HomeMy WebLinkAbout20061911 RESOLUTION
RE: APPROVALOF RENEWALAPPLICATIONANDCORPORATEREPORT OF CHANGES
FOR TAVERN LICENSE FROM VIPER2,INC., DBA BORDERLINE AND AUTHORIZE
CHAIR TO SIGN - EXPIRES SEPTEMBER 7, 2007
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,Viper2, Inc.,dba Borderline, presented to the Board of County Commissioners
of Weld County,Colorado,a Renewal Application and a Corporate Report of Changes for a Tavern
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$125.00 to the County of Weld for the renewal of the existing license, and $100.00 for said
corporate report of changes, and
WHEREAS,after review,the Board deems it advisable to approve said Corporate Report
of Changes, a copy of which is attached hereto and incorporated herein by reference, 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:
68947 Highway 85, Carr, Colorado 80612
NOW, THEREFORE, BE IT RESOLVED by the Board that the Corporate Report of
Changes submitted by Viper2, Inc., dba Borderline, be, and hereby is, approved.
BE IT FURTHER 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 2006-12 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 September 7, 2007, providing that said place where the licensee is authorized to
sell malt,vinous,and spirituous liquors for consumption by the drink on the premises only,shall be
conducted in strict conformity to all of the laws of the State of Colorado and the rules and regulations
relating thereto, heretofore passed by the Board of County Commissioners of Weld County,
Colorado, and any violations thereof shall be cause for revocation of the license.
2006-1911
LC0047
00 . SO, /int OFcR/-oG
RENEWAL LIQUOR LICENSE AND CORPORATE REPORT OF CHANGES - BORDERLINE
PAGE 2
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said application and corporate report of changes.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 17th day of July, A.D., 2006.
ti ^ > BOARD OF C NTY COMMISSIONERS
ads p WELD COU , COLORADO
A L dace,-
71".el le,le, Chair
Weld °Board
EXCUSED
David E. Long, Pro-Tem
BY:
De ty Cler o the Board
Willis Jerke
5Attorn&y
ASTOF `\
Robe r . Masd
Glenn Vaad
Date of signature: gIl - fay
2006-1911
LC0047
THIS LICENSE MUST BE POSTED IN PUBLIC VIEW
DR 8402 O2/03/04)
STATE OF COLORADO
DEPARTMENT OF REVENUE
Liquor Enforcement Division
1881 Pierce Street,Suite 108
Lakewood,Colorado 80214
VIPER 2 INC
BORDERLINE
68947 HIGHWAY 85
CARR CO 80612
ALCOHOLIC BEVERAGE LICENSE
Liability Information
Account Number County City Indust. Type Liability Date LICENSE EXPIRES AT MIDNIGHT
42-07852-0000 03 020 722110 C 090805 SEP 07, 2007
Type Name and Description of License Fee
2010 TAVERN LIQUOR LICENSE - $ 75.00
MALT, VINOUS, AND
SPIRITUOUS
2190 COUNTY 85 PERCENT OAP FEE $ 0.00
TOTAL FEEISI $ 75.00
This license is issued subject to the laws of the State of Colorado and especially under the
provision 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.Questions concerning this license should
be addressed to the Department of Revenue,Liquor Enforcement Division, 1375 Sherman
Street,Denver,CO 80261.
In testimony whereof,I have hereunto set my hand.
AUG 1 0 2006 40P,<_
sw
Division Director Executive Director
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DR sago lol/o7h License Number License Type
QUO O1DPCE OF
TEDINUE LIQUOR OR 3.2 BEER LICENSE 42-07852-0000 2010
L1881 AKEWOODEC ST O 80214 RENEWAL APPLICATION Liability 0 1020 a7221 10 C 090805
Business Location
68947 HIGHWAY 85
BORDERLINE CARR CO
CHAVEZ KIMBERLY Current License Expires
4853 KINGBIRD DR SEP 07, 2006
FREDERICK CO 80504
FI REST'One
9 This renewal reflects no changes from the last Wholesaler, manufacturer, importer,and public transportation
application.Complete page 2 and file now! system license renewals do not need Local Licensing Authority
XYes there are charges from the last application approval and must be returned directly to the Colorado
If applicant is a Corporation or Limited Liability Department of Revenue at least 30 days prior to the current
company, use DR 8177 and send in with this license expiration date.
