HomeMy WebLinkAbout20102479.tiffRESOLUTION
RE: APPROVAL OF RENEWAL APPLICATION FOR HOTEL AND RESTAURANT LIQUOR
LICENSE FOR LA FIESTA MEXICAN GRILL, INC., DBA LA FIESTA MEXICAN GRILL
AND AUTHORIZE CHAIR TO SIGN - EXPIRES OCTOBER 19, 2011
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, La Fiesta Mexican Grill, Inc., dba La Fiesta Mexican Grill, c/o Miguel Ruiz,
presented to the Board of County Commissioners of Weld County, Colorado, an application for the
renewal of a Hotel and Restaurant Liquor License, 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:
4322 Highway 66, Longmont, Colorado 80542
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.
WHEREAS, the Board has determined the application for the renewal of a Hotel and
Restaurant Liquor License shall be conditionally approved, with the requirements that a building
permit must be obtained for the patio area, as well as the "modification of premises" process being
completed.
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 2010-16 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 October 19, 2011, 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
Lc- 361
I a- i0 2010-2479
LC0032
RENEW LIQUOR LICENSE - LA FIESTA MEXICAN GRILL, INC., DBA LA FIESTA MEXICAN
GRILL
PAGE 2
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.
BE IT FURTHER RESOLVED by the Board that the application for the renewal of a Hotel
and Restaurant Liquor License shall be conditionally approved, with the requirements that a building
permit must be obtained for the patio area, as well as the "modification of premises" process being
completed.
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 18th day of October, A.D., 2010.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY COLORADO
ATTEST:
Weld County Clerk to the Bo
BY.
Dep
APPROVED
oGn orney
Date of signature: 14'31 lib
Chair
ara Kirkmeyer, Pro-Tem
'
�r�Sean�P. Cp
Wiliam F. Garcia
David E. Long
2010-2479
LC0032
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of County Commissioners has
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The Board of County Commissioners
lerk to the Board
THIS LICENSE MUST BE POSTED IN PUBLIC VIEW
DR 8402
(10/29/07)
DEPARTMENT
ALCOHOLIC
STATE OF COLORADO
OF REVENUE
Liquor Enforcement Division
1881 Pierce Street, Suite 108
Lakewood, Colorado 80214
LA FIESTA MEXICAN
GRILL INC
LA FIESTA MEXICAN
GRILL
4322 HWY 66
LONGMONT CO 80504
BEVERAGE LICENSE
LiabilityInformation
Account Number
County City Indust. Type Liability Date
LICENSE EXPIRES AT MIDNIGHT
12-78949-0000
07 206 722110 C 102009
OCT 19, 2011
Type
Name and Description of License
Fee
1971
2190
HOTEL AND RESTAURANT
LIQUOR LICENSE - MALT,
VINOUS, AND SPIRITUOUS
COUNTY 85 PERCENT OAP FEE
$ 75.00
$ 425.00
TOTALFEE(S)
This license is issued subject to the laws of the State of Colorado and especially
of Title 12, Articles 46 or 47, CRS 1973, as amended. This license is nontransferable
conspicuously posted in the place above described. This license is only valid through
date shown above. Questions concerning this license should be addressed to
Revenue, Liquor Enforcement Division, 1375 Sherman Street, Denver, CO 80261.
In testimony whereof, I have hereunto set my hand.
K.YIaa/�a./ry i� G1 /.
