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HomeMy WebLinkAbout20122187.tiffRESOLUTION RE: APPROVAL OF RENEWAL APPLICATION FOR HOTEL AND RESTAURANT LIQUOR LICENSE, WITH OPTIONAL PREMISES, FROM THE EATON COUNTRY CLUB AND AUTHORIZE CHAIR TO SIGN - EXPIRES NOVEMBER 16, 2013 WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Eaton Country Club presented to the Board of County Commissioners of Weld County, Colorado, an application for the renewal of a Hotel and Restaurant Liquor License, with Optional Premises, for the sale of malt, vinous and spirituous liquors, and WHEREAS, pursuant to Exhibit 5-H of the Weld County Code, said applicant has paid the sum of $175.00 to the County of Weld for the renewal of the existing license, and WHEREAS, said applicant has exhibited a State Liquor License for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, outside the corporate limits of any town or city in the County of Weld at the location described as follows: 37661 County Road 39 Eaton, Colorado 80615-0240 WHEREAS, the Licensee shall host "responsible vendor" training every six (6) months as agreeable to the Colorado Department of Revenue Liquor Enforcement Division, and this training shall be open to other area licensees. Each employee shall be "responsible vendor" trained, and the Licensee shall provide documentary evidence that each employee has been "responsible vendor" trained to the Weld County Clerk to the Board within thirty (30) days of the first available "responsible vendor" class after hiring. NOW, THEREFORE, BE IT RESOLVED that the Board of County Commissioners of Weld County, Colorado, having examined said application and the other qualifications of the applicant, does hereby grant License Number 2012-20 to said applicant to sell malt, vinous and spirituous liquors for consumption by the drink on the premises only, only at retail at said location; and the Board does hereby authorize and direct the issuance of said license by the Chair of the Board of County Commissioners, attested to by the Clerk to the Board of Weld County, Colorado, which license shall be in effect until November 16, 2013, providing that said place where the licensee is authorized to sell malt, vinous, and spirituous liquors for consumption by the drink on the premises only, shall be conducted in strict conformity to all of the laws of the State of Colorado and the rules and regulations relating thereto, heretofore passed by the Board of County Commissioners of Weld County, Colorado, and any violations thereof shall be cause for revocation of the license. c -t-. 5O, vappi 3y -13 2012-2187 LC0037 RENEW LIQUOR LICENSE - EATON COUNTRY CLUB PAGE 2 BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 20th day of August, A.D., 2012. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST:-_ Weld County Clerk to the Board ouglas ademac Date of signature 2012-2187 LC0037 trrrrrer...MMC-Wrr.CCM H Ln LI) Ln License Fee $175.00 �F . ft. ‘Ni eA ttl 2 BY AUTHORITY OF THE BOARD OF COUNTY COMMISSIONERS z U 0 a H z Cl O O fz.4 TO SELL AT RETAIL MALT, VINOUS, AND SPIRITUOUS LIQUOR ci v 44-4 w v Ct rip ct 00 O w U O C, c ct rt '4 -54-4 oct U C U • C) O .5 O o - C1 04-4 C) H ci ct -c .o b ci O V E O o 2 U C f wcicl f. ..C C ci r�C) C) f 0 . ch •C� U f 4-4 O O 0 0 f • 3 C fCt V, g ro ct c o x A 4.4 f Via ccs C) fC) f� • c U C •I arm _ G. C C v U Ct w �1 ^ CZ 1-O C) v O tr ▪ C O C.) Cr; ci .5 J • C ci U O C) 4J L'' 4-4 C N 0 CC 0 O U 0 W M ct 0 1-4 N O cn C) ci ci -5 cid (�1 O Cl) Cn Cn C, N 4-•i 0 z Ct. O .C 1-O Ct C Na o z ci J 0 .C . a 0 O ci 0 6 ci 0 U ci C) b O O ci C) C f 0 Ct • r/ Ct C . -4 11 C) 4J . eo ti C C ) .