renewal.Any other changes of ownership require a
transfer of ownership. See your Local Licensing
Authority immediately. This application for renewal roust be retuned to your CITY
❑ Delivery Permit requested?Retail Liquor Store.Drug OR COUNTY Licensing Authority at bast 45 days prior to the
Store or 3.2%Beer-Combination On/Off Premises expiation date of your current licersa Fatihre to do so may
Licenses ONLY. Check the box if you want the resutnyav license not being renewed Include both pages
permit to be issued of this renewal aid payment
:: .. QAII'taF:APpLff+APIGT. : o:
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 kngwledge.
Au o ze Sig lure / B sine sPhone
Od.....)
06 X 376151
Si pet(if porpora I s Tax Number
es;d en . _--171-2L—C'715
* ;> T ANPiA rpvAt epaTY oFtco 7laifyp i AvotoRm ; .
The foregoing application has been examined and the premises.business conducts¢afid cltaricter of the Applicant are satisfactory,and we do
hereby report that such license, if granted, will comply with the provisions of•Title 42.-Articles 46 and 47, C.R.S. THEREFORE THIS
APPLICATION IS APPROVED.
Local Licensing Authority for i` , ` - Date
❑ Town/City 8106
Weld County Colored t y' ,�1 Ltqunry
Signature Title Chair, Board of (e ck.rAt
M. J. Geile�� Qen.. Commissioners `C By: tYL 2..L.O.,.-j_.
- •-- DC NOT DETACH DO NOT DETACH . . ti. .r'' uty .J.tt I.° ttt(1r ithirH
DR 9400 101102) 21
DR 8400 1C tarn of REVENUE
LIQUOR OR 3.2 BEER LICENSE
LAK PIERCE COoe RENEWAL APPLICATION
LAKEWOOD O 80214
Business Name LICENSE NUMBER)Use for ell reference) RENEWED LICENSE EXPIRES AFTER
BORDERLINE 42-07852-0000 09-07-07
TYPE OF LICENSE ISSUED CASH FUND STATE FEE
TAVERN LIQUOR LICENSE - COUNTY 85% OAP
MALT , VINOUS, AND 2320- 100(999) 2010-750(999) 2190- 100(999)
SPIRITUOUS
$ 50. 00 $ 25. 00 $ 425. 00
SUB-TOTAL $ 500. 00
ADD $100. 00 TO RENEW RETAIL WAREHOUSE STORAGE PERMIT2210- 100(999) $ •
TOTAL AMOUNT DUE $_ _.
Make check payable to:Colorado Department of Revenue 2006-1911
Li'0O-17
DR 8401 (0797)
COLORADO DEPARTMENT OF REVENUE
UOUOR ENFORCEMENT DIVISION
1981 PIERCE ATTACHMENT TO LIQUOR OR
LAKEWOOD,CO 80281
"°" 2300 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.
T tram&ol Establishment
17'?i ik 2liu 'tiez 111-11r7
r
Yes 2. Do you have leg possession of the premises fpr which this application r license Is made?
Are the No
premises owned or rented: Vp�'�-�y If rented,expiration date of lease: (01-2/6/0 (TO
❑
3. Has there been any change In financial Interest(new notes,loans,owners,etc.)since the last annual application?If yes,explain in es
detail and attach a listing of all liquor businesses in which these new lenders or owners,(other than licensed financial Institutions)are Yes No,
materially interested.