i
Division Director Executive
$ 500.00
under the provision
and shall be
the expiration
the Department of
(/
Director
1976 ❑ Brew Pub License (County)
1980 ❑ Hotel and Restaurant License w/opt premises (City)$500.00
1981 ❑ Hotel and Restaurant License w/opt premises (County) $500.00
1983 ❑ Manager Registration - H & R $ 75.00
DR 8404 (05/17/07) Page 1
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
DENVER CO 80261
COLORADO LIQUOR
RETAIL LICENSE APPLICATION
21
ElNEW LICENSE ElTRANSFER OF OWNERSHIP kLICENSE RENEWAL
MUST BE PRINTED IN BLACK INK OR TYPE ITTEN
• ALL
• APPLICANT MUST CHECK THE APPROPRIATE BOX(ES)
• LOCAL LICENSE FEE $ I IS"DD
• APPLICANT SHOULD OBTAIN A COPY OF THE COLORADO LIQUOR AND BEER CODE(Call 303-370-2165)
1. Applicant is applying as a
%Corporation
❑ Partnership (includes Limited Liability and Husband and Wife Partnerships)
2. Applicant If an LLC, name of LLC; if partnership, at least 2 partner's names; if corporation, name of corporation
A f?Sta_ Iuecicoot\ Grt u, fit
2a.Trade Name of Establishment (DBA)
c cfct (�l-eulcav 0wl11
DEPARTMENT USE ONLY
n Individual
cr.-Limited Liability Company
❑ Association or Other
3. Address of Premises (specify exact location of premises
Lt3eY4 StCG V h U1(0
City
L -Do. wort
4. Mailing Address (Number and Street)
Sankt as abett)
5. If the premises currently have a liquor or beer license, you MUST answer the following questions:
County
Weld
City or Town
State Sales Tax No.
I3- 1NC(-l9 -O00
State
Co
State
Fein Number
tic- 331953- 3
Business Telephone
'giic)53ss-2--
ZIP Code
eC Soy
ZIP Code
Present Trade Name of Establishment (DBA)
LA Fiesta Cy(
LIAB SECTION A NONREFUNDABLE APPLICATION FEES
2300 ❑ Application Fee for New License $1,025.00
2302 ❑ Application Fee for New License -
w/Concurrent Review $1,125 00
2310 ❑ Application Fee for Transfer $1,025.00
2312 ❑ Application Fee for Transfer -
w/Concurrent Review $1,125.00
LIAB SECTION B LIQUOR LICENSE FEES
1905 ❑ Retail Gaming Tavern License (City) $500.00
1906 ❑ Retail Gaming Tavern License (County) $500.00
1940 ❑ Retail Liquor Store License (City) $227.50
1941 ❑ Retail Liquor Store License (County) $312.50
1950 ❑ Liquor Licensed Drugstore (City) $227.50
1951 ❑ Liquor Licensed Drugstore (County) $312.50
1960 ❑ Beer and Wine License (City) $351.25
1961 ❑ Beer and Wine License (County) $436.25
1970 ❑ Hotel and Restaurant License (City) $500.00
1971 Hotel and Restaurant License (County) $500.00
1975 ❑ Brew Pub License (City) $750.00
$750.00
Present State License No.
I LECI COO
Present Class of License
fktcl( (ZE'51ZLwut
a
LIAB SE
SECTION B CONT.)
1985 ❑ Resort Complex License (City) $500.00
1986 ❑ Resort Complex License (County) $500.00
1988 ❑ Add Related Facility to Resort Complex... $ 75.00 X_Total
1990 ❑ Club License (City) $308.75
1991 ❑ Club License (County) $308.75
2010 ❑ Tavern License (City) $500.00
2011 ❑ Tavern License (County) $500.00
2012 ❑ Manager Registration - Tavern $ 75.00
2020 ❑ Arts License (City) $308.75
2021 ❑ Arts License (County) $308.75
2030 ❑ Racetrack License (City) $500.00
2031 ❑ Racetrack License (County) $500.00
2040 ❑ Optional Premises License (City) $500.00
2041 ❑ Optional Premises License (County) $500.00
2045 ❑ Vintners Restaurant License (City) $750.00
2046 ❑ Vintners Restaurant License (County) $750.00
2220 ❑ Add Optional Premises to H & R $100.00 X Total
2370 ❑ Master File Location Fee $ 25.00 X Total
2375 ❑ Master File Background $250.00 X Total
Present Expire ion Date
(44(9/20 0
LIQUOR LICENSE FEES
DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY
LIABILITY INFORMATION
County
City
Industry Type
License Account Number
Liability Date
License Issued Through
(Expiration Date)
FROM
TO
State
-750 (999)
City
2180-100(999)
County
2190-100(999)
Managers Reg
-750 (999)
Cash Fund Nem Unitas
2300-100
(999)
2310-100
(999)
TOTAL
W
•
2010-2479
L c o O 3',2_
DR 8404 (05/17/07) Page 4
19. If applicant is a corporation, partnership, association or limited liability company, applicant must list ALL OFFICERS, DIRECTORS,
GENERAL PARTNERS, AND MANAGING MEMBERS. In addition applicant must list any stockholders, partners or members with OWNER-
SHIP OF 10% OR MORE IN THE APPLICANT. ALL PERSONS LISTED BELOW must also attach form DR 8404-I (Individual History record),
and submit finger print cards to their local licensing authority.