• U) C) -a rs C) Cl) C) ci ci C 4 r., U C) ct v; J O ci C) C U license is issued f • H rci C C) f ci f C) ci rfj •f C) C ci U officers du f E f r U) C C f f C) .C f 0 U C 0 LE -4 4-4 P4 C) Lti has hereunto subscribed x z O C J H cNi N f authorized this 20th day o The Board of County Commissioners W x • . z z O z 1) D U z O U t A O rn O H d�TJ_J _J _J_1J�J6'J_C'J�"�:J_CJ�'J�GJ� THIS LICENSE MUST BE POSTED IN PUBLIC VIEW DR 8402 (07/01/2012) STATE OF COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1881 Pierce Street, Suite 108 Lakewood, Colorado 80214 EATON COUNTRY CLUB dba EATON COUNTRY CLUB 37661 W C R 39 EATON CO 80615 ALCOHOL BEVERAGE LICENSE Liquor License Number 14088390000 License Expires at Midnight November 16, 2013 License Type HOTEL & RESTAURANT / OPTIONAL (COUNTY) Authorized Beverages MALT, VINOUS, AND SPIRITUOUS This license is issued subject to the laws of the State of Colorado and especially under the provisions of Title 12, Articles 46 or 47, CRS 1973. as amended. This license is nontransferable and shall be conspicuously posted in the place above described. This license is only valid through the expiration date shown above. Any questions concerning this license should be addressed to: Colorado Liquor Enforcement Division, 1881 Pierce Street, Suite 108, Lakewood, CO 80214. In testimony whereof, I have hereunto set my hand. 9/14/2012 CT Division Director Executive Director DR 8400 (11/09/06) LIQUOR OR 3.2 BEER LICENSE COLORADO DEPARTMENT OF REVENUE RENEWAL APPLICATION DENVER, COLORADO 80261 IIrr6I6,rrll 1.61.11 II I,.III,,,, I,,IIIr11 II1r,I EATON COUNTRY CLUB PO BOX 240 EATON CO 80615-0240 ❑ This renewal reflects no changes from the last ap- plication. Complete page 2 and file now! O Yes there are changes from the last application. If applicant is a Corporation or Limited Liability com- pany, use DR 8177 and send in with this renewal. Any other changes of ownership require a transfer of ownership. See your Local Licensing Authority immediately. LicenseNumber 14-08839-0000 License p 1981 Liability Information 03 206 713910 C 111705 Business Location 37661 W C R 39 EATON CO Current License Expires NOV 16, 2012 DEPARTMENTAL USE ONLY Total Amount Due Total Paid $ Date Wholesaler, manufacturer, importer, and public transportation system license renewals do not need Local Licensing Author- ity approval and must be returned directly to the Colorado De- partment of Revenue at least 30 days prior to the current li- cense expiration date. This application for renewal must be returned to your CITY OR COUNTY Licensing Authority at least 45 days prior to the expira- tion date of your current license. Failure to do so may result In your license not being renewed. Include both pages of this renewal and payment. 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. Authorized Signature S QS � Date -2" ) LO -jo(1 Business Phone 91O 451--,i1 Olp Title \ C),11 A A Sales Tax Number & -t '373,1 Ai 1 V EPORT AND APPROVAL OF CITY OR COUNTY LICENSING AUTHORITY The foregoing application has been examined and the premises, business conducted a_ •_ aracter of the applicant are satisfactory, and we do hereby report that such license, if granted, will comply with the provisions of Titl1•-,4L-nd 47, C.R.S. THEREFORE THIS APPLICATION IS APPROVED. Local Licensing Authority for..,`. Weld Count , Colorado ,d r_. -1♦'i Date ! 2012 AUGG Signature Sean P. Conway Title Chair, Board .at6 e�: :c't County Commission•rs ;. :vA. A_; cl:). get— DO NOT DETACH DO NOT OETA DR 8400 (11/09/06) LIQUOR OR 3.2 BEER LICENSE COLORADO DEPARTMENT OF REVENUE RENEWAL APPLICATION DENVER, COLORADO 80261 leric LO Ltte�!lSO@TfP�t!