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Home My WebLink About20122587.tiffRESOLUTION RE: APPROVAL OF RENEWAL APPLICATION AND REPORT OF CHANGES FOR 3.2 PERCENT BEER RETAIL LICENSE (ON/OFF PREMISES) ISSUED TO LAWRENCE JENSEN, DBA HIGHLANDLAKE, INC., AND AUTHORIZE CHAIR TO SIGN - EXPIRES NOVEMBER 9, 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, Lawrence Jensen, dba Highlandlake, Inc., presented to the Board of County Commissioners of Weld County, Colorado, an application for the renewal of a 3.2 Percent Beer Retail Liquor License for the sale of fermented malt beverages, containing not more than 3.2 percent of alcohol by weight, for consumption by the drink on the premises, and in sealed containers not for consumption at the place where sold, and WHEREAS, Lawrence Jensen, dba Highlandlake, Inc., has also presented the Board with a Corporate Report of Changes as follows: Lawrence Jensen replaces Mary Jensen, deceased, as President, and WHEREAS, pursuant to Exhibit 5-H of the Weld County Code, said applicant has paid the sum of $107.50 to the County of Weld for the renewal of the existing license, as well as $100.00 for the Corporate Report of Changes, and WHEREAS, said applicant has exhibited a State License for the sale of fermented malt beverages containing not more than 3.2 percent of alcohol by weight for consumption by the drink on the premises, and in sealed containers not for consumption at the place where sold, outside the corporate limits of any town or city in the County of Weld at the location described as follows: 16983 County Road 5 Mead, Colorado 80542 NOW, THEREFORE, BE IT RESOLVED that the Board of County Commissioners of Weld County, Colorado, having examined said applications and the other qualifications of the applicant, does hereby grant License Number 2012-21 to said applicant to sell fermented malt beverages, containing not more than 3.2 percent of alcohol by weight, for consumption by the drink on the premises, and in sealed containers not for consumption at the place where sold, 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 9, 2013, providing that said place where the licensee is authorized to sell fermented malt beverages containing not more than 3.2 percent of alcohol by weight, for consumption by the drink on the premises, and in sealed containers not for consumption at the place where sold, 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. EL Appl. , _SO 2012-2587 // -C.'i,7 LC0035 RENEW 3.2 PERCENT BEER RETAIL LICENSE - HIGHLANDLAKE, INC. PAGE 2 BE IT FURTHER RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Corporate Report of Changes submitted by Lawrence Jensen, dba Highlandlake, Inc., be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said Renewal Application and Report of Changes. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 24th day of September, A.D., 2012. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: Weld County Clerk to the BY: Deputy Clerk to the B AP ttorney Date of signature: 11 )7 Sean P. way, Chair Willi -m F. Garcia, Pro-Te ?'•ara Kirkmeyer David E. Long tIU (nS �3 Douglas P ademacher 2012-2587 LC0035 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 HIGHLAND LAKE INC dba HIGHLAND LAKE INC 16893 WCR5 MEAD CO 80542-9737 ALCOHOL BEVERAGE LICENSE Liquor License Number 14273240000 License Expires at Midnight November 09, 2013 License Type 3.2% BEER ON/OFF PREMISES (COUNTY) Authorized Beverages 3.2 PERCENT BEER 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. 10/29/2012 TJJ 073 Division Director Executive Director THIS LICENSE EXPIRES NOVEMBER 9, 2013 i � li ▪ b —�° Q 1-4 • Li w w VCC▪ S U' rtS ' V) o eg N u .� , N O U oo p ct o ., c b o (75 O O- oo z u N b cc' gs O U O V cc w O C C o x -o -d ccs Ct C cc --a 1 U O H arnenniLittranniligin/� a w w z O z TO BE POSTED IN A CONSPICUOUS PLACE. DR8400(11/09/06) LIQUOR OR 3.2 BEER LICENSE COLORADO DEPARTMENT OF REVENUE RENEWAL APPLICATION DENVER, COLORADO 80261 HIGHLANDLAKE INC 17-929 R-9 5 f,O. 8o- �01-- MEAD CO 80542 This renewal reflects no changes from the last ap- plication. Complete page 2 and file now! dYes 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. License Number 14-27324-0000 License Type 2126 Liability Information 03 206 451110 C 111087 Business Location 16983 CR 5 MEAD CO Current License Expires NOV 09, 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 mayresult 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 m knowledge. Authori ignature / Date '=5-i2. Business Phone 9`7O-537-5436; TI a f tcdert- Sales Tax Number /54-017301 — 6000 REPORT AND APPROVAL OF CITY OR COUNTY LICENSING AUTHORITY The foregoing application has been examined and the premises, business conducted and character of the applicant are satisfactory, and wr do hereby report that such license, if granted, will comply with the provisions of Title 12,tArticles 46 and 47, C.R.S. THEREFORE THIS APPLICATION IS APPROVED. .----c,„ „ I [ t _ . Local Licensing Authority for Sean P. Conway, Chair " '"= Weld County Board of Commission s t' Date ni% Signatu /./�'�! - c -------Chair TitleK AO SSSSSSt , ...- �' fiL4it �i1 c - (/ DO NOT DETACH DR 8400 (11/09/06) COLORADO DEPARTMENT OF REVENUE DENVER, COLORADO 80261 DO NOT. DETACH LIQUOR OR 3.2 BEER LICENSE RENEWAL APPLICATION 'r _. DO- NOT .DETAC Make Department of Revenue.The State may convert your check to =nme- •= nki g transaction. Your bank account may be debited as early as the same day received byt eStale. t converted, your check will not be returned. 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. 