HomeMy WebLinkAbout20090389.tiff W Carr
W. Carr
1. Coates
Alan Dill
,rtA. Dill
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�_"� r t,.. (` ii. M. Dunn
455 Sherman Street, Suite 300 iutchings
Denver. Colo raao 80203 R,i 1 ''t '-- r 'I ! 't,- .n M. Lee
Phone. 303-777-3737 tr dsukage*
Fax 303-777-3823 ' ). Pringle
Dr_r Di_r CARR STONBRAKER & H.,rcHisos PC www,dlllonddlll com
t'� It ti s' ,' r, iti urthwaite
P Stapen
Direct Dial(303)282-4127 rt „1 rs {i, onbraker
E-Mail: cfontenott dillanddill.com D. Tooley
Iin Nevada
January 16, 2009 ,ldbaum,
of Counsel
VIA FEDERAL EXPRESS
Jenny Van Egdom
Office of Clerk to the Board
Weld County Government
915 10th Street
Greeley, CO 80631
RE: Circle K Stores, Inc.
Retail 3.2% Beer Off-Premises Licenses
Circle K Store 2709846; 10963 1-25 Access Rd.; Lic#21-65089-0120
Attorney for Licensee: H. Alan Dill
Corporate Report of Changes— Master File#21-65089
Dear Ms. Van Egdom:
A Corporate Report of Changes Form DR8177 for the above-referenced Master File
Licensee was filed with State Liquor Enforcement on May 30, 2008. This Report of
Changes reflects two (2) new officers for Circle K Stores, Inc. This filing has been
approved and a new Master File letter was issued on January 12, 2009. A copy of the
filing and new Master File letter are provided for your file.
Thank you for your consideration in this matter. Should you have any questions, please
call me at 303-282-4127.
Sincerely,
i
Christine Fontenot
Paralegal -.
encl./cc: our file 3
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STATE OF COLORADO
DEPARTMENT Of REVENUE ria7a✓J{
liquor Enforcement Division
Business Location Rl r
1881 Pierce Street,Suite 108A
Lakewood,Colorado 80214
Phone:(303)205-2300 Dill W�rJr
Pax: (303)205-2341 Governor
E-mail; LEDpspike.dor.state.co.us Roxanne Huber
Exeative Director
Website:www.revenue.stare:o.lts/Liquor Enforcement Laura K Harris
Division Director
January 12, 2009
Circle K Stores, Inc.
Circle K Stores
1130 W Warner Rd.
Tempe, AZ 85284
Re: State Master File for Circle K Stores, Inc.
DBA Circle K Stores
Dear Sir or Madam:
This is to advise you that the Colorado Liquor Enforcement Division ("Division")has, at your
request, created a "master file" for the above-listed Licensee.
As of the date of this letter our master file includes the following items which you have
submitted:
1. Individual History Records (Form DR-8404-1) for the following persons:
Daniel A. Abernathy
Brian P. Hannasch
Geoffrey C. Haxel
Lou J. Valdes
2. Fingerprint cards bearing the names and birth dates of the persons listed in
paragraph 1. The CBI and FBI have checked the prints and reportedly found
no record of any criminal history for those listed above.
Eye V00/E00d IEtpV:04 6002 Zl 4VEZ50ZEOE xed 1NA3DUOdN3 dof1011
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3. Certificate of Authority or a Certificate of Good Corporate standing from the
Colorado Secretary of State which indicates that Circle K Stores, Inc. is a
corporation authorized to do business in Colorado.
When filing a new application for additional licensed locations, you must check with the
local licensing authority to determine what documents they may require to process your
application. Please feel free to provide them with this letter, as many local authorities will
not require you again to submit fingerprint cards to them if you have already submitted
such documents to the Division This letter will serve to inform the local authorities exactly
which documents you have already submitted to the Division.
Finally, once the local authority has approved your new license or transfer of ownership
application, it must be sent to the Division.
The local authority need not send change of corporate structure information previously
reported to the Division, as listed in and approved by this letter.