NAME
HOME ADDRESS, CITY & STATE
DOB
POSITION
%OWNED'
if total ownership percentage disclosed here does not total 100% applicant must check this box
❑ Applicant affirms that no individual other than these disclosed herein, owns 10% or more of the applicant
Additional
III
❑
❑
❑
Documents to be submitted by type of entity
CORPORATION ❑ Cert. of Incorp. ❑ Cert. of Good Standing (if more than 2 yrs. old) ❑ Cert. of Auth. (if a foreign corp.)
PARTNERSHIP ❑ Partnership Agreement (General or Limited) ❑ Husband and Wife partnership (no written agreement)
LIMITED LIABILITY COMPANY ❑ Articles of Organization ❑ Cert. of Authority (if foreign company) ❑ Operating Agrmt.
ASSOCIATION OR OTHER Attach copy of agreements creating association or relationship between the parties
Registered Agent (if applicable)
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. 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
1/n .4. ,,,)• o
Title
w 6-1.C.(2___e
Date d
REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY/COUNTY)
Date application filed with local authority
09/21/2010
Date of local authority hearing (for new license applicants; cannot be less
than 30 days from date of application 12-47-311 (1)) C.R.S.
THE LOCAL LICENSING AUTHORITY HEREBY AFFIRMS:
Yes No
That each person required to file DR 8404-I (Individual History Reco d) has:
in Been fingerprinted n •
® Been subject to background investigation, including NCIC/CCIC check for outstanding warrants i1 •
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 I ■
(Check One)
Date of Inspection or Anticipated Date
■ Upon approval of state licensing authority.
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 12, Article 46 or 47, C.R.S. THEREFORE, THIS APPLICATION IS APPROVED.
Local Licensing Authority for
.
Weld County, Colorado
Telephone Number
970-356-4000 x 4228
❑ TOWN, CITY
C] COUNTY
.45-1..20
dnature .≥ . oard of County Commissioners
C� Q
Date
OCT 1 8 2010
Signature attest)
Ail pf
to the Board
lerk to the Board
Date
OCT 18 2610
/C
,310/D -- .94/72
DR 8401 (0797)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1881 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
1 - -nee>) (C }'1dZXiCa01 CIO II
State License Number
la- --7gyLief -COO
1. Operating Manager
itucu2,1 Cute
Home Address
i033 fl-jpine S , Lovlcron+, CO eC5oLl
Date of Birth
f✓
Do you have legal possession of the premises for which this application for license is made?
Are the premises owned or rented: C..elttid If rented, expiration date of lease: T v i'F
Yes No
g ❑
J`
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, principals, or lenders
(other than licensed financial institutions), been convicted of a crime? If yes, attach a detailed explanation.
Yes
No
5. Since the date of filing 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
6. Does the applicant, or any of its agents, owners, managers, principals, or lenders (other than licensed financial institutions), have a
direct 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
rf
VII
7. Sole owners or husband -wife partnerships answer this question. Since the date of filing of the last annual license application:
Has ownership changed in whole or in part, from a sole owner to any other person, partnership, corporation, or limited liability
company other than the licensee listed on your state liquor license? If yes, this license must be transferred to the new owner and
may not be renewed. Contact your Local Authority immediately.
Yes
No
8. Partnership applicants must answer this question. Since the date of filing of the last annual license application:
(a) Are there, or have there been any general partners added to, or deleted from the partnership? If yes, this license must be
transferred to the new partnership and may not be renewed. Contact your Local Authority immediately.
(b) Are there, or have there been any limited partners with a 10% or more interest, added or deleted from the partnership? If yes, this
license must be transferred to the new partnership and may not be renewed. Contact your Local Authority immediately.