❑
4. Since the date of filing of the last annual application,has the applicant,or any of its agents,owners,managers,principals,or lenders Yes
(other than licensed financial institutions),been convicted of a crime?If yes,attach a detailed explanation. ❑ h7`1
5. Since the date of filing of the last annual application,has the applicant,or any of its agents,owners,managers,principals,or lenders KK��II
(other than licensed financial institutions),been denied an alcoholic beverage license,had an alcoholic beverage license suspended or Yes
revoked,or had interest in any entity that had an alcoholic beverage license denied,suspended or revoked?If yes,attach a detailed n
explanation.
•
6. Does the applicant,or any of its agents,owners,managers,principals,or lenders(other than licensed financial institutions),have a Yes No,
direct or Indirect Interest In any other Colorado liquor license(include loans to or from any licensee,or interest In a loan to any I45
licensee)?If yes,attach a detailed explanation. El
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 Yes No
company other than the licensee listed on your slate liquor license?If yes,this license must be transferred to the new owner and n n
may not be renewed.Contact your Local Authority immediately.
8. Partnership applicants must answer this question.Since the date of filing of the last annual license application: Yes No
(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 I�I license must be transferred to the new partnership and may not be renewed.Contact your Local Authority immediately. f I ❑
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 Yes No
DR 8177 and submit to your Local Authority immediately. ❑ Tic(
(b) Are there,or have there been any stockholders with 10%or more of the Issued stock,added to,or deleted from the corporation? Ley,
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: 136.1
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?II yes,complete and attach Yes No
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:
11. Bed and Breakfast applicants must answer this question and certify compliance with t2-47-118.5 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 TUESDAY HOURS WEDNESDAY HOURS THURSDAY HOURS FRIDAY HOURS SATURDAY HOURS SUNDAY HOURS
From: m. From: m. From: m. From: m. From: m. From: m, From:
To: m. To: m, m.
To: m. To: m. To: m. To: m. To: m.
DR 9177(05197) PAGE 1 /21
COLORADO DEPARTMENT OF REVENUE
LIQUOR SSTREET ENFORCEMENT DIVISION
75 LIMITED LIABILITY COMPANY AND
CO DENVER 00261
(3031 205 CORPORATE REPORT OF CHANGES
DE
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)XCORPORATION $100 PER PRINCIPLE FOR BACKGROUND INV. DO NOT WRITE IN THIS SPACE
rporateiL.L.C.Name 2„slato Tea Account Number 3 bailor se Number
Nam rc [I Telephone u ben
itrciCVl ( ✓(' 720fl"tt,lFil (10 �c&d. 6.,m7
Ad re of reisenenct Ci S to ZIP Code
ress II fie nt tq±ot
ve S le ZIP ode
' °� Ivr-1 I`�/ ' `(YPSIt� ��� (C) &Y ( I
8.LIST ALL officers, ctors(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 8404-1(Individual History Record).
Position Names of ALL Officers, Home Address DOB Replaces
Held Directors or Managing Memberspaces
9. LIST ALL 10%(or more)Stockholders or 10%(or more)Members. All 10%(or more)stockholders and members
MUST also fill out DR 8404-I(Individual History Record).
StockholdersiMembers X Home Address DOB Replaces
ni q 10%(or more)of business OwnedP
im� • 1iLf do t�l-e, S/f. 4% 3 Kin bi-v . I-i-rSitirt
NA-
10.Registered Agent Address For Service
el n' c (Thant ? i '/ ,c3 fan jiivdy. rive.syttin r0 itctty
OATH OF,APPLICAMT
I declare under penatfyotpetr. tasecxlfztdegcea hatihrssappllc'atfonandallattachments
areft »l dprfg gnat Dompita tc the t of lttj7 tlnow)edge.
i 1 A or zed Sig re i
! {�c el witrit 6/416
REPOA F LOCAL LICLNSINGAUTHORITY
•
The foregoing c nges " ed and examined by the Local Licensing Authority.