The only documents which are needed for a new or transfer of ownership application by
the Division are:
1, The approved application signed by the local authority;
2. The appropriate fees;
3. A copy of this letter;
4. Proof of possession of the premises;
5. A diagram of the licensed premises;
6. Completed form DR 8442, and an Individual History Record (DR 8404-1) if
manager's registration is required.
Sincerely,
alattita_.
Laura Harris
Licensing Director
Circlek2.mas
NS
Qr0 ➢OO/VOOd 11081 '0l 6002 dl ue' IVEZ9OZEUE Xe3 IN3W30a0dN3 bOn01l
FILED ON BEHALF OF THE APPLICANT
BY DILL DILL CARR STONBRAKER&HUTCHINGS.P.C.
DR 8177(05/97) PAGE 1 (303)777-3737 21
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN STREET LIMITED LIABILITY COMPANY AND
ENVER CO 80261
(303)205-2300 CORPORATE REPORT OF CHANGES
(
Liquor and 3.2 Beer Licenses
Submit to Local Authority(Local Authority will submit to State)
(2355) ❑ LLC $100 PER MEMBER FOR BACKGROUND INV.
(2350) CORPORATION $100 PER PRINCIPLE FOR BACKGROUND INV. Do NOT WRITE IN THIS SPACE
1. Corporate/L.L.C.Name 2.State Tax Account Number 3.State Liquor License Number
Circle K Stores Inc. I Various: Please see attachment
4.Trade Name 5.Telephone Number
Various: Please see attachment 602-728-8000
6.Address of Licensed Premises City State ZIP Code
Various: Please see attachment for listing of all licensed premises
7.Mailing Address if different than above City State ZIP Code
1130 W. Warner Road Tempe AZ 85284
8, LIST ALL officers, directors (corporation) or Managing Members (L.L.C.). Attach a certificate of designation
(good standing) and each officer, director or manager MUST FILL OUT a DR 8404-I (Individual History Record).
Position Names of ALL Officers, Home Address DOB Replaces
Held Directors or Managing Members P
Dir/Pres. Brian P. Hannasch 4422 Mallard Point, Columbus, IN 47201
ADDITION
9. LIST ALL 10%(ormore)Stockholdersor10%(ormore)Members. All 10%(ormore)stockholders and members
MUST also fill out DR 8404-I (Individual History Record).
Stockholders/Members
owning 10%(or more)of business Owned Home Address DOB Replaces
Circle K Corporation 100% 1130 W. Warner Road, Tempe, AZ 85284 N/A NONE
10. Registered Agent Address For Service
Corporation Service Company 1560 Broadway, Suite 2090, Denver, CO 80202
�l OATH OF'APPLICANT- _ t
/declare under penalty ofperjury in the second degree that this application and all attachments
are fr )correct an omple to the best of my knowledge
11.Authorized Signature �� Title Dale
�� Director/President/Secretary 5-22—08
�� REPORT' FOFO LO AC LICENSING AUTHORITY
T e foregoing changes have been received and examined by the Local Licensing Authority. .
12. Local Licensing Authority For
County Town/City
Signature Title Date
Attest Date
DO NOT WRITE IN THIS SPACE — FOR DEPARTMENT 9F REVENUE USE ONLY
'- LIABILITY INFORMATION' ,
License Account Number Period Cash Fund TOTAL
-100 (999)
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SECRETARY'S CERTIFICATE
I, the undersigned, Kim Kwiatkowski, Assistant Secretary of Circle K Stores Inc, a
corporation organized and existing under and by virtue of the laws of the state of Texas
(the "Corporation"), hereby certify as follows:
1. As Assistant Secretary, I am authorized to execute and deliver this
Certificate on behalf of the Corporation.
2. Effective 10/01/2007, Paul F. Murphy will resign as the
Treasurer/Assistant Secretary/Director of the corporation.
3. Effective 10/01/2007, Daniel A. Abernathy has been elected as
the Treasurer/Assistant Secretary/Director of the corporation.
4. Effective 05/01/2008, Lou Valdes has been elected as a Vice
President of the corporation
IN WITNESS WHEREOF, I have hereunto set my hand as Assistant Secretary
and affixed the corporate seal of said Corporation this 28th day of May 2008.
