Fillable Form 2030 Fermented Malt Beverage License Application (Town of Buena Vista)

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Form 2030 Fermented Malt Beverage License Application (Town of Buena Vista)

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The Form 2030 Fermented Malt Beverage License Application (Town of Buena Vista) form is 5 pages long and contains:

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1
New License New-Concurrent Transfer of Ownership
• All answers must be printed in black ink or typewritten
• Applicant must check the appropriate box(es)
• Local license fee $ __________________________
• Applicant should obtain a copy of the Colorado Liquor and Beer Code: www.colorado.gov/enforcement/liquor
1. Applicant is applying as a/an
Corporation Partnership (includes Limited Liability and Husband and Wife Partnerships)
Individual Limited Liability Company Association or Other
2. Applicant(s) If an LLC, name of LLC; if partnership, at least 2 partners' names; if corporation, name of corporation FEIN
2a. Trade Name of Establishment (DBA) State Sales Tax No. Business Telephone
3. Address of Premises (specify exact location of premises)
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 No. Present Class of License Present Expiration Date
Section A Nonrefundable Application Fees Section B Fermented Malt Beverage Beer 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
Retail Fermented Malt Beverage On-Premises (City) $96.25
Retail Fermented Malt Beverage On-Premises (County) $117.50
Retail Fermented Malt Beverage Off-Premises (City) $96.25
Retail Fermented Malt Beverage Off-Premises (County) $117.50
Retail Fermented Malt Beverage On/Off-Premises (City) $96.25
Retail Fermented Malt Beverage On/Off-Premises (County) $117.50
Master File Location Fee ............. $25.00 x To
Master File Background ............... $250.00 x Total
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
$
DR 8403 (09/25/19)
COLORADO DEPARTMENT OF REVENUE
Liquor Enforcement Division
(303) 205-2300
Colorado Fermented Malt Beverage
License Application
2
Application Documents Checklist and Worksheet
Instructions: This check list 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. Submit originals to local authority
E. Additional information required by the local licensing authority
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 control (fences, walls, etc.)
C. Separate diagram for each oor (if multiple levels)
D. Bold/Outlined licensed premises
III. Proof of Property Possession (One Year Needed)
A. Deed in name of the applicant ONLY (or) (matching question #2) date stamped/led with County Clerk
B. Lease in the name of the applicant ONLY (matching question #2)
C.
Lease Assignment in the name of the applicant (ONLY) with proper consent from the Landlord and acceptance by the applicant
D. Other agreement if not deed or lease
IV. Background Information (DR 8404-I) and Financial Documents
A. Individual History Record(s) (Form DR 8404-I) 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.
Master File applicants submit results to the State.
The Vendors are as follows:
IdentoGO – https://uenroll.identogo.com/
Phone: (844) 539-5539 (toll-free)
IdentoGO FAQs: https://www.colorado.gov/pacic/cbi/identication-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.
V. Sole Proprietor/Husband and Wife Partnership (if applicable)
A. Form DR 4679
B. Copy of State Issued Driver's License or 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 Authorization if foreign LLC (out of state applicants only)
DR 8403 (09/25/19)
3
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 Fermented Malt Beverage license for the premises to be licensed been denied within the preceding one year? If
"yes," explain in detail.
10. Is the proposed Retail Fermented Malt Beverage Off Premises license within 500 feet of any public or parochial school,
the principal campus of any college, university, or seminary? NOTE: The distances are to be computed using the
methods outlined under C.R.S. 44-3-313(1)(d)(II). Some limited exceptions apply under C.R.S. 44-3-313.
11. Is the proposed Retail Fermented Malt Beverage Off Premises license, or On/Off premises license, within 500 feet of a
Retail Liquor Store licensed under section 44-3-409 C.R.S.?
Distance should be determined using guidelines outlined in 44-3-301(12)(c) C.R.S.
12. 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 or former nancial interest in said business including any loans to or from a licensee.
13. Does the applicant, as listed on line 2 of this application, have legal possession of the premises by virtue of 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 12.
c. Attach a diagram or designate 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".
14. 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
Last Name First Name Date of Birth FEIN or SSN Interest
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.
15. Name of Manager(s) for all on premises applicants.
Last Name First Name Date of Birth
16. 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.
17. 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
DR 8403 (09/25/19)
4
18. If applicant is a corporation, partnership, association or limited liability company, applicant must list all Ofcers, 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 to be ngerprinted by an approved
State Vendor through the Vendor's website. See application checklist, Section IV, for details.
Name Home Address, City & State Date of Birth Position % Owned
Name Home Address, City & State Date of Birth Position % Owned
Name Home Address, City & State Date of Birth Position % Owned
Name Home Address, City & State Date of Birth 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.
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 44-3-311(1) C.R.S.
Each person required to le DR 8404-I 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 _____________________________________
Upon approval of state licensing authority
New Fermented Malt Beverage Off Premises licenses, and On/Off Premises licenses, distance requirements of 44-3-301 C.R.S. are satised
New Fermented Malt Beverage On/Off premises licenses must meet the qualications of 44-4-104 C.R.S.
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 Printed Name Title Date
Signature (attest) Printed Name Title Date
DR 8403 (09/25/19)
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
5
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Form 2030 Fermented Malt Beverage License Application (Town of Buena Vista)

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Completed 14 July 2020

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