�'-' Make check payo Department of Revenue.The State may convert your check to a one time electronic banking transaction. Your bank account may be debited as 21 eery as the same day received by t e State. It converted, your check will not be returned, L If your check is rejected due to insufficient or uncollected funds, the Department of Rev- enue may collect the payment amount directly from your banking account electronically. Business Name EATON COUNTRY CLUB LICENSE NUMBER (Use for all reference) 14-08839-0000 PERIOD 11-13 TYPE OF LICENSE ISSUED HOTEL AND RESTAURANT LIQUOR LICENSE WITH OPTIONAL PREMISES - MALT, VINOUS, AND SPIRITUOUS CASH FUND 2320-100(999) $ 50.00 STATE FEE 1981-750(999) $ 25.00 COUNTY 85% OAP 2190-100(999) $ 425.00 SUB -TOTAL $ 500.00 ADD $100.00 TO RENEW RETAIL WAREHOUSE SOTRE PERMIT 2210-100 (999) $ . OPTIONAL PREMISES $100 X (NO OF OPT. PREMISES) 2220-100 (999) $ kon.y� 2012-2187 LC003---) 08/21/2012 10:43 FAX 970 454 3095 EATON COUNTRY CLUB 002 DR 8401 (02119/09) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1681 PIERCE LAKEWOOD. CO 80261 (303) 205-2300 ATTACHMENT TO LIQUOR OR 3.2 BEER LICENSE RENEWAL APPLICATION This page must be completed and attached to your signed renewal application form. Failure to include this page with the application may result in your license not being renewed. Trade Name \ of Establishment c2EoA t, (\ flak' Cx.,k\ State License Number 1 y-n�(ic 9- fob C) 1. Operating Manager -R.I. 'nr"A Scr4m Home Address .03'"? 4) I. .L�(eeI&i C.oa0LciSi Date of Birth 2. Do you have legal possession of the premises for which this application for license is made? Are the premises owned or rented: N P`7 If rented, expiration date of lease: Yes No ® I ( I 3_ Has there been any change in financial interest (new notes, loans. owners, etc.) since the last annual application? If yes, explain in detail and attach a listing of all liquor businesses in which these new lenders or owners. (other than licensed financial institutions) are materially interested. Yes No ❑ 4. Since the date of filing of the last annual application, has the applicant, or any of its agents, owners, managers, pnncipels, or lenders (other than licensed financial institutions), been convicted of a crime? If yes, attach a detailed explanation. Yes No 5. Since the date piffling of the last annual application, has the applicant, or any of its agents, owners, managers, principals, or lenders (other than licensed financial institutions), been denied an alcoholic beverage license, had an alcoholic beverage license suspended or revoked, or had interest in any entity that had an alcoholic beverage license denied, suspended or revoked? If yes, attach a detailed explanation. Yes No ❑ Itii 6. Does the applicant, or any of its agents, owners, managers, principal, or lenders (other than licensed financial institutions), have a di- rest or indirect interest in any other Colorado liquor license (include loans to or from any licensee. or interest In a loan to any licensee)? If yes, attach a detailed explanation. Yes No P ❑ Pi 7. Corporation or Limited Liability Company (LLC) or Partnership applicants must answer these questions. Since the date of filing of the last annual license application: (a) Are there, or have there been: any officers or directors: or managing members; or general partners added to or deleted from ap plicant for renewal of a 3.2 beer or liquor license? (b) Are there or have there been: any stockholders with 10% or more of the Issued stock of the Corporation; or any members with 10% or more membership interest in the LLC; or any partners with 10% or more interest in the partnership added to or deleted from the applicant for renewal of a 3.2 beer or liquor license? (c) If Yes to (a) or (b), complete and attach Form DR 8177: Corporation, limited Liability Company or Partnership Report of Changes, and all supporting documentation, and fees your Local Licensing Authority immediately. Yes �No7 7 N I Yes No X, ..8....Ro e -proprietorships -'Husband Wile.Pennerehips-orPartnerain-General Each person Identified above must complete Each person must also provide a copy of their Inlieu of form DR 4679, the undersigned swears that (check one): ❑ I am a United States Citizen Partnerships'... EVIDENCE OF LAWFUL PRESENCE and sign the following affidavit. Please make additional copies if necessary. driver's license or state Issued Identification card. or affirms under penalty of perjury under the laws of the State of Colorado a Permanent Resident of the United States present in the United States pursuant to Federal Law in the United States by law because I have applied for a public benefit. I understand that state law re- in the United States prior to receipt of this public benefit I further acknowledge that in this sworn affidavit is punishable under the criminal laws or Colorado a separate criminal offense eadt time a public benefit ie fraudulently received, II I am not a United States Citizen but I am ❑ I am not a United States Citizen but I am lawfully 0 I am a foreign national not physically present I understand that this sworn statement is required quires me to provide proof that I em lawfully present making a false, or fraudulent statement or misrepresentation Revised Statute 18-8-503 and it shall constitute Signal Printed Printed name eR; c� Sin `('1 Date 17-(10 t� To: Weld County Board of Commissioners From: Deputy Lisa Carpenter Date: August 2, 2012 RE: Eaton County Club Dear Commissioners, I have researched and found no reported calls for service to the Eaton Country Club, located at 37661 Weld County Road 39, Eaton, CO 80615 for the Calendar year of 2011 to present day. I find no grounds for disapproval for the renewal of the liquor license. Respectfully Submitted, eputy Lisa Carpenter Community Resource Officer Weld County Sheriff's Office 1950 "O" Street Greeley, CO 80631 LIQUOR/BEER RENEWAL REVIEW FORM Date: August 2, 2012 TO: Deputies Lisa Carpenter and Jeremy Frey FROM: CTB — Tonya Johnson SUBJECT: Liquor License Check In accordance with the new procedure for Liquor and/or beer license checks, please review all records on the following establishment for any associated reports during the last year and return your report to the Weld County Clerk to the Board's Office within two weeks. Your report will be used by the Board of County Commissioners in considering renewal of the liquor and/or beer license. PLEASE RESPOND NO LATER THAN August 13, 2012 ESTABLISHMENT: THE EATON COUNTRY CLUB 37661 WELD COUNTY ROAD 39 PO BOX 240 EATON, CO 80615-0240 Current license expires: November 16, 2011 ***************************************************************** No concerns Deputy's Initials The Sheriffs Office had a concern and the deputy has mutually worked with the licensee to correct the concern. (Complete Attached Worksheet) Unresolved concerns exist requiring a Probable Cause Hearing scheduled by the Board of County Commissioners. (Complete Attached Worksheet) Please notify at Extension Board of Commissioner's renewal hearing. of the date and time of the Liquor/Beer License Worksheet The fol owing concerns are noted: The Licensee and the Sheriffs Office have collectively agreed to implement the following to correct concerns noted above: (A time line and corrective action should be listed for each concern) Establishme Establish ature Date Deputy's Signatu Use another sheet of paper or attach separate proposal to this