. 6 . /�
12.Loc Licensing Authority For 1` .��.�� County Town/City
Weld County Colored [�',T�, � ❑
Signature t # -� dIIT' ,• air, Board of County Date 17 2006
M. J. it ib5t ? ' `f;( mmissioners JUL
Attest
��= ry.(' he Board i Data 2006
J 'I
BY [.t L i 1 ^ .. ,. 2 lftrk. to the Arland I �"� 1 7
DO NOT WRITE It HIS SP1?E-FOR DEPARTMENT OF REVENUE USE ONLY
�„
li :I .. � :M,wJ�i�'INFOR1iM1ATION •.�:.
License Account Number Perlpd Cash Fund TOTAL 0?ate -/5//
OR8404-I (01/08451
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1881 PIERCE STREET RM 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 o1 Businegs_
1 r 2 n<i 3nv[lei/ 1 Lne ra,11i1 cJ
2.Y ur Full Name(last,first,middle) 3.List any other names you have used.
(Via we Dean) --
4.Mailing address(if differgnt from residence) Home Telephone
-30� q��? L/ ' 2?_
5.List all residence addresses below.Include current and previous addresses for the past five years.
STREET AND NUMBER CITY,STATE, ZIP FROM TO
Current
8'100 .c. {1rnmv,1S Stt . I NfieI Y) , In a/ZS Crtig3 61L fir wf
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 I TO
Vi�Yv2 f�<- (iQl/'/ /7LLICJfv J Oar, to Pa'/5 MQ Y %1/45 ctkr ilenf
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
km ahavr Z '> rs - In-1 ao , estden
8.Have you ever applied for,held,or had an interest in a State of Colorado Liquor r B r License,or loaned money,furniture or fixtures,equipment or
inventory,to any liquor or beer licensee?If yes,answer in detail. El Yes No
9.Have you ever received a violation notice suspension or revocation,tor a liquor I w v lotion,or have you applied for or been denied a liquor or beer
license anywhere in the U.S.?If yes,explain in detail. ❑Yes 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 y oo
e any charges pending?Include arrests for DUI and DWAI.(II yes,explain in detail.)
Yes )No
11.' ufurrenty under probation(supervised or unsupervised),parole,or completing the requirements of a deferred sentence? (if yes,explain in detail.)
'Yes Y No
12.Hay y 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.S.,information provided below will be treated as CONFIDENTIAL.
Colorado liquor licensing authorities require the following personal information in order to determine your suitability far licensure pursuant to 12-47-307 C.R.S.
✓ Do1uvc�s WVkocL i it?ct�'l e: No
e.If Naturalized,State where f.When / I g.Nam of District Court
I
h.Naturalization Certificate Number I I.Date of Certification j.If an Alien,Give Alien's Registration Card Number I k.Permanent Residence Card Number
I.Height er� I m.Weight� n.Hair Color o.Eye Color p.Sex ace ,�yDp you have a current Driver's License?If so,give number and state
5 10 110 V i ('1 ?' 1"c , t1(Yes L No
14.Financial Information.
A_
a.Total purchase price$-_-._--�\_._ ___.._. .____...(g buying an existing business)or investment being made by the applying entity.corporation.
partnership,limited liability company,other$._...��A- _._.__
b.List the total amount of your investment in this business including any notes,loans,cash,services or equipment,operating capital,
t�n w•
stock purchases and fees paid$_ .�� _..._/... r --
c.Provide details of investment. You must account for the sources of ALL cash(how acquired).Attach a separate sheet it needed.
Type: Cash,Services or Equipment Source:Name of Bank;Account Type r and Number I —Amount
d.Loan Information(attach copies of all notes or loans)
'Name
of Lender and Account Number Address Term Security Amount
1 dA l'\.MLCkW&LQ P.(j,txr 'q-8'ox37 '7QJJV 1rtclthenct 1937-*s7
15.Give name of bank where business account will be maintained;Account Name and Account Number;and the name or names of persons authorize41\1F�CS tnVCIO I'-1o1 Cop-101 aVe, Chptyrtn. LRA Qonl A-t1it I ►hatic
307- 71 I-'2,73;01 . Ile c-.1 -
Oath of Applicant
I declare under penalty of perjury in the second degree that this application and all attachments are true,correct,and complete to the best of
my knowledge.