Yes
No
9. Corporate applicants must answer this question. Since the date of filing of the last annual license application:
(a) Are there, or have there been any officers or directors added to, or deleted from the corporation? If yes, complete and attach
DR 8177 and submit to your Local Authority immediately.
(b) Are there, or have there been any stockholders with 10% or more of the issued stock, added to, or deleted from the corporation?
If yes, complete and attach DR 8177 and submit to your Local Authority immediately.
(c) Date of filing last annual corporate report with the Colorado Secretary of State:
Yes
No
LJ
10. Limited Liability Company applicants must answer this question. Since the date of filing of the last annual license application:
(a) Are there, or have there been any managing members added to, or deleted from the company? If yes, complete and attach
DR 8177 and submit to your Local Authority immediately.
(b) Are there, or have there been any members with 10% or more membership interest, added to, or deleted from the company?
If yes, complete and attach DR 8177 and submit to your Local Authority immediately.
(c) Date of filing last annual LLCO report with the Colorado Secretary of State:
Yes
No
IFI
11. Bed and Breakfast applicants must answer this question and certify compliance with 12-47-118.5 C.R.S., to the state licensing
authority by initialing the following listed questions:
That it has no more than 20 sleeping rooms and
That it provides at least 1 meal per day at no charge other than for overnight lodging, and
That it does not sell alcoholic beverages by the drink or in sealed containers, and
That it shall not serve alcoholic beverages for more than 4 hours In any one day, as follows:
MONDAY HOURS
From: m.
To: m.
TUESDAY HOURS
From: m.
To: m.
WEDNESDAY HOURS
From: m.
To: m.
THURSDAY HOURS
From: m.
To: m.
FRIDAY HOURS
From: m.
To: m.
SATURDAY HOURS
From: m.
To: m.
SUNDAY HOURS
From: m.
To: m.
COLORADO
6t
MEMORANDUM
TO: JENNY VANEGDOM
FROM: DAN JOSEPH
ENVIRONMENTAL HEALTH SERVICE
SUBJECT: LIQUOR LICENSE INQUIRY
DATE: 9/27/10
CC: CINDY SALAZAR; DEBRA ADAMSON
In response to your request, Environmental Health Services has reviewed the Retail Food
Service Establishment file for La Fiesta Mexican Grill, located at 4322 HWY 66, in
Longmont, 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
djoseph@co.weld.co.us or by phone at 970-304-6415 extension 2206.
Thank you.
Dan Joseph
Environmental Specialist III
Ar/ _ a MEMORANDUM
t; To: Jenny VanEgdom, Deputy Clerk to the Board October 4, 2010
VI From: Bethany Salzman, Zoning Compliance Officer, Dept of Planning Services
COLORADO Subject: LC0032
Review of the following liquor license renewal by the Department of Planning Services shows the following:
La Fiesta Mexican Grill, Inc.
dba La Fiesta Mexican Grill
4322 Highway 66
Longmont, Colorado 80542
Sales Tax #:12-78949
Zone District: C-3
This use is a permissible use allowed in this zone district through the appropriately amended permits. A
courtesy letter was sent by staff to Mr. Ruiz on September 15, 2009 regarding modifications made to the site
which appear to be a substantial change to SPR-258. The letter advised Mr. Ruiz to complete and submit a
Pre -Application Request form so the modifications could be reviewed and discussed between staff and the
applicant. To date nothing has been submitted to staff nor have any meetings been requested.
Furthermore, the property is currently in violation of the Weld County Building Code for an expired permit.
Please contact Peggy Gregory, Building Compliance Officer with any questions (Contact Information: 970-
353-6100, Ext. 3568).
Staff would recommend denial of this request, until the applicant first addresses the physical modifications
made to the property.
Staff received the following e-mail from Dan Dean, Mead Town Manager on September 27, 2010:
From: Dan Dean [mailto:DDean@townofinead.org]
Sent: Monday, September 27, 2010 10:45 AM
To: Bethany Salzman
Subject: RE: Annexation Requests
Bethany,
Thanks for your email. The Board of Trustees have held all of the necessary public hearings to annex the
enclave at Highway 66 and 125. We have been working with a number of the owners to complete
annexations with them. My goal is to complete them by the middle of November of this year. I hope this
is helpful. If you have questions please call me.