Assistant Secretary:
Circle K Stores Inc:
SECRETARY'S CERTIFICATE
I, the undersigned, Kim Kwiatkowski, Assistant Secretary of Circle K Stores Inc, a
corporation organized and existing under and by virtue of the laws of the state of Texas
(the "Corporation"), hereby certify as follows:
1. As Assistant Secretary, I am authorized to execute and deliver this
Certificate on behalf of the Corporation.
2. The following persons have been elected to the offices set
opposite their names to serve until their successors shall be
elected and qualified:
Brian Hannasch President & Secretary
Geoffrey C. Haxel Vice President
Timothy Shawn Tourek Vice President
Robert G. Campau Vice President
Michael L. Struble Vice President
Lou Valdes Vice President
Jason Broussard Vice President
Daniel A. Abernathy Treasurer and Assistant Secretary
Scott J. Stevenson Assistant Secretary
Kim Kwiatkowski Assistant Secretary
Sylvain Aubry Assistant Secretary
Richard Douglas Hamlin Assistant Secretary
Marc Lee Flanary Assistant Secretary
David G. Morgan Assistant Secretary
Mathew Levi Hermansen Assistant Secretary
David O. Wilkins Assistant Secretary
Robert J. Kittleson Assistant Secretary
3. The following persons have been elected as directors until their
successors shall be elected and qualified:
Brian Hannasch Director
Geoffrey C. Haxel Director
Daniel A. Abernathy Director
IN WITNESS WHEREOF, I have hereunto set my hand as Assistant Secretary
and affixed the corporate seal of said Corporation this 14th day of May 2008.
Assistant Secretary
Circle K Stores Inc.
FILED ON BEHALF OFTHE APPLICANT
DR 8404-'. (01/06/06) BY DILL DILL CARR STONBRAICR&HUTCHINGS.PC
COLORADO DEPARTMENT OF REVENUE (303)777-3737
LtOUOR ENFORCEMENT DIVISION
1881 °IERCE STREET RN 108A
DENVER CO 80261
INDIVIDUAL HISTORY RECORD
To be completed by each individual applicant, all general partners of a partnership, and limited partners owning 10% (or more) of
a partnership; all officers and directors of a corporation, and stockholders of a corporation owning 10% (or more) of the stock of
such corporation; all limited liability company MANAGING members, and officers or other limited liability company members
with a 10% (or more) ownership interest in such company and all managers of a Hotel and Restaurant or a Tavern License.
NOTICE: This individual history record provides basic information which is necessary for the licensing authority investigation.
All questions must be answered in their entirety or your application may be delayed or not processed. EVERY answer you give
will be checked for its truthfulness.A deliberate falsehood or omission will jeopardize the application as such falsehood
within itself constitutes evidence regarding the character of the applicant
1.Name of Business
Circle K Stores Inc.
2.Your Full Name(last,first, middle) 3. List any other names you have used.
Abernathy, Daniel, Adolph None
4.Mailing address (if different from residence) Home Telephone
113O W. Warner Road, Tempe, AZ 85284 6O2-728-31O7
5.List all residence addresses below. Include current and previous addresses for the past five years.
STREET AND NUMBER CITY, STATE, ZIP FROM 1, TO
Current
15186 S. 15th Place Phoenix, AZ 85O48 O6/1997 Present
Previous
6.List all current and former employers or businesses engaged in within the last five years (Attach separate sheet if necessary)
NAME OF EMPLOYER ADDRESS(STREET, NUMBER,CITY, STATE, ZIP) POSITION HELD FROM TO
113O W. Warner Road Dir/Treas/Asst. 10/2007 Present
Circle K Stores Inc. Tempe, AZ 85284 Secretary !
113O W. Warner Road Accounting
Circle K Stores Inc. ! Tempe, AZ 85284 Director 15/1996 1O/2OO7
I '
7.List the name(s) of relatives working in or holding a financial interest in the Colorado alcohol beverage industry.