21 Business Name HIGHLANDLAKE INC LICENSE NUMBER (Use for all reference) 14-27324-0000 PERIOD 11-13 TYPE OF LICENSE ISSUED 3.2 PERCENT BEER RETAIL LICENSE (ON/OFF PREMISES) CASH FUND 2330-100(999) $ 50.00 STATE FEE 2126-750(999) $ 25.00 COUNTY 85% OAP 2190-100(999) $ 42.50 $ 117.5 2012-2587 LQcb35 R 8401 (02/19/09) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1881 PIERCE LAKEWOOD, CO 80261 (303) 205-2300 ATTACHMENT TO LIQUOR OR LO COUNTY 3.2 BEER LICENSE RENEWAL APPLICATIQhH;SSWONERS This page must be completed and attached to your signed renewal appliRprcfl P 3 22 Failure to include this page with the application may result in your license notbeing renewed. c. E DR 8442 (09/24/09) Pape 1 COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION DENVER. COLORADO 80281 (303)-205-2300 PERMIT APPLICATION AND REPORT OF CHANGES FOR DEPARTMENT USE ONLY CURRENT LICENSE ALL ANSWERS LOCAL LICENSE APPLICANT SHOULD NUMBER MUST BE PRINTED FEE $ /47. /if' -tit 71151- OOO'O TO ORDER CALL (303) 370-2165 IN BLACK INK OR TYPEWRITTEN Sea OBTAIN A COLORADO LIQUOR & BEER CODE BOOK 1. Applicant is a PRESENT LICENSE NUMBER Mr Corporation O Individual ❑ Partnership • Limited Liability Company 2. Name of Licensee 3. Trade Name /-1/ahkmSLnKp :E-WG 4.Location Address /6'OZ9 C2 S City County ZIP e 6-d CD tos5la SELECT THE APPROPRIATE SECTION BELOW AND PROCEED TO THE INSTRUCTIONS ON PAGE 2. Section A — Manager reg/change Section C 2210-100 (999) ❑ Retail Warehouse Storage Permit (ea) $100.00 • License Account No. Branch House Permit (ea).... 100.00 2200-100 (999) • Wholesale 1983-750 (999) 0 Managers Registration (Hotel & Restr.)..$75.00 2260-100 (999) ❑ Change Corp. or Trade Name Permit (ea).50.00 2012-750(999) ❑ Manager's Registration (Tavern) $75.00 ■ Change of Manager (Other Licenses) NO FEE 2230-100 (999) • Change Location Permit (ea) 150.00 2280-100 (999) ❑ Change, Alter or Modify Premises Section B — Duplicate License $150.00 x Total Fee of Optional Premises to Existing H/R 2220-100 (999) • Addition • Liquor License No. $100.00 x Total Fee 2270-100 (999) ❑ Duplicate License $50.00 1988-100 (999) ❑ Addition of Related Facility to Resort Complex $75.00 x Total Fee DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY DATE LICENSE ISSUED LICENSE ACCOUNT NUMBER PERIOD The State my mown yourcheck to a one tine electrawc banking transaction. Your bank account may be debited as ea y as the sane day received by the State. it converted, your check will not be reamed. If your died is rejected TOTAL -750 (999) -100 (999) y °O °r firbbaPe,,,b' d maYmil`d AMOUNT DUE $ .00 DR 8442 (09/24/09) Page 2 INSTRUCTION SHEET FOR ALL SECTIONS. COMPLETE QUESTIONS 1-4 LOCATED ON PAGE 1 ❑ Section A To Register or Change Managers, check the appropriate box in section A and complete question 8 on page 4. Proceed to the Oath of Applicant for signature (Please note: Hotel, Restaurant, and Tavern licensees are required to register their managers). ❑ Section B For a Duplicate license, be sure to include the liquor license number in section B on page 1 and proceed to page 4 for Oath of Applicant signature. ❑ Section C Check the appropriate box in section C and proceed below. 1) For a Retail Warehouse Storage Permit, go to page 3 complete question 5 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 2) For a Wholesale Branch House Permit, go to page 3 and complete question 5 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 3) To Change Trade Name or Corporation Name, go to page 3 and complete question 6 (be sure to check the appropriate box). Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 4) To modify Premise, go to page 4 and complete question 9. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 5) For Optional Premises or Related Facilities go to page 4 and complete question 9. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. 6) To Change Location, go to page 3 and complete question 7. Submit the necessary information and proceed to page 4 for Oath of Applicant signature. DR 8442 (09/24/09) Page 3 s— 2 ce ui a w O ct i- 5. Retail Warehouse Storage Permit or a Wholesalers Branch House Permit etc.) • Retail Warehouse Permit for: ❑ On —Premises Licensee (Taverns, Restaurants 0 Off —Premises Licensee (Liquor stores) • Wholesalers Branch House Permit Address of storage premise: City County Zip Attach a deed/ lease or rental agreement for the storage premises. Attach a detailed diagram of the storage premises. O 6. Change of Trade Name or Corporation Name 0 Change of Trade name / DBA only supporting documents) of State, or of State snt Members meeting, Partnership agreement. W W z z um p l- z z i- O ■ Corporate Name Change (Attach the following 1. Certificate of Amendment filed with the Secretary 2. Statement of Change filed with the Secretary 3. Minutes of Corporate meeting, Limited Liability 0 O Z 6 V Old Trade Name New Trade Name 5 Old Corporate Name New Corporate Name z O a U O LL 0 w a I U 7. Change of Location NOTE TO RETAIL LICENSEES: An application to change location has a local application fee of $750 payable to your local licensing authority. You may only change location within the same jurisdiction a the original license that was issued. Pursuant to 1247- 311 (1) C.R.S. Your application must be on file with the local authority thirty (30) days before a public hearing can be held. Date filed with Local Authority Date of Hearing (a) Address of current premises City County Zip (b) Address of proposed New Premises (Attach copy of the deed or lease that establishes possession of the premises by the licensee) Address City County Zip (c) New mailing address if applicable. Address City County State Zip (d) Attach detailed diagram of the premises showing where the alcohol beverages will be stored, served, possessed or consumed. Include kitchen area(s) for hotel and restaurants. DR 8442 (09/24/09) Page 4 8. Change of Manager or to Register the Manager of a Tavern or a Hotel and Restaurant liquor license. (a) Change of Manager (attach Individual History DR 8404-I H/R and Tavern only) Former manager's name /Y £ J , Sal 1 New manager's name 2, a v en.s-- en (b) Date of Employment 4M.