Dan J. Dean
Town Manager
Town of Mead
(970) 535-4477
ddean@townofmead.org
SERVICE, TEAMWORK INTEGRITY, QUALITY
Esther Gesick
From:
Sent:
To:
Subject:
Bethany Salzman
Monday, September 27, 2010 10:47 AM
Esther Gesick; Bruce Barker
FW: Annexation Requests
RE: La Fiesta Mexican Grill
Bethany Salzman
Zoning Compliance Officer II
1555 North 17th Avenue
Greeley, CO 80631
Office: (970)353-6100 Ext. 3555
Fax: (970)304-6498
Web: www.co.weld.co.us
From: Dan Dean [mailto:DDean@townofinead.org]
Sent: Monday, September 27, 2010 10:45 AM
To: Bethany Salzman
Subject: RE: Annexation Requests
Bethany,
Thanks for your email. The Board of Trustees have held all of the necessary public hearings to annex the enclave at
Highway 66 and 125. We have been working with a number of the owners to complete annexations with them. My goal
is to complete them by the middle of November of this year. I hope this is helpful. If you have questions please call me.
Dan J. Dean
Town Manager
Town of Mead
(970) 535-4477
ddean@townofinead.org
From: Bethany Salzman [mailto:bsalzman@co.weld.co.us]
Sent: Friday, September 24, 2010 4:10 PM
To: Dan Dean
Subject: Annexation Requests
First I would like to thank -you for taking the time to discuss the following cases with me:
John Deere property on Hwy 66
Silva, John & Micah
As we discussed I am requesting written documentation regarding the status of the John Deere annexation,
specifically the projected timeline in order to record the annexation plat and the case history. I will forward
1
this documentation to the Board of County Commissioners for their consideration in Mr. Ruiz's Liquor License
annual renewal request.
Thank -you again
Bethany Salzman
Zoning Compliance Officer II
1555 North 17th Avenue
Greeley, CO 80631
Office: (970)353-6100 Ext. 3555
Fax: (970)304-6498
Web: www.co.weld.co.us
2
LIQUOR/BEER RENEWAL REVIEW FORM
Date: September 22, 2010
TO: {DEPUTY} 7-\,e iiRCCE l 13`IT)
FROM: CTB
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: OCTOBER 1, 2010, OR ASAP
ESTABLISHMENT: LA FIESTA MEXICAN GRILL, INC.
DBA LA FIESTA MEXICAN GRILL
4322 HIGHWAY 66
LONGMOIT, COLORADO 80542
Current license expires: OCTOBER 19, 2010
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 Dot
Board of Commis loner
IS, -e R at Extension397-33y6 of the date and time of the
renewal hearing.
J
Liquor/Beer License Worksheet
The following concerns are noted:
nail -r1 c*ed_
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)
pi (14O(2 (I mcpn e.)
Establishment Owner, Please Print
Establishment Signatur
C Jo
Date
LAVA eYrl9 �' &
eputy'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.
0003 5224 8096
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U.S. Postal Service,,.,
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
(reet, Apt No.;
or PO Box No. q3,19. 4
3 ,z2'. %Wl4(au
City, State, I' 4
Postmark
Here
)Di3-)47�)
OW- .410ii
• Complete hems 1, 2, and 3. Also complete
hem 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 mailplece,
or on the front If space permits.
1. Article Addressed to:
143a VA t"-)1 ljlj
ts)v-N yn o - CO 2O5 a
A. Sig re
X
B.
ecely:. by (Printed Name)
D. Is delivery address different from item 17 0 Yes
If YES, enter delivery address below: 0 No
❑ Agent
0 Addressee
C. Date of Delivery
3. Service Type
g Certified Mail
0 Registered
0 Insured Mall
▪ Express Mall
❑ Return Receipt for Merchandise
❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7005 1820 0003 5224 8096
(Transfer horn san4ce label)
PS Form 3811, February 2004
Domestic Return Receipt
102595-02-M-1540
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