Authorized 7nature ---.,. T' __II
J
u �2F ��C �1� i.-2I a
CIVIL APPLICAET RESPONSE
ICN IFCS0002000017275567 CIDN OCA OO0620000LLQ
CHAVEZ,DEAN ARTHUR W 510 1 68/12/01
MNU SOC S: X M
FPC
HENRY CLASS API
COCBI0000 COLORADO B OF I DAT FP
DENVER CO 20 '6/06/16
A SEARCH OF THE FINGERPRINTS ON THE ABOVE
INDIVIDUAL HAS FAILED TO DISCLOSE PRIOR ARREST
DATA. CJIS DIVISION
2006/07/19 FEDERAL BUREAU OF INVESTIGATION
** SPECIAL INFORMATION
CIVIL NON-IDENT TEN-PRINT SUBMISSION FOR THIS SUBJECT HAS BEEN DESTROYED
Huhn IIIII 111
COCBI0000
CO BUREAU OF INVEST
COLORADO CRIME INFO CTR
STE 3000
690 KIPLING ST
DENVER, CO 80215-8001
0091102 0109541
1$ Washington Mutual Page 1 of 2
HOME LOANS Home Loan Statement
Customer Service:Toll free 1.866.926.8937 Se habla esparlol June 2006
TDD:Dial 7-1-1 for relay assistance
o www.wamu.com Statement Date: June 02,2006
O N Activity Since: May 02, 2006
#BWNCLNN Your Loan Number: 0685368318
z #2906859368931895#
0001102 01 AT0.308 "'AUTO 1609085801256211 1 4 MA1 I Your Property and Loan Information
D 16.1.11 III•Isl l..I.llllr lsl1lmIlmlllll,IIi III Property Address: 8700 SOUTH AMMONS ST
'"-7 DEAN A CHAVEZ
SUSAN E CHAVEZ LITTLETON CO 80128
I-- 8700 S AMMONS ST Principal Balance: $ 237,165.53
Z LITTLETON CO 80128-6211 Interest Rate: 6.69300%
Escrow Balance: $ 64.33
W Unpaid Interest, Loan to Date: $ 1,820.23
2
IW-- I Your Next Payment Other Important Messages
IQNext Payment Due: July 01,2006 This billing statement Is for your records only.Your
-"' Principal and Interest: $ 856.92 payment is made directly through our autodrsft system
Li) - _ escrow: $ 291.81 and will draft on 07/02/06.
ZCurrent Payment: �$ 1,148.73 —
Q Total Amount Due.* `a 1,148.7
0 •
-J
W
2
O Additional Payment Options: Adjustable Rate Mortgage Information
Each of the following payment options will include an Escrow
Payment and/or Late Charges,when applicable. Index Value: 4.14300
1.Minimum Payment: $ 1,148.73 Margin: 2.55000
2.Interest Only Payment: $ 1,614.60 For Payment Due: July 01, 2006
3.Full Principal and Interest Payment: $ 1,837.74 Interest Rate: 6.6930%
(based on the remaining scheduled term of your loan)
4.Full Principal and Interest Payment: $ 2,470.37
(based on a 15-year term) Year to Date Account Activity
Important Messages •Principal Paid: $ 2,915.66
"To avoid a late charge of$42.85,we must receive your Interest Paid: $ 7,367.18
payment of principal,interest,and any escrow deposits Property Taxes Paid: $ 2,186.84
and/or past-clue payments by 07/16/06 during our business Insurance Paid: $ 666.00
hours. if this date falls on a weekend or holiday,your
payment must be received by the next business day.