---• Has manager ever managed a liquor licensed establishment? Yes' No ❑ Does manager have a financial interest in any other liquor licensed establishment? Ye4U" NA If yes, give name and location of establishment fYis"JJlc11C/ 9. Modification of Premises, Addition of an Optional Premises, or Addition of Related Facility NOTE: Licensees may not modify or add to their licensed premises until approved by state and local authorities. (a) Describe change proposed (b) If the modification is temporary, when will the proposed change: Start (mo/day/year) End (mo/day/year) NOTE: THE TOTAL STATE FEE FOR TEMPORARY MODIFICATION IS $300.00 (c) Will the proposed change result in the licensed premises now being located 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? (If yes, explain in detail and describe any exemptions that apply) Yes ❑ No ❑ (d) Is the proposed change in compliance with local building and zoning laws? Yes O No ❑ (e) If this modification is for an additional Hotel and Restaurant Optional Premises or Resort Complex Related Facility, has the local authority authorized by resolution or ordinance the issuance of optional premises? Yes ❑ No ❑ (f) Attach a diagram of the current licensed premises and a diagram of the proposed changes for the licensed premises. (g) Attach any existing lease that is revised due to the modification. OATH OF APPLICANT I declare under penalty of perjury in the second degree that I have read the foregoing application and all attachments thereto, and that all information therein is true, correct, and complete to the best of my knowledge. Signature REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY / COUNTY) The foregoing application has been examined and the premises, business conducted and character of the applicant is satisfactory, and we do report that such permit, if granted, will comply with the applicable provisions of Title 12, Articles 46 and 47, C.R.S., as amended. THEREFORE, THIS APPLICATION IS APPROVED. Local Licensing Authority ( ity or County) Date filed with Local Authority Weld County, Colorado Signature The foregoing has been examined Signature 8/16/2012 Title Chair, Weld County Board of Commissioners 9 24 2012 REPORT OF STATE LICENSING AUTHORITY and compiles wire the filing requirements of Title 12, Article 47, C.R.S., as amended. Title Date .C 1 let 14;k; 'Itiotoit .,.1. ,.,.,,y.•.e• ;:. y''i`- Ire, oil• STATE OF COLORADO COLORADO DEPARTMENT OF PUE C HEALT-? ENV'ROAJ MENT t•OL.C) TO LIGHT TO ', V W WATERI,1:; DECEDENTS Nil (Pint. Mltlde. Lash Mary Elizabeth STATE OF COLORADO CERTIFICATE OF DEATH . JENSEN f 2. SEX' I Female STATE FILE NUMBER IibATE OF DEATH (Month, Dey, Year) May 11,2012 I SOCIAL SECURITY NUMBER rte. AGE - ab. UNDER 1 rEARISc. UNDER 1 DAY --My, 6, �ATacr 1WM --- T. KWithAZE;C,ty and 5u10 or Foreign Country I (Years) 97— Hi. - Isar. Mane 1 Niemand Lake. Co:oradc . WA5 DECEDENT EVER 6e. PLACE OF DEATH (Cheat one one) - IN V S ARMED FORCES? ye. No HOSTITA : OTHt ,r. •d:,*,,ynau,p,oNaow Q •+aw:. O t>.c•0linre aniarnc► --- spawn O EftrOmpwient DOA O 01A1(per r (Sway; -TOW -Mr lTP7JA CC LifeCare Center of WO. WO St(0e1 end number) 19c. CITY LLCAT lOWCF-DEATR 7a0N ITo OF 'DEATH-- -- Longmont I Longmont Ji Boulder 0 !Oa DECEDENT'S USUAL OCCUPATION GMy Idnd Se work 1121 U T)7� CL done dung most 01 waking He DONUT use retied) I W President ! Recreation Area 1 1t}S - 12.8?tDtl (n w7ro, 9wi miolan name) M.l.d 8 Ntwnr Nomad rca w�.w °�° I Chris Jensen untrown S13e RESIDENCE • STATE ,130 COUNTY 3e. grit TOWN, OA LOCATON 734 STREET AND NUMBER - - Coloratlo I Bdutder �mont 12444 Nag Street wii ec 131 I g LIMIT l W y "" 0'80501, 131. C 14, OE HISPANIC MOW 115 RACE. Marian eldan, Stet, mile. elc. iMalr,gwdlycuben.Meiicen,PUMP REws.sic.j (Spey) No I White (t i at. a�rytV•1Z) 14 =I 77A. • NAME WI" feel) IL Malcolm Mead --T2 19. MOTHER - NAME (Post. MOP, AAeiden) Florence Baker 19. INFORM Lawrence Jensen and ratedalitep to deceased - Son ary, rnmMho 20a, METHOD OF DISOOSIT1pN O a......;.; b place) OF DISPOSIt1ON (Nana ci re n m my, or 1200. LOCATION • City a Tenn Slate _ ... - —1 eur•onee.nr Q C liQ R on eeem horn, f D.s.E Domino DOa»l19050M MountNn View Cemetery I Longmont, Colorado 12i$ ERAL E AnNel43UN--'-� !210 NAME AND ACILiTY -- - brawn:brawn:,�4� r Sc' L Carroll-Lewelien F,;neral & CromahOn ServlCea !. 503 Terry Street, Lorry, mops, Cdtxatlo 80501 ++ IKPIA ® AYeMey II' �WA 112012 1015 0 PM car.�J..etKETaO fY M0*lala }NYs1OAM2eOt [Q�Aar CORONER — e be91 d mykrMdge. des91 mend u Pe ten. dale and die10 9y Cesee(l) era merlrle( M fe10t1 t -I ND )Uy dsr a O l ile ban searcadon adJa taesig0n. in ny opywon t1e11h eMM�irq platy. end 6:0 I B c.w(a) Md menne 7i slVsd "r�� UMwov.PAYCamm 250 DATE SIGNED Mono. D.y. Tor) LI Z _ 271 DATE SIGNED Mona. Doss Yon May 14, 2012 D lac. NMAE. AND MALI NG ADDRESS OF SIDONO PHYSICIAN D 27c, NAME AND cowry .+- - - Emma R. Hall, Boulder County 2 21. NAME OFATTENDING P.— OgANIFOffRTHANSIGNNGPHYSICIAN Q 24 umsisk OF DEATh . 30.1)4510EFCLY5USE CONTRIaME TO DEATH Newat {t7AWgeN OaWua• 1 0 y.. Oft a Yroo.oly D uren:4m >or..od. 0 arewq .n.aly.iun T)Dndranerya 31 IF FEMALE. -- m Not salvers.n'e law yaw O Net pregnant. but prpnw l 43 days a 1 ❑v.pn.nr at aro.W awl, Venn 0.040,9 wen O No Ongnrt. put mows we sa 42 day. d clan in ci Unknown a parent wlerw M. p..1 y.•r = 11 al 3. Isar a, 2012 E il7Ff1T-- 1730 []AM Ora OW c I SO.,ck n•.0 On eat. wnI. laNng to Moo, DV,. ¢J N° J2e FDF)Fa TIVI At hone farm. sweet. b(7Ory, poky , ate. (SpecJTy)r321. L T?0N RW UkED iSew end Nun0p a Rural Rua Number, Cie Cossite SION Assisted Llyinp , 2444 Pratt Street, Longmont, Boulder County, CO 33 IMMEDIATE CAUSE - Wen arty one cause per Me kr (a), (b). WO (c). Oo not ere* Mae 01 Warp (e.g. Camac or Peap•alory Arrest) Had - Nano Dawson are* and duals Poi 1. .I Complications of Subdure Hematoma . One Week coneiseemars,imich gams ,W Cit./ TO OR AS A CONSEOUENGE OF - aI medNe Mechanical Fall MOO acting are ICJ Waal a.Iwa.n temp end clean)) One Week c,+.denyngcause DUE 1000 ASACONSEOUENCEOF tall (c). (auras lb.-.wa.nonael150awls l -!7f! y CO..uanwnoo rm aur/`rvrVTMIC . r,..,.raw,- .,,,,v.a,....., .........