NAME OF RELATIVE i RELATIONSHIP TO YOU POSITION HELD NAME OF LICENSEE
NONE N/A N/A N/A
I i
8.Have you ever applied for, held, or had an interest in a State of Colorado Liquor or Beer License, or loaned money,furniture or fixtures, equipment or
inventory,to any liquor or beer licensee?If yes, answer in detail. Yes X),No
•
•
9.Have you ever received a violation notice suspension or revocation,for a liquor law violation, or have you applied for or been denied a liquor or beer
license anywhere in the U.S.? If yes, explain in detail. iI Yes X 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?Include arrests for DUI and DWAI.(If yes,explain in detail.)
Yes X No
11.Are you currently under probation(supervised or unsupervised),parole,or completing the requirements of a deferred sentence? (if yes, explain in detail.)
Yes rNo
•
12. Have you ever had any STATE issued licenses suspended, revoked,or denied including a drivers license? (If yes,explain in detail.)
❑Yes ®No
PERSONAL AND FINANCIAL INFORMATION
Unless otherwise provided by law in 24-72-204 C.R.5.,information provided below will be treated as CONFIDENTIAL.
Colorado liquor licensing authorities require the following personal information in order to determine your suitability for licensure pursuant to 12-47-307 C.R.S.
13a.Date of Birth b.Social Security Number SSN c.Place of Birth d.U.S. Citizen?
Festus, Missouri ®Yes ❑Nc
e.If Naturalized,State where f.When g. Name of District Court
N/A N/A N/A
h.Naturalization Certificate Number i i.Date of Certification j. If an Alien,Give Alien's Registration Card Number k.Permanent Residence Card Number
N/A N A N/A N/A
I.Height m.Weight n.Hair Color o. Eye Color p.Sex q.Race r.Do you have a current Driver's License? If so,give number and state
5'7" 185 Brown Brown M Cauc ®Yes ❑No
14.Financial Information,
N/A
a.Total purchase price$ (if buying an existing business)or investment being made by the applying entity,corporation,
partnership, limited liability company,other$ N/A
b.List the total amount of your investment in this business including any notes,loans,cash,services or equipment, operating capital,
stock purchases and fees paid$ N/A
c.Provide details of Investment. You must account for the sources of ALL cash(how acquired).Attach a separate sheet if needed.
Type:Cash, Services or Equipment 5ource:Name of Bank;Account Type and Number Amount
NONE . N/A N/A
•
d.Loan Information(attach copies of all notes or loans)
Name of Lender and Account Number Address Term Security Amount
NONE N/A N/A N/A . N/A
•
15.Give name of bank where business account will be maintained;Account Name and Account Number;and the name or names of persons
m ohnrincrr in rlrmw thcrnnn
N/A .
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. . - -
Auth° ized SSiignnatureJr� Tile Date
Director/Treasurer/Asst. Secretary 5-22—08
FLED ON BEHALF OF THE APPLICANT
CO 5404- IC :05/O5i
BY DILL DELL
.CARR STONER ACER&HUTr-HINGS.P.C..
COLORADO DEPARTMENT OF RWENJE (303)777-3737
.CJOR ENFOROEMEN'T D',"S!ON
7aa- R=,RCE o r._= RN 108A
DENVER.CC 3025'.
INDIVIDUAL HISTORY RECORD
To ce completed by each individua; applicant, all genera; partners of a partnership, and limited partners owning 10% (or more) o
a partnership; all officers and directors of a corporation, and stockholders of a corporation owning 10% (or more) of the stock a
such corporation; all limited liability company MANAGING members, and officers or other limited [lability company member:
with a 10% (or more) ownership interest in such company and all managers of a Hotel ano Restaurant or a Tavern License,
I NOTICE:This individual history record provides basic information which is necessary for the licensing authority investigation.
All questions must be answered in their entirety or your application may be delayed or not processed. EVERY answer you give
will be checked for its truthfulness. A deliberate falsehood or omission will jeopardize the application as such falsehood
within itself constitutes evidence regarding the character of the applicant.
1. Name of Business
Circle K Stores Inc.
2.Your Full Name(last, first, middle) _ 13.List any other names you have used.