For additional information about your payment options end
for Recent Account Activity,please see the reverse side of ,
this statement. _
Washington Mutual Bank 1566
�`- -`
Please allow 7.10 days for postal delivery. - -
tIaJ Washington Mutual 1s6-a Payment Due Date: July 01,2006
Current Payment: $ 1,148.73
HOME LOANS Total Amount Due: $ 1,149.73
DEAN A CHAVEZ If Received After: July 16,2006
SUSAN E CHAVEZ Total Amount Plus Late Charges: $ 1,191.58
Loan Number: 0685368918 Making Your Payment
Statement Date: June 02,2006 Please write In your payment amount—either the Total Amount
Ptease write your loan number on check. Due or one of the Additional Payment Options selected from the
Make check payable a to umbeWashir on your M diecl. Your Next Payment'section above—and indicate how to app&
ler any additional funds, If you include additional funds and do not
CI Please check here if change of address or telephone indicate how to apply them,we will apply them first to applicable
number is indicated on the reverse side of this form. advances,then to any fees due and then to principal.
Payment Amount
Ilulu11,lluuilnulsll..lnullslullllipinillpl,.11 .I Late Charges + •
WASHINGTON MUTUAL Additional Principal +
PO BOX 78148 Additional Escrow +
PHOENIX AZ 85062-8148
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIlI11II.II,III11III.111..1...1.1.1.1.. Future Payments +
Total Amount Enclosed - AUTODRAFT
0247037 0183774 0161460 0685368318 0114873 0004285 0114873 0
DR 8177 PROTO(05/97) Page 2
INSTRUCTIONS
LIMITED LIABILITY COMPANY AND CORPORATE REPORT OF CHANGES
Do not use this form to reflect a change in partnership. If there is a change in partnership,you must file a transfer
of ownership with your local licensing authority.
NOTE: If you are a Limited Liability Company (LLC) check box number 2355. Enclose a check payable to the
authority where this information will be filed, for$100.00 (for every person listed in the box numbered 2350 and
enclose a check payable to the authority where this information will be filed, for$100.00 (for every person listed
in sections 8 & 9 on the application).
Attach the following documents to the Report of Changes Application:
❑ Certificate of Incorporation (or) Date stamped Articles or, if the corporation has been in existence for at
least 2 years, a
Certificate of Good Standing dated within the last two years
Ti Certificate of Authority (only if a foreign corporation)
NOTE: If the Applicant's sole stockholder is a corporation or LLC, attach a letter designating one officer or
member to be the"principal person"for the stockholder.This person MUST ALSO fill out DR 8404-I(Individual
History Record).
This application and all supporting documents must FIRST BE FILED WITH,AND APPROVED BY,THE LOCAL
LICENSING AUTHORITY (CITY, TOWN, COUNTY). Applications will not be accepted unless all applicable
questions are fully answered, all supporting documents correspond exactly with the name of the applicant.
1. List the name of the Corporation or Limited Liability Company.
2. List the State Sales Tax Number.
3. List the Applicant's State Liquor License Number.
4. List the Trade name of the business.
5. List the area code and telephone number of the business.
6. List the complete address, City, State and Zip Code, of the licensed premises.
7. List your mailing address if different than number 6 above.
8. List all officers,directors of a corporation,or all managing members of the LLC,and that persons position,
home address, date of birth, and the name of the person being replaced (if applicable).
9. List all 10%(or more)stockholders or members and indicate their names,%owned, home address,date
of birth, and the name of the person they purchased their stock from (if applicable).
10. List the name and address for service of the Registered Agent.
11. A person authorized to sign on behalf of the Applicant must sign the application,list their title,and the date
the application was signed.
12.To be filled out by the local licensing authority only. List the name of the authority and indicate if
the authority is a county, town/city. Then sign the application, list your title and attest the city/
county officials signature and date the application.
OFFICE OF THE SECRETARY OF STATE
OF THE STATE OF COLORADO
CERTIFICATE
I, Ginette Dennis, as the Secretary of State of the State of Colorado, hereby certify that,
according to the records of this office,
VIPER2,INC.
is a
Corporation
formed or registered on 04/14/2005 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 20051156382
This certificate reflects facts established or disclosed by documents delivered to this office on
paper through 06/08/2006 that have been posted, and by documents delivered to this office
electronically through 06/12/2006 @ 14:55:51 .