• ......... a.....a...ww r lv Alrrro*v 135 11 . YES . *a llnTina.cv,ilwn .d HyDOthyrad Ve. rlyp.ry.a.O.t yid conows.. Hon Fmk. In d.A.rrmn,np cause o! 4.110? Y•11 QNd ❑ Y. ❑ nor MAY 1 4 2012 DATE ISSUED THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS RECORDED IN THIS OFFICE. Do not accept unless prepared on security' paper with engraved border displaying the Colorado Blatt: seal and signature of the Registrar PENALTY BY LAW. Section 25 -2 -Ilk. Cutored() Res iced Statutes. I QS2. if a parson alters. uses. attempts to use or furnishes to another for decepti‘ a use an) vital statistics record NOT VALID IF PHOTOCOPIED. RONALD S. HYMAN STATE REGISTRAR I 11IIIII#ItIliII It HI1 UI 1 0 0 5 4 4 8 0 2 2 REV 01'07 r DR 6404-I (07/25/11) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1881 PIERCE STREET RM 108A DENVER CO 80261 INDIVIDUAL HISTORY RECORD To be completed by the following persons, as applicable: sole proprietors; general partners regardless of percentage ownership, and limited partners owning 10% or more of the partnership; all principal officers of a corporation, all directors of a corporation, and any stockholder of a corporation owning 10% or more of the outstanding stock; managing members or officers of a limited liability company, and members owning 10% or more of the company; and any intended registered manager of Hotel and Restaurant or Tavern class of retail license. NOTICE: This individual history record requires information that is necessary for the licensing investigation or inquiry. All questions must be answered in their entirety or the license application may be delayed or denied. If a question is not applicable, please indicate so by "N/A". Any deliberate misrepresentation or material omission may jeopardize the license application. 1. Name of Business 414 kttn cLl a�.tce. The . r4V' , 2. Your I Name (last, first, middle) i_awcernce IlAea-a J'eanse-+n 3. List any other names you have used. Laxr9 1.-e_ nseln (if different / from residence) J /7 tee. �7 �q,�—,,/,� 4. Mailing Pa, 1 (1, e� .l?6� n- e�i-CI _( ,CJ C17 IC<.I 120 5. List current residence address. Include any previous addresses within the last five years (attach separate sheet if necessary). STREET AND NUMBER CITY, STATE, ZIP FROM TO Current c{63 Kacsk Ur, Leo 9moni- C'0 &0504 1471 2-0 I -- 1resenr Previous 6. List all employment within the last five years. Include any sett employment. (Attach separate sheet if necessary) NAME OF EMPLOYER OR BUSINESS ADDRESS (STREET, NUMBER, CITY, STATE, ZIP) POSITION HELD FROM TO ht I.AnK Cotc�uttdo 110 11. Mato Sr, Lonirnonl-CO \J(Ce 4-105) don r 2Q° Co Z°(2_ 9)i 7. List the name(s) of relatives working in or holding a financial interest in the Colorado alcohol beverage industry. NAME OF RELATIVE RELATIONSHIP TO YOU POSITION HELD NAME OF LICENSEE 8. Have you ever applied for, held, or had an interest in a Colorado Liquor or Beer License, or loaned money, furniture, fixtures, equipment or inventory to any licensee? If yes, answer in detail. ❑ Yes fGl No 9. Have you ever received a violation notice, suspension, or revocation for a liquor lawviolation, or have you applied for or been denied a liquor or beer license anywhere in the United States? If yes, explain in detail. ❑ Yes I —I No 10. Have you ever been convicted of a crime or received a suspended sentence, deferred sentence, or forfeited bail for any offense in criminal or military court or do you have any charges pending? (If yes, explain in detail.) Yes cxNo 11. Are you currently under probation (supervised or unsupervised), parole, or completing the requirements of a deferred sentence? (if yes. explain in detail.) JD Yes [No 12. Have you ever had any professional license suspended, revoked, or denied? (If yes, explain in detail.) Yes tkrNo PERSONAL AND FINANCIAL INFORMATION Unless otherwise provided by law, the personal information required in question #13 will be treated as confidential. The personal information required in question #13 is solely for identification purposes. 13a. Date of Birth ?- b. Social Security Number SSN c. Place of Birth L6n9rozo t CO d. U.S. Citizen? L.Yes ENo e. If Naturalized, State where f. When g. Name of District Court h. Naturalization Certificate Number I. Date of Certification j. If an Alien, Give Alien's Registration Card Number k. Permanent Residence Card Number I. Height (o/S," m. Weight 215 n. Hair Color G-rati o. E e Color p. Sex ivl q. Race W?)r{p r. Do you have a current Driver's License? If so, give number and state 1g4-/ Financial Information. a. Total purchase price $ n (Pr (if buying an existing business) or investment being made by the applying entity, corporation, partnership, limited liability company, other $ b. List the total amount of your investment in this business including any notes, loans, cash, services or equipment, operating capital, stock purchases or fees paid $ c. Provide details of the Investment described in 14.b. You must account for all of the sources of this investment. Attach a separate sheet if needed. Type: Cash, Services or Equipment Source Amount (A- d. Loan Information (attach copies of all notes or loans) Name of Lender Address Term Security Amount Oath of Applicant I declare un. -r penalty of perjury that this application and all attachments are true, correct, and complete to the best of my knowledge. Authori d nature -L4-e- idkJI Title Date Statement of Authority • (Section 38-30-172, C.R.S.) 1. This Statement of Authority Relates to an entity named Highlandlake, Inc. 2. The type of entity is a A Colorado Corporation The entity is formed under the laws of COLORADO The mailing address of the entity is: 403 Karsh Drive, PO Box 6052, Longmont, CO 80504 5. The name and position of each person authorized to execute instruments conveying, encumbering, or otherwise affecting title to real property on behalf of the entity is: Lawrence Jensen, President 6. The authority of the foregoing person (s) to bind the entity is limited as follows: 7. This Statement of Authority is executed on behalf of the entity pursuant to the provisions of S 38-30-172, C.R.S. 8. This Statement of Authority amends and supersedes in all respects any prior Statement of Authority executed on behalf of the entity. Executed this aday of August , 2012 . ;1 Name: IIG��ik� ence Jensen, President STATE OF COLORADO ) ss. COUNTY OF BOULDER The Foregoing instrument was acknowledged before me this • qthday of Lawrence Jensen, Pesident of Highlandlake, Inc. Witness my hand and official seal. My commission expires: .D1 3I a01 fa 2012 by CORPORATE RESOLUTION OF HIGHLANDLAKE, INC. TO: THE OFFICERS AND DIRECTORS OF HIGHIANDLAKE,INC. Pursuant to the Bylaws of Highlandlake, Inc., a Colorado Corporation, the undersigned, being a quorum of the members of the Board of Directors of said corporation, hereby enact