicant is a corporation, partnership, association or limited liability company, applicant must list all Ofcers, Directors, General Partners,
and Managing Members. In addition, applicant must list any stockholders, partners, or members with ownership of 10% or more in the
applicant. All persons listed below must also attach form DR 8404-I (Individual History Record), and make an appointment with an approved
State Vendor through their website. See application checklist, Section IV, for details.
Name Home Address, City & State DOB Position %Owned
Name Home Address, City & State DOB Position %Owned
Name Home Address, City & State DOB Position %Owned
Name Home Address, City & State DOB Position %Owned
Name Home Address, City & State DOB Position %Owned
** If applicant is owned 100% by a parent company, please list the designated principal ofcer on above.
** Corporations - the President, Vice-President, Secretary and Treasurer must be accounted for above (Include ownership percentage if applicable)
** If total ownership percentage disclosed here does not total 100%, applicant must check this box:
Applicant afrms that no individual other than these disclosed herein owns 10% or more of the applicant and does not have nancial interest in a
prohibited liquor license pursuant to Article 3 or 5, C.R.S.
5
DR 8404 (09/25/19)
Name Type of License Account Number
Oath Of Applicant
I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my
knowledge. I also acknowledge that it is my responsibility and the responsibility of my agents and employees to comply with the provisions of the
Colorado Liquor or Beer Code which affect my license.
Authorized Signature Printed Name and Title Date
Report and Approval of Local Licensing Authority (City/County)
Date application led with local authority Date of local authority hearing (for new license applicants; cannot be less than 30 days from date of application)
The Local Licensing Authority Hereby Afrms that each person required to le DR 8404-I (Individual History Record) or a DR 8000 (Manager Permit) has
been:
Fingerprinted
Subject to background investigation, including NCIC/CCIC check for outstanding warrants
That the local authority has conducted, or intends to conduct, an inspection of the proposed premises to ensure that the applicant is in compliance with
and aware of, liquor code provisions affecting their class of license
(Check One)
Date of inspection or anticipated date _____________________
Will conduct inspection upon approval of state licensing authority
Is the Liquor Licensed Drugstore (LLDS) or Retail Liquor Store (RLS) within 1,500 feet of another retail liquor license for off-
premises sales in a jurisdiction with a population of > 10,0000?
Yes No
Is the Liquor Licensed Drugstore(LLDS) or Retail Liquor Store (RLS) within 3,000 feet of another retail liquor license for off-
premises sales in a jurisdiction with a population of < 10,0000?
NOTE: The distance shall be determined by a radius measurement that begins at the principal doorway of the LLDS/RLS premises
for which the application is being made and ends at the principal doorway of the Licensed LLDS/RLS.
Does the Liquor-Licensed Drugstore (LLDS) have at least twenty percent (20%) of the applicant's gross annual income derived
from the sale of food, during the prior twelve (12) month period?
The foregoing application has been examined; and the premises, business to be conducted, and character of the applicant are satisfactory. We do
report that such license, if granted, will meet the reasonable requirements of the neighborhood and the desires of the adult inhabitants, and will comply
with the provisions of Title 44, Article 4 or 3, C.R.S., and Liquor Rules. Therefore, this application is approved.
Local Licensing Authority for Telephone Number
Town, City
County
Signature Print Title Date
Signature Print Title Date
Tax Check Authorization, Waiver,
and Request to Release Information
I, am signing this Tax Check Authorization, Waiver and Request to Release
Information (hereinafter “Waiver”) on behalf of
(the “Applicant/Licensee”)
to permit the Colorado Department of Revenue and any other state or local taxing authority to release information and
documentation that may otherwise be condential, as provided below. If I am signing this Waiver for someone other than
myself, including on behalf of a business entity, I certify that I have the authority to execute this Waiver on behalf of the
Applicant/Licensee.
The Executive Director of the Colorado Department of Revenue is the State Licensing Authority, and oversees the
Colorado Liquor Enforcement Division as his or her agents, clerks, and employees. The information and documentation
obtained pursuant to this Waiver may be used in connection with the Applicant/Licensee’s liquor license application
and ongoing licensure by the state and local licensing authorities. The Colorado Liquor Code, section 44-3-101. et seq.
(“Liquor Code”), and the Colorado Liquor Rules, 1 CCR 203-2 (“Liquor Rules”), require compliance with certain tax
obligations, and set forth the investigative, disciplinary and licensure actions the state and local licensing authorities may
take for violations of the Liquor Code and Liquor Rules, including failure to meet tax reporting and payment obligations.
The Waiver is made pursuant to section 39-21-113(4), C.R.S., and any other law, regulation, resolution or ordinance
concerning the condentiality of tax information, or any document, report or return led in connection with state or local
taxes. This Waiver shall be valid until the expiration or revocation of a license, or until both the state and local licensing
authorities take nal action to approve or deny any application(s) for the renewal of the license, whichever is later.
Applicant/Licensee agrees to execute a new waiver for each subsequent licensing period in connection with the renewal
of any license, if requested.
By signing below, Applicant/Licensee requests that the Colorado Department of Revenue and any other state or local
taxing authority or agency in the possession of tax documents or information, release information and documentation to
the Colorado Liquor Enforcement Division, and is duly authorized employees, to act as the Applicant’s/Licensee’s duly
authorized representative under section 39-21-113(4), C.R.S., solely to allow the state and local licensing authorities, and
their duly authorized employees, to investigate compliance with the Liquor Code and Liquor Rules. Applicant/Licensee
authorizes the state and local licensing authorities, their duly authorized employees, and their legal representatives, to
use the information and documentation obtained using this Waiver in any administrative or judicial action regarding the
application or license.
Name (Individual/Business) Social Security Number/Tax Identication Number
Address
City State Zip
Home Phone Number Business/Work Phone Number
Printed name of person signing on behalf of the Applicant/Licensee
Applicant/Licensee’s Signature (Signature authorizing the disclosure of condential tax information) Date signed
Privacy Act Statement
Providing your Social Security Number is voluntary and no right, benet or privilege provided by law will be denied as a
result of refusal to disclose it. § 7 of Privacy Act, 5 USCS § 552a (note).
DR 8495 (07/23/19)
COLORADO DEPARTMENT OF REVENUE
Liquor Enforcement Division
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Form 2027 Retail License Application (Town of Buena Vista)

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Completed 14 July 2020

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