1 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 06/12/2006 @ 14:55:51 pursuant to and in accordance with applicable law. This certificate is
assigned Confirmation Number 6513063 .
Ar4 -z
Secretary of State of the State of Colorado
End of Cestificat
notice:A certificate issued electronically from the Colorado Secretary of S State's Web stir is fully and immediate/v valid and effective However.
as an option,the issuance and validity of a certificate obtained electronically may be established by visiting the Certificate Confirmation Page of
the Secretary of State's Web sire, btrp-.2'www sin.state COS,Aiz'Certlfcgty5earchCrimria.Jo entering the certificate's confirmation number
displayed on the certificate, and following the instructions displayed. Confirming the issuance of certificate is merely optional and is not
necessary to the valid and effective Issuance ofa rerrifirate. For more information.visit our Web site, hop: ,r.sos.Siale early click Business
Center and select"Frequently Asked Questions."
CERT GS_U Revised 09/22/2005
T
ARTICLES OF INCORPORATION
OF
VIPER2, INC.
The undersigned acting as the incorporator of a corporation for profit pursuant to
Colorado Revised Statutes (C.R.S.) 7-102-102, delivers these Articles of Incorporation to the
Colorado Secretary of State for filing, and states as follows:
ARTICLE I
NAME
The name of the corporation shall be Viper2, Inc.
ARTICLE II
STOCK
The total number of shares that the corporation is authorized to issue is 1,000 shares of no
par common stock.
ARTICLE III
INDEMNIFICATION
The corporation shall indemnify, to the fullest extent permitted by applicable law in
effect from time to time, any person, and the estate and personal representative of any such
person, against all liability and expense (including attorney's fees) incurred by reason of the fact
that he is or was a director or officer of the corporation or, while serving as a director or officer'
of the corporation, he is or was serving at the request of the corporation as a director, officer,
employee, fiduciary, or agent of, or in any similar managerial or fiduciary position of, another
domestic or foreign corporation or other individual or entity or of an employee benefit plan. The
corporation shall also indemnify any person who is serving or has served the corporation as
director, officer, employee, fiduciary, or agent, and that person's estate and personal
representative, to the extent and in the manner provided in any bylaw, resolution of the
shareholders or directors, contract or otherwise, so long as such provision is legally permissible.
ARTICLE IV
LIMITATION ON DIRECTOR LIABILITY
A director of the corporation shall not be personally liable to the corporation or to it's
shareholders for monetary damages for breach of fiduciary duty as a director; except that this
provision shall not eliminate or limit the liability of a director to the corporation or to its
shareholders for monetary damages otherwise existing for(i) any breach of the director's duty of
loyalty to the corporation or to its shareholders; (ii) acts or omissions not in good faith or which
involve intentional misconduct or a knowing violation of law; (iii) any transaction from which
the director directly or indirectly derived any improper personal benefit.
ARTICLE V
PRINCIPAL OFFICE AND REGISTERED AGENT
The street address of the corporation's initial registered office and the name of its initial
registered igent at that office is Greg Chavez, 4853 Kingbird Drive, Firestone, Colorado 80504.
ARTICLE VI
PRINCIPAL OFFICE
The address of the corporation's initial principal office is 4853 Kingbird Drive, Firestone,
Colorado 80504.
ARTICLE VII -
INCORPORATORS
The name and address of the incorporator is:
Kimberly Chavez 4853 Kingbird Drive
Firestone, Colorado 80504
2
APR-14-2005 THU 02:43 PM COMPASS BANK FAX NO. 3034855937 P. 06
�-- '- . - -- - -~ •- _ 739-590-9602 P•6
Apr. t4 OS ;3:29p
•
I,IClmberly Chavez,acting as incorporator,hive sigged these Articles of Iacorppration
this ? /1/ of April 2005.
• i4
mberly Chavez,InXati
CONSENT OF REGISTERED AGENT
The undersigned consents to appointment as the corporation's Mina(registered agent.
.Registered Agent
•
•
••
• l
I
•�
•
SPECIAL MEETING MINUTES
VIPER2. INC.