the following Resolution, to wit: A meeting of Highlandlake, Inc. was held on August 4, 2012 for the purpose of appointing new officers of the corporation due to the death of the President, Mary Jensen. I, Lawrence Jensen, the Treasurer, and only remaining officer of Highland Lake, Inc. hereby makes a motion to name a new president of the corporation. After much discussion, a vote was taken. The motion was passed naming Lawrence Jensen as the new President of Highlandlake, Inc. Dated this 4th day of August, 2012 Jensen, Treasurer Document must be filed electronically. Paper documents will not be accepted. Document processing fee Late fee if entity is in noncompliant status Fees & forms/cover sheets are subject to change. To access other information or print copies of filed documents, visit v, VOA .sosgate_ .Li) us and select Business. and select Business Center. E -Filed $10.00 $40.00 Colorado Secretary of State Date and Time: 09/07/2011 03:06 PM ID Number: 19871638512 Document number: 20111509691 Amount Paid: 510.00 ABOVE SPACE FOR OFFICE USE ONLY Periodic Report Sled pursuant to t' .yo -?u I, et seq. and r•9 -co I of the Colorado Revised Statutes (C.R.S) ID number: 19871636512 Entity name: HIGHLANDLAKE, INC. Jurisdiction under the law of which the Colorado was formed or registered: I. Principal office street address: 403 Karsh Drive 2. Principal office mailing address: (if different from above) (Surer at and member) LONGMONT CO 80504 (City) Aired States (Postal/Zip Code) (Province - ifappliaabbe) (Country- dno) US) (Street name and number or Post Office Box trgarnation) (City) (State) (PostaVZip Cade) (Province -((applicabk) (Country -- (not LS) 3. Registered agent names (if an individual) JENSEN (mil OR (if a business organization) LAWRENCE M. (First) @fiddle) ester) 4. The person identified above as registered agent has consented to being so appointed. 5. Registered agent street address: REPORT 403 Karsh Drive (Street name and number) LONGMONT (City) CO 80504 (State) (Postal'Zip Code) Pap 1 oft Rev. 8/112010 6. Registered agent mailing address: (if differed front above) (Street name and mmther or Post OfficeBar njornatan) Notice: (City/ (Stare) (Postal/Zip Code) Tsarina - ifappllcable) (Cowury-ifnor US) Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the individual's act and deed, or that the individual in good faith believes the document is the act and deed of the person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic statutes, and that the individual in good faith believes the facts stated in the document are true and the document complies with the requirements of that Part, the constituent documents, and the organic statutes. This perjury notice applies to each individual who causes this document to be delivered to the secretary of state, whether or not such individual is named in the document as one who has caused it to be delivered. 7. Name(s) and address(es) of the individual(s) causing the document to be delivered for filing: Jensen Lawrence (First) (law 403 Karsh Dr. (Middle) (Stiffir) (Street nentie and timber or Post Office Bar information) Longmont (City) CO 80504 oni�lStates (PostalZip Code) (Province -ifapplteable) (Country- if not US) (The dement need not state the treat name and address clam than one individual. However. if)ou wish to state the name and address of any additional Individuals causing the h,esmnem n be delivered for filing, mark this bar O and include an attachment stating the name and address of such individuals) Disclaimer. This form, and any related instructions, are not intended to provide legal, business or tax advice, and arc offered as a public service without representation or may. While this form is believed to satisfy minimum legal requirements as of its revision date, compliance with applicable law, as the same may be amended from time to time, remains the responsibility of the user of this form. Questions should be addressed to the user's attorney. REPORT Page 2 of 2 Rev 8/11/2010 6,38SO ARTICLES Of INCORPORATION ! 48 of NIGNLANDLAKE, INC. The undersigned person, who is more than eighteen years of age, hereby establishes a corporation pursuant to the statutes of the State of Colorado. and adopts the following Articles of Incorporation. I. NAME The name of the Corporation is Highlandlake. Inc. II. TERM The Corporation shall have perpetual existence. III. PURPOSES AND POWERS A. Purposes. The Corporation shall be permitted to engage in or conduct all business or businesses permitted by law. B. Powers. In furtherance of the foregoing purposes, the Corporation shall have and may exercise all of the rights. powers and privile-es now or hereafter conferred upon corporations organized under the laws of Colorado. In addition. it may do everything necessary, suit- able or proper for the accomplishment of any of its corporate purposes. IV. SHARES A. Number of Shares. The aggregate number of shares which the Corporation shall have authority to issue is SO,000 shares of common stock, ‘ . a.out par value. B. !Vann. s. Each shareholder if record shall have one vote for lact share of stock standing in his name on the books of the Corporat!c. and end tlt hi A. except that. in the election of WuAiL��u n. Aft 6,1 directors, he shall have the right to vote such number of shares fir as many persons as there a►e directors to be elected. Cumulative votl..1 shall not be allowed in the el•ction of directors or for any other purposes. C. Distributions to Shareholders. The Board of Directors may, from time to time. distribute to the shareholders in partial liquidation, out of stated capital or capital surplus of the Corporation, a portion of its assets. in cash or property, subject to the limitations contained in the statutes of Colorado. D. Restrictions on Share Transfer. The Board of Directors is authorized to impose any restriction on the sale, pledge, transfer, or other disposition of shares of the Corporation which. in its sole discretion, is necessary or desirable for the Corporation, including, but not limited to. those restrictions necessary to enable the Corporation to comply with state or federal securities laws. The following legend will