Valdes, Lou, Joseph I NONE
4.Mailing address (if different from residence) I Home Telephone
113O W. Warner Road, Tempe, AZ 85284 I 6O2-728-31O3
5.List all residence addresses below. Include current and previous addresses for the past five years.
STREET AND NUMBER F CITY, STATE, ZIP FROM TO
Current
496O S. Springs Drive Chandler, AZ 85249 O9/2OO4 Present
Previous •
1645 W. Lark Drive Chandler, AZ 85248 O1/1998 O9/2OO4
6,List all current and former employers or businesses engaged in within the last five years (Attach separate sheet If necessary)
NAME OF EMPLOYER ADDRESS (STREET, NUMBER, CITY, STATE, ZIP) POSITION HELD I FROM TO
113O W. Warner Road
Circle K Stores Inc. Tempe, AZ 85284 Vice President 5/1/2OO8 Present
113O W. Warner Road Regional
Circle K Stores Inc. Tempe, AZ 85284 Operating Dir. 6/1998 5/1/2OOE
7.List the name(s)of relatives working in or holding a financial interest in the Coiorado alcohol beverage industry.
NAME OF RELATIVE RELATIONSHIP TO YOU POSITION HELD NAME OF LICENSEE
NONE N/A N/A N/A
B.Have you ever applied for, held, or had an interest in a State of Colorado Liquor or Beer License, or loaned money,furniture or fixtures, eeuipment or
inventory,to any liquor or beer licensee? If yes, answer in detail, j Yes gi No
9. Have you ever receivec a violation notice suspension or revocation, for a Ilcuor law violation, or have you applied for cr been(Denied a liquor or beer
license anywhere in the G.S.? If yes, explain in(Detail.
Yes .TiNo
10.Have you ever beer)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"Include arrests for DUI and DWAI.(If yes,explain in detail.)
Yes (X]No
11.Are you currently under probation(supervised or unsupervised), parole,or completing the requirements of a deferred sentence'? (if yes,explain in detail.)
Yes ir]No
12.Have you ever had any STATE issued licenses suspended,revoked,or denied including a drivers license? (If yes,explain in detail.)
rj Yes [)No
•
PERSONAL AND FINANCIAL INFORMATION
Unless otherwise provided by law in 24-72-204 C.R.S.,information provided below will be treated as CONFIDENTIAL.
Colorado liquor licensing authorities require the following personal information in order to determine your suitability for licensure pursuant to 12-47-307 C.R.S.
13a.Date of Birth b.Social Security Number SSN c.Place of Birth d.U.S.Citizen?
10/12/65 527-19-0946 El Paso, TX Yes No
e.if Naturalized,State where f.When g.Name of District Court
N/A N/A N/A
h.Naturalization Certificate Number i. Date of Certification j.If an Alien,Give Alien's Registration Cara Number k.Permanent Residence Card Number
N/A N/A N/A N/A
I.Height m.Weight n.Hair Color o. Eye Color p.Sex q. Race r.Do you have a current Driver's License?if so,give number and state
6'4" _ 275 Black Brown M ,Hispanic ®Yes ❑No D03914675, Arizona
14.Financial Information.
a.Total purchase price$ N/A _(if buying an existing business)or investment being made by the applying entity,corporation,
partnership,limited liability company,other$ N/A
b.List the total amount of your investment in this business including any notes,loans,cash,services or equipment,operating capital,
stock purchases and fees paid$ N/A
c.Provide details of Investment. You must account for the sources of ALL cash(how acquired).Attach a separate sheet if needed.
Type: Cash, Services or Equipment Source:Name of Bank;Account Type and Number Amount
NONE N/A N/A
d.Loan information(attach copies of ail notes or loans)
•
Name of Lender and Account Number Address Term I Security Amount
NONE N/A N/A N/A N/A
•
15.Give name of bank where business account will be maintained;Account Name and Account Number;and the name or names of persons
atrthnri7ort to draw thernnn
N/A
•
Oath of Applicant
l declare under penalty of p5rruty l9�the second degree that this application and all attachments are true, correct, and complete to the best of
my knowledge.
Authorized Sig t ",/ Title Date
/�~ J Vice President
5-22-08
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