packet if needed. Attach copies of all reports associated with this establishment for the last year. Both the Deputy and the Owner of the establishment will be required to attend the Liquor Hearing to testify to the above agreement. WELD COUNTY SHERIFF'S OFFICE Community Resource Office LtQUOR ENFORCEMENT WORKSHEET 19511 0 Street Greeley, Coleiado 80631 Voice (970) 356-4015 • Fax (970) 304-6467 Lem -me T:ade Were License #1 Type Iftsp ction Report Incident Report Yes No NIA CR1: Licensee Name: e \-O C ,7 Date of Report/ Incident g Person Contacted 1CL Yes No N!A State Li L i License Posted / L Manager Registered I '� I ✓j State Sales Tax License Posted , _ ' License in Control of Premises ✓ — Coun L1 License Posted ,/ T Trade Name Properly Registered ✓ Premises Physical Control Adequate ✓ Federal Form 11 ' Call (800 398-2822 Food Service License Posted ✓ Acceptable Dispensing System V 1 MinorWami Si Posted / Off Premise Storage Licensed 1 Meals and Snacks Available l ✓ Only Permitted Items Sold i.---'i Cleanliness Me to ✓ Alcohol From Permitted Source . .---- Books & Invoices Available ' Disc Sales of Liquor to Minors I _ Alcohol Beverage Stock Acceptable Di c� Sales to lioxicatedjhersobs ✓ 1 [Warning [Follow -Up Inspection •• � ll Dte epr entative S' nature " Vrlalion: i Date: Time: Subieat: DOB: I Hgt: I Wm: I Eyes: 1 Hair. Clothing: DL /Of State: Address: r City: State: Zip: Evidence: Yes NO WV Phone f. Summons #: Court Date: fit' �. Yes NO Narrative: t cC3C1 a(pc) #J.uu0/ Se Date: S "a)- I L-- Tonya Disney From: Sent: To: Subject: Janet Carter Wednesday, August 01, 2012 7:50 AM Tonya Johnson RE: Eaton Country Club Liquor Renewal This is an existing location. Public works does not have any comments at this time. Janet L Carter Traffic Engineer Weld County Public Works Dept. P.O. Box 758, Greeley, CO 80632 Tele-970.356.4000 ext 3726 Fax- 970.304.6497 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Tonya Johnson Sent: Tuesday, July 31, 2012 11:56 AM To: Bethany Salzman; Dan Joseph; Janet Carter; Jeremy Frey; Jonathan Gesick; Lisa Carpenter; Roy Rudisill Cc: Brad Yatabe; David Clarke; Deb Adamson; Margie Martinez; Sara Evans; Tonya Johnson Subject: Eaton Country Club Liquor Renewal The following applicant has submitted a request for renewal of its Hotel/Restaurant Optional Premises Liquor License, LC0037. Please provide any comments you may have before August 13, 2012. A .pdf copy of the application materials is attached. License Number: 14-08839-0000 Applicant: Eaton Country Club 37661 WCR 39 Eaton CO 80615 Current License Expires: November 16, 2012 Tonya (Disney) Johnson MEMORANDUM To: Tonya Johnson, Deputy Clerk to the Board August 7, 2012 From: Bethany Salzman, Zoning Compliance Officer, Dept. of Planning Services Subject: LC0037 Review of the following liquor license renewal by the Department of Planning Services shows the following: 14-08839-0000 The Eaton Country Club Dba: The Eaton Country Club 37661 Weld County Road 39 PO Box 240 Eaton, CO 80615-0240 Zone District: A (Agricultural) This use is permitted through a Use by Special Review permit (USR-1241). No violations are occurring on the property at this time. SERVICE, TEAMWORK, INTEGRITY, QUALITY Tonya Johnson From: Sent: To: Subject: No concerns from OEM. Roy Rudisill Wednesday, August 08, 2012 5:01 PM Tonya Johnson Re: Eaton Country Club Liquor Renewal From: Tonya Johnson Sent: Wednesday, August 08, 2012 02:23 PM To: Dan Joseph; Roy Rudisill; Jonathan Gesick Subject: Eaton Country Club Liquor Renewal Just a friendly reminder that I need to have referrals for Eaton Country Club by Monday, August 13m. Thank you, Tonya (Disney) Johnson Clerk to the Board 1150 