be placed on each share certificate issued by the Corporation to restrict the transferability of the Corporation's share: The shares represented by this certificate are subject to restrictions on transfer. A copy of the restrictions will be furnished by the corporation to the holder of this certificate upon written request and without charge. V. BOARD OF DIRECTORS The business and affairs of the Corporation shall be managed by a board of directors which shall exercise all of the powers of the Cor- poration. except as otherwise provided by law or by these Articles of Incorporation. The number of directors of the Corporation. which shall constitute the whole Board of Directors, shall be such as is from time to time fixed by, or in the manner provided in, the Bylaws. No decrease in the number of directors stall shorten the term of any incumbent director. the Board of Directors shall have the power to adopt such Bylaws as may be necessary and proper for the management of the of airs of the Corpora- tion and to alter, amend or repeal the same in accordance with the pro- visions to that effect contained in said Bylaws. VI. INITIAL BOARD OF DIRECTORS Three directors shall constitute the initial Board, their names and addresses being as follows: Mary Jensen 17029 Weld Csunty Road S Platteville, Colorado 80651 Dorothy Scott 730 Kimbark Street Longmont, Colorado 80501 Lawrence M. Jensen 515 Kimbark Street Longmont, Colorado 80501 VII. REGISTERED OFFICE AND AGENT The address of the initial registered office of the Corporation is 515 Kimbark Street, Suite 107, Longmont, Colorado 80501. The name of its initial registered agent at such addi:ss is Lawrence M. Jensen. The Corporation may conduct all or part of its business in any other part of Colorado, of the United States or of the world. It may hold, mortgage, lease and convey real and personal property in any of such places. a VIII. MISCELLANEOUS The following provisio►,s are inserted for the management of the business and for the conduct of the affairs of the Corporation, and the same are in furtherance of and not in 11mit:tion or exclusion of the powers conferred by law. A. Contracts with Directorst etc. No contract or other transaction. of the Corporation with any other person. firm or corpora- t1un, or in which this Corporation is interested. shall be affected or invalidated by: 1. The fact that any one or more of the directors or officers of this Corporation is interested in or is a director or officer of another corporation; or 2. The fact that any director or officer. individually or jointly with others. pay be a party to or may be interested in any such contract or transaction. Each person who may become a director or officer of the Corporation is hereby relieved from any liability that might otherwise exist :►y reason of his contracting with the Corporation for the benefit of himself or any firm or corporation in which he may be in any way interested. B. Negation of Equitable Interests in Shares or Rights. The Corporation shall be entitled to treat the registered holder of any shares of the Corporation as the owner thereof for all purposes. includ- ing all rights deriving from such shares, and shall not be bound to rec- ognize any equitable or other claim to, or interest in, such shares or rights deriving from such shares, on the part of any other person, in- cluding, but without limiting the generality hereof, a purchaser, assignee or transferee of su h shares or rights deriving from such 4 shares. unless and until such purchaser, assignee, transferee or other person becomes the registered holder of such shares, whether or not the Corporation shall have either actual or constructive notice of the inter- est of such purchaser, assignee or transferee or other person. The pur- chaser, assignee or transferee of any of the shares of the Corporation shall not be entitled: to receive notice of the meeting of the share- holders; to vote at such meetings; to examine a list of the shareholders; to be paid dividends or other sums payable to shareholders; or to own, enjoy and exercise any other property or rights deriving from such shares against the Cr.'potation, until such purchaser, assignee or transferee has become the registered holder of such shares. IX INCORPORATOR The name and address of the incorporator are: Lawrence M. Jensen 515 Kimb•rk Street Longmont, Colorado 80501 Dated: /0.r STATE OF COLORADO ) ) ss. COUNTY OF BOULDER ) I,jkaa dare certify that on the welidgi day of .' _ - ' , 19i3_ personally .;peared before me Lawrence M. Jensen, who being by me first duly sworn, a Notary Public. hereby 5 declared that he was the person who signed the foregoing Articles of incorporation as incorporator and that the statements therein contained are U" LKS:bs hand and official seal. ion expires: f.2 , y YUDIiC f, OFFICE OF THE SECRETARY OF STATE OF THE STATE OF COLORADO CERTIFICATE I, Scott Gessler, as the Secretary of State of the State of Colorado, hereby certify that, according to the records of this office, HIGHLANDLAKE, INC. is a Corporation formed or registered on 09/25/1985 under the law of Colorado, has complied with all applicable requirements of this office, and is in good standing with this office. This entity has been assigned entity identification number 19871638512. This certificate reflects facts established or disclosed by documents delivered to this office on paper through 08/07/2012 that have been posted, and by documents delivered to this office electronically through 08/08/2012 @ 09:45:36. I have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, authenticated, issued, delivered and communicated this official certificate at Denver, Colorado on 08/08/2012 @ 09:45:36 pursuant to and in accordance with applicable law. This certificate is assigned Confirmation Number 8310606. Secretary of State of the State of Colorado End of Certificate ,Vona: it certificate issued ekcntically from the Cdoradr Secretary afStae's Web site is filly aid iwmedisely valid and effective However as an option. the immure and validity eta certifkae obaruned electronically may be established by visiting the Certificate Confirmation Page of the