The directors, officers and shareholders of VIPER2, INC. (the "Corporation") met
unanimously by consent as of December 31,2005. All directors, officers and shareholders waived
notice and consented to the actions taken at the meeting as shown by their signatures endorsed
hereon. The purpose of the meeting was to reduce to writing and ratify actions previously
authorized since the inception of the Corporation.
The president announced that the initial shareholder of the Corporation as of April 14.2005
was Kimberly Chavez and that 1,000 uncertificated shares had been issued to Kimberly Chavez as
set forth in the Organization Meetine Minutes of the Corporation dated April 14,2005. Shortly after
the incorporation. Kimberly Chavez transferred 490 of her shares of uncertificated common stock
to Dean Chavez by agreement of the directors and shareholders. Therefore, the shareholders of the
Corporation as of December 31, 2005 are as follows:
Name Cert. No. No. of Shares
Kimberly Chavez n/a 5 10
Dean Chavez n/a 490
TOTAL SHARES ISSUED 1,000
The President reported generally about the business of the corporation over the past year,
including the acquisition of the assets of 2 Busy, Inc. as set forth in the respective Asset Purchase
Agreement. It was agreed that the President would attempt to reduce her remarks to writing and
attach it to the minutes of this meeting.
The following resolution unanimously was adopted:
RATIFYING RESOLUTION
RESOLVED, that the acts of all of the officers and directors
through the date hereof are hereby approved and ratified, and the
Corporation hereby agrees to indemnify and save them harmless for
all such acts done for the Corporation, and they are instructed to
proceed with the management of the Corporation as in the past.
The undersigned. being all of the directors, officers and shareholders of VIPER2, INC.
hereby waive all notice of the foregoing consent meeting of directors,officers and shareholders,and
we consent to all actions taken at the above meeting as shown by the above minutes. This consent
may be executed in one or more counterparts.
Oa-
Dean Chavez Kimberley L. Chave j
-2-
a MEMORANDUM
is t TO: JENNY LUNA,DEPUTY CTB
FROM: DAN JOSEPH
ENVIRONMENTAL HEALTH SERVICE
0 DATE:CT 06/Q30/06 UOR LICENSE INQUIRY
111
COLORADO CC: CINDY SALAZAR; SARA EVANS
In response to your request, Environmental Health Services has reviewed the Retail Food
Service Establishment file for Borderline Cafe, located at 68947 Highway 85, Carr,
Colorado. At this time, there are no problems or concerns regarding this establishment.
Should you have any questions regarding this matter, please contact me at extension 2206
or via e-mail at djoseph@co.weld.co.us.
Thank you.
Dan Joseph
Environmental Specialist Ill
MEMORANDUM
AtClirs To: Jenny Luna, Deputy Clerk to the Board July 11, 2006
Elk From: Bethany Salzman, Zoning Compliance Officer, Dept. of Planning Services
COLORADO Subject: LC0047
Review of the following liquor license renewal by the Department of Planning Services shows the following:
42-07852-0000
Viper2, Inc.
dba Borderline
68947 Highway 85
Carr, CO 80612
Zone District: A(Agricultural)
This use is permitted through an "Amended Use by Special Review" (AmUSR-1096).
Currently there are no active zoning violations on the above mentioned property.
SERVICE,TEAMWORK,INTEGRITY,QUALITY
LIQUOR/BEER RENEWAL REVIEW FORM
Date: July 10, 2006
TO: Deputy Les Wiemers
FROM: John Broderius
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 Boards 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: JULY 12, 2006
ESTABLISHMENT: VIPER2, INC.
DBA BORDERLINE
68847 HIGHWAY 85
CARR, CO 80612
Current license expires: SEPTEMBER 7, 2006
T
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
•*********It**
i** ****** +Atte*thed Worksheet)
****
**•fMtl*tM*H•11Mt Snit*N1M4M*M*M*-MAM+MMMM*
Please notify at Extension of the date and time of the
Board of Commissioner's renewal hearing.
Hello