0 StreetIPO Box 758I6reeley, Colorado 80632 Phone: 970-336-7215 x 5226 trjohnson@co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Tonya Johnson Sent: Tuesday, July 31, 2012 11:56 AM To: Bethany Salzman; Dan Joseph; Janet Carter; Jeremy Frey; Jonathan Gesick; Lisa Carpenter; Roy Rudisill Cc: Brad Yatabe; David Clarke; Deb Adamson; Margie Martinez; Sara Evans; Tonya Johnson Subject: Eaton Country Club Liquor Renewal The following applicant has submitted a request for renewal of its Hotel/Restaurant Optional Premises Liquor License, LC0037. Please provide any comments you may have before August 13, 2012. A .pdf copy of the application materials is attached. License Number: 14-08839-0000 Applicant: Eaton Country Club 37661 WCR 39 Eaton CO 80615 Current License Expires: November 16, 2012 Tonya (Disney) Johnson Clerk to the Board 1150 O Street IPO Box 758IGreeley , Colorado 80632 Phone: 970-336-7215 x 5226 trjohnson@co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 2 Memorandum TO: Tonya Johnson FROM: Dan Joseph SUBJECT: Liquor license inquiry DATE: August 9, 2012 CC: Cindy Salazar; Debra Adamson In response to your request, Environmental Health Services has reviewed the Retail Food Service Establishment file for the Eaton Country Club, located at 37661 CR 39, in Eaton, Colorado. At this time, there are no problems or concerns regarding this establishment. Should you have any questions regarding this matter, please contact me via e-mail at dioseph(i_.b,co.weld.co.us or by phone at 970-304-6415 extension 2206. Thank you. Dan Joseph Environmental Specialist III Tonya Johnson From: Sent: To: Subject: Jonathan Gesick Thursday, August 09, 2012 2:37 PM Tonya Johnson RE: Eaton Country Club Liquor Renewal No concerns from the building department. Jonathan D Gesick Plans Examiner/Building Inpsector Building Department 1555 N 17th Ave Greeley, CO 80631 tel: (970)353-6100 Ext. 3532 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Tonya Johnson Sent: Tuesday, July 31, 2012 11:56 AM To: Bethany Salzman; Dan Joseph; Janet Carter; Jeremy Frey; Jonathan Gesick; Lisa Carpenter; Roy Rudisill Cc: Brad Yatabe; David Clarke; Deb Adamson; Margie Martinez; Sara Evans; Tonya Johnson Subject: Eaton Country Club Liquor Renewal The following applicant has submitted a request for renewal of its Hotel/Restaurant Optional Premises Liquor License, LC0037. Please provide any comments you may have before August 13, 2012. A .pdf copy of the application materials is attached. License Number: 14-08839-0000 Applicant: Eaton Country Club 37661 WCR 39 Eaton CO 80615 Current License Expires: November 16, 2012 Tony° (Disney) Johnson 1 U.S. Postal Servicer CERTIFIED MAIL RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) Postage Certified Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage & Fees Sent To flM. sh 1/Cy.13.7tod a , Ems., Ca.nAy d Street, Apt No.; or PO Box No. ON State, ZIP+4 >f 9 -ay -/e2 Postmark Here &t 929'O • Complete items 1, 2, and 3. Also complete Item 4 if Restricted Delivery is desired. • Print your name and address on the reverse so that we can return the card to you. • Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: AN+_-�rn�: She) 11l Ca 7'C1"1 Ce�l.rl"N ? u 3>x ago Ees.4o Cc 3u(,1S Ten ctwio 2. Article Number (Transfer from service label) C. Date of Delivery 94to la D. Is deliv= address different from ttem l? ❑ Yes If YES, enter delivery address below: ❑ No 3. Service Type 93 Certified Mail 0 Express Mail ❑ Registered 0 Return Receipt for Merchandise ❑ Insured Mall 0 C.O.D. 4. Restricted Delivery? (Extra Fee) O Yes 7004 2890 0003 5709 8907 PS Form 3811, February 2004 Domestic Return Receipt 102696-02-M-1540 Hello