Secretary of State's Web rte p . �, o -_r, . _: e, ewenng the cernfrcate s can annahan number displayed on the cenvkate. and following the instrucoora �displayed Con4rmrtre the aiawe of a certificate is merely optional and is not necessary to the valid and elkctiw issuance ofa cersdaite. For more information visit or Web site. - -• click Business Center and select "Fregrmty Asked Qwstia r CE'RI GS D Ro'ssrd 08 10 2008 O a la O -O N 3 8 TO co La 0 0• > o <> U g aB a Y m v O 20 2-) F Clk c4 _p m RECEIPT DATE 51-I L - I a RECEIVED FROM th ADDRESS '-ID yi4 ikwLd L.a Jb, Cil (7dC.t , I n c_ urine 4Q�iea, 4 `eIIFb NO. 86542 $ 01.50 FOR Lceo35 I1Guy-RunR4,GQ S, Z o lase4.r HOW PAID CASH CHECK MONEY ORDER Iog BY HIGHLANDLAKE, INC. MARY E. JENSEN P O BOX 652 MEAD, CO 80542 PAY TO THE ORDER OF ne a PW w1 4 5°70 cr _ 7-21-12 DATE Wills Fargo Bank NA Colorado walxhrgocomm 2685 23-7/102010: 4478019184 I $ W7 6-= DOLLARS ea .e FOR 44 I Lef Ccct L.iQ l `Q% lLW 4 hi-elzaitattilo C Jar Harland Clare RECEIPT RECEIVED FROM \-K DRESS G DATE 4;3 - V\L NO. b6543 1\_ Ath-tIa+OAk nr,r� loo— $ FOR LC a -in Cit iC C�2YtSu ia�Q 3 . at s-us- HOW PAID CASH CHECK 0 E //7 5`0 Ck . a S9-1 BY Ac HIGHLANDLAKE, INC. MicRASSRIOINSEN -main ¶YhoNje&VI P 0 BOX 652 MEAD, CO 80542 7-27-12 DATE PAYOHE ( ORDETT R OF \ �IOt'Q�� 5© WRlk Fargo Bank NA Colorado wAslam-mm 2684 23-7/10201052 4478019184 (A RS a FOR Lipiri I.EcvAs.'Q g2.G1SLL.0 ull.(il 0t ttia C� xv A x X DR 8177 (05/09/08) PAGE 1 REPORT OF CHANGES 21 COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 CORPORATION, LIMITED LIABILITY; (303) 205-2300 WELD COUNT rCOMPANY AND PARTNERSHIP S :p COMMISSIONER3-iquor and 3.2 Beer Licenses (2355) ❑ L@81.P+A66NEWISHW 3 23 SEE INSTRUCTIONS AND (2350) i iCORPORATION FEE SCHEDULE ON PAGE 2 1. CorporateiL.L.C.� LY )C - a 1-Eighlcund L 2. a State Tax Account Number /q --Gat,- 000n 3. State Liquor License Number �-P,,I.,4- 4. Trade Name 5. Telephone Number 6. Address of Licensed Premises 16tci3 WC,R5, City/)„ 'YI � CO Z Code Q S y Z 7. Mailing Address 6 different Man above, ---, C� .r . ` PO 652_ CitY 'NI GnState A ZIP Code ko5yz— 8. UST ALL officers, directors (corporation or Managing Members (L.LC.) or General Officer, Director, Managing Member or Partner MUST FILL OUT a DR 8404-I (Individual Partner(s). Each History Record). Position Held Names Home Address DOB Replaces PR'Sidcn'- i O u 7reyrsa 3P-nsev) k103 KarsIneq-nnyin tm t CrO bocol $- Maly -Se inSto_n 9. LIST ALL 10% (or more) Stockholders or 10% (or more) Members or 10% (or more) Limited Partners. Each person listed Must Fill out a DR 8404-I (Individual History Record) Stockholders/Wlembers/Pertners owning 10% (or more) of business % Owned }Ionia Address DOB Replaces Lau)u co 3 n&ev\ )00 , Lfo3 Kays , 1-ony rle1c:nf- Co 8Ct5ai M&ry.cP l4tn 10. Registered Agent Address For Service 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. 11. A z gnature "��ilti T' a r�idon i- Date 5 I Z REPORT OF LOCAL LICENSING AUTHORITY The foregoing changes have been received and examined by the Local Licensing Authority. 12. Local Licensing Authority For ' Weld ado �, ❑X County ❑ Town/City b ~ y Signature Sean P. Co wa ''1�1�i ! e �►' Chair, Board Weld s my Commissioners Date AUG 2 2 2012 1 .rk to theBoard ut y Clerk othe Board Date AUG 2 2 2012 Anent : • By:�.,, ' i.11�°�a _ , cs..'►, _ DO > W t ral�, H ' 'I - f =-} 'r R DEPARTMENT OF REVENUE USE ONLY ITY INFORMATION `OTL_,� License Account Number 1�n�La+�� - Cash Fund -100 (999) TOTAL A DO NOT WRITE IN THIS SPACE eceived G 5 20;2 AUG 3 0 2012 <' ;1 Liquor Enf Div. 2012-2231 L.ia,003S US Airbill xpress Forth Tracking Number 8715 2808 1807 0215 1 From ..otaroornshara 8-24-12 Senders FedEx Date Account Number 1253-1948-3 Senders Name CLERK TO THE BOARD .0 Ni C "' OF WELD Compaq ; f-�lr•,1'L!` OF WELD Address R I 1 rC.TH Phone(970) 356-4000 X5726 — Deptifloor/Swionloom rrr�E'r CO 80631-1 1 1 7 shy ' State ZIP 2 Your Internal Billing Reference rest nmaramrepall apseerm r.om.. 3 To NaRecmeipients LIQUOR ENFORCEMENT DIVISIOI4honel 303) 205-2300 HOLD Weekday HOW Satrday company COLORADO DEPARTMENT OF .Feda�� rq b „gym FewP a.niga REVENUE Address 1881 PIERCE STREET RM 108A We cannot delver to Po. home or PO. ZIP codes. Doptifirrix/Suitellioom Address Prim Fears Incetron address here a POLO option is selected. city DENVER State CO ZIP 80261 4a Express Package Service Iaeri is rcrf': unnl DVPrriii FrcEc 2Duv Poo Ex Fxpre ss S aver Packages op to 750 redrx OralOvsunn(lr avilivary axial 4h Express Freight Service — Torrrovraations FeoEx I Day Pe ',flan nr Sot ID'' n ,ais recEx 7DovT ud�a.n . unarm 'mr° Packages over ISO Fed& 30ay Freight __. 15 re Aussie, any sa,NMoaren NOT as leek 5 Packaging 'Declared earns lima") X E'd Ex I FedEx Pak' Envelope' r ,V2Fres FedEx Box I FedEx Tube Ol D 6 Special Handling and Delivery Signature Options SATURDAY DrIWary drain, art Om Olt FLOE,I St 0up't FWEs Express Saver orbaEs,Day Freight No Signature Required a:disarray de !en with sir Direct Signature Smieoris rUfliAllers address Does this shipment contain dangerous goods? No I yes raoasane y-_ Yes No Snappers 0erlarauon. no gonad. mneeaaw gwu,r. nuneang dry wspoor n stowed in redk sasY g.g or prnada n r sob uor„ss oven Anti Indirect Signature -- II no one is availablepent. address someone ar a eipnmeng —_ addressa sect fur dewery Fix �esti r lolvenne WYE' ".r Drylce orvicae. ON 1845 — C. Cargo Aircraft Only 7 Payment Billie' Sender — _. __ foie faeraca Nu eCMaCai Na Mow. --rra ,. r,,;iceglyn�$v°"" I Recipient Third Party I Credit Card Cash/CI 041572239`9' Falb aeeNo Exp credncard rvo date 0`j Store your addresses at fedex.com Simplify your shipping. Manage your account Access all the tools you need. 9,g1Ar-i 0 V CANA)41S Q0rpDrC G 5�� , 90 &- as --1 Total Packages Total Weight Total Declared Value' Ins I CO 11:111 Canary is limited to MO unless one hpn S. bank tor. r eases eymng ate SNruyou agree Tr the mad aaflum"nl in its sumo Pedro Service cne6.xang toss, dal row our tidbit,.. etc Data zvo-r sat nse2spslgw 2008 rearo.EPINTSO IN osw.sos 553 0 MEMORANDUM Tonya Johnson, Deputy Clerk to the Board August 23, 2012 From: Bethany Salzman, Zoning Compliance