HomeMy WebLinkAbout20043283.tiff RESOLUTION
RE: APPROVE PERMIT APPLICATION AND REPORT OF CHANGES FOR TAVERN
LIQUOR LICENSE AND AUTHORIZE CHAIR TO SIGN -A AND G CONCEPTS, DBA
BEARS SPORTS SALOON
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, A and G Concepts, dba Bears Sports Saloon, holder of a Tavern Liquor
License for the sale of malt, vinous and spirituous liquors by the drink for consumption on the
premises where sold in Weld County,Colorado,has presented the Board with a Permit Application
and Report of Changes, and
WHEREAS, after study and review, the Board deems it advisable to approve said permit
application and report of changes.
NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Permit Application and Report of Changes submitted by A and G
Concepts, dba Bears Sports Saloon, be, and hereby is, approved.
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 15th day of November, A.D., 2004.
BOARD OF COUNTY COMMISSIONERS
�) ��� W D COUNTY, COLORADO
s: p,,� Robert D. Masden, Chair
Ia€I iSH erk to the Board
William H. rke, Pro-Tem
Deputy Clerk o the Board
Geile
APP DAST
David . Long /
ty Atto e
��..-✓t �
ounty y
r� Glenn Vaad
7a- !/ -S'' —rt-c._d% J2��O/
2004-3283
LC0009
< C� . St in 3O
DR 8442 (06/02) Page 1 21
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1881 PIERCE STREET#108 PERMIT APPLICATION
LAKEWOOD CO 80214
(303)205-2300 & REPORT OF CHANGES
CURRENT LICENSE NUMBER
ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPEWRITTEN
LOCAL LICENSE FEE $
APPLICANT SHOULD OBTAIN A COLORADO LIQUOR&BEER CODE BOOK
TO ORDER CALL(303)370-2165 DO NOT WRITE IN THIS SPACE
1. Applicant is a PRESENT LICENSE NUMBER
XI Corporation ❑ Individual❑ Partnership ❑ Limited Liability Company 07_7UF
z'J d o6
2. Name of Applicant 3.Trade Name
f 1,6 Govtcetb 0 is of1J .5;70&k\
4. Address S �� dGe_
City fr2 l (c Y e(County S ZIP
teo (
S-I ctth • • •r• •ri•t s cti•n I•w •n• •r•c t•/tl/h instructi•ns •n • . • 2.
SECTION A-MANAGER REG/CHANGE SECTION C
1)❑2210-100(999)Retail Warehouse Storage Permit(ea) $100.00
• License Account No. 2)❑2200-100(999)Wholesale Branch House Permit(ea) 100.00
1970-750(999) ❑Managers Registration (Hotel&Restr.) $75.00 3)❑2260-100(999)Change Corp or Trade Name Permit(ea) 50.00
�j 2010.750(999) Managers Registration (Tavern) $75.00 4)❑2230-100(999)Change Location Permit(ea) 150.00
-plange of Manager(Other Licenses) NO FEE 5)❑2280-100(999)Change,Alter or Modify Premises
$150.00 x Total Fee
SECTION B—DUPLICATE LICENSE
6)❑2220-100(999)Addition of Optional Premises of Existing H/R
• LIQUOR LICENSE No. $100.00 x Total Fee
❑2270-100(999)DUPLICATE LICENSE $ 50.00 7)❑2340-100(999)Bed and Breakfast Permit 50.00
DO NOT WRITE IN THIS SPACE-FOR DEPARTMENT OF REVENUE USE ONLY
DATE LICENSE ISSUED LICENSE ACCOUNT NUMBER PERIOD
-100 (999) TOTAL
2004-3283
DR 8442(06/02) Page 2
INSTRUCTION SHEET
For all sections, complete questions 