Officer, Dept. of Planning Services Subject: LC0035 Review of the following liquor license renewal by the Department of Planning Services shows the following: License Number: 14-27324-0000 Applicant: Mary Jensen dba Highlandlake, Inc. 16983 CR 5 PO Box 652 Mead, CO 80542 Zone District: A (Agricultural) This use has existed prior to zoning and a Nonconforming Use File (NCU-141), has been set up by the Department of Planning Services. Any expansion or remodel may require updated zoning permits. The Department of Planning Services is not aware of any violations occurring on the property at this time. SERVICE, TEAMWORK, INTEGRITY, QUALITY Tonya Johnson From: Sent: To: Subject: Janet Carter Thursday, August 30, 2012 10:21 AM Tonya Johnson RE: Liquor Renewal - Highlandlake, Inc This is an existing site. Public Works doesn't have any comments at this time. Thanks, Janet L Carter Traffic Engineer Weld County Public Works Dept. P,0. 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: Thursday, August 23, 2012 4:16 PM 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: Liquor Renewal - Highlandlake, Inc The following applicant has submitted a request for renewal of its 3.2 Percent Beer Retail License, LC0035. Please provide any comments you may have before September 13, 2012. A .pdf copy of the application materials is attached. License Number: 14-27324-0000 Applicant: Highlandlake, Inc. P.O. Box 652 Mead, CO 80542 Establishment address: 16983 County Road 5 Mead, CO 80542 Current License Expires: November 9, 2012 Thank you, Tanya (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 LIQUOR/BEER RENEWAL REVIEW FORM Date: August 30, 2012 TO: Lisa Carpenter/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: September 13, 2012 ESTABLISHMENT: HIGHLANDLAKE, INC. DBA HIGHLANDLAKE, INC. 16983 WELD COUNTY ROAD 5 MEAD, CO 80542 Current license expires: November 9, 2012 ********************************************************************************************************** No concerns C�'�c 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 following concerns are noted: )•.) ^C. 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) , 0'6"7 I2 Establishment Owner, Please Print Date s lishme t Signature Deputy's Signature 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..Resoiire Office h LlcnLJOR ENFORCE Tl' T WORKSHEET 1950'b'Street Greeley, Colorado 80631 Voice (970) 356-4015 • Fax (970) 304-6467 Inspection Report 0 incident Report CR#: License Trade time: License #/Type: . A LkL _ CO . $''St -1 licensee Name: L. cx„) C -�4. .t - %.z 46 — Date of Report / Incident: cZ Q -7 Person Contacted: '3'c•„ rc✓'- Telephone #: £'i 7O • 5 8 -7 ''—t d L. et Yes No NIA State Liquor License Postod .._ Manager Registered X State Sales Tax License Posted License In Control of Premises County liquor License Posted Trade Name Properly Registered Federal Form 11 *Gall 5800) 398-2822 r . Premises Physical Control Adequate Y . Mirror Warning Sign Posted W Oil Premise Storage Licensed lv Meals and Snacks Available Only Permitted Items Sold J JC Cleanliness Adequate Alcohol Front Permitted Source Books & Invoices Available Discuss Sales of liquor to Minors Alcohol Beverage Stock Acceptable Discuss Sales to Intoxicateyersons ❑Warning ❑Fofow-Up Inspection Time Volafica Dale: Subject DOD: Clothing: WgC Eyes: DL) IDt≥ Hair: State: Address: Fl/W Phone t_ City: Slate: Summons if: Zip: £"' Yes NO Court Date: Photos: Yes NO Narrative: SLCc t 1 i-1 - a 3 L) - 0000 Depu #: L .) z b Date: Oct o -) To: Weld County Board of Commissioners From: Deputy Jeremy Frey Date: September 7, 2012 RE: Highland Lake Inc. Dear Commissioners, I have completed the inspection for Highland Lake Inc. located at 16983 WCR 5 Mead CO, 80542. Everything was in order and there have been no issues. I find no grounds for disapproval for the renewal of the liquor license. Respectfully Submitted, Deputy Jeremy Frey Community Resource Officer Weld County Sheriffs Office 1950 "O" Street Greeley, CO 80631 Tonya Johnson From: Sent: To: Subject: No Concerns Jonathan Gesick Wednesday, September 12, 2012 9:28 AM Tonya Johnson RE: Liquor Renewal - Highlandlake, Inc 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: Thursday, August 23, 2012 4:16 PM 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: Liquor Renewal - Highlandlake, Inc The following applicant has submitted a request for renewal of its 3.2 Percent Beer Retail License, LC0035. Please provide any comments you may have before September 13, 2012. A .pdf copy of the application materials is attached. license Number: 14-27324-0000 Applicant: Highlandlake, Inc. P.O. Box 652 Mead, CO 80542 Establishment address: 16983 County Road 5 Mead, CO 80542 Current License Expires: November 9, 2012 t Thank you, Tonya (Disney) Johnson Clerk to the Board 1150 O Street IPO Box 758 'Greeley, 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 a r I:O rr O m U.S. Postal Service.M CERTIFIED MAIL RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) Postage m O Certified Fee O C Return Receipt Fee (Endorsement Required) Restricted Delivery Fee 0" (Endorsement Required) nJ O O N Total Postage 8 Fees Sent Ti Postmark Here (AZ MC Street, Apt.Ala; �/ or PO Box No. (4 n?)7� (. tv/(le C¢y. State, ZIP+4 • a c- m C N In m C C D C C ru D D U.S. Postal ServicelM CERTIFIED MAILTM RECEIPT (Domestic Mall Only; No Insurance Coverage Provided) Postage Certified Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required Total Postage 8 Fees SENDER: COMPLETE THIS SECTION • 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: Lij)(i fjk h IL(i4 !l(', t y('; Lk.:7)-c( tint I,I-(��1. c(14 Postmark Here COMPLETE THIS SECTION ON DELIVERY ' I$I�. ure B... eived by( Printed hlame)11'' C. to of Delivery V. 'Y1 l D. Is delivery address different rtbm Rem I? 0Weis If YES, enter delivery address below: Agent Addressee C No 3, Service Type .,.Q Certified Mail ❑ Registered o Insured Mail o Express Mail ❑ Return Receipt for Merchandise ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) O Yes 2. Article Number (Transfer from service tabol) PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 7004 2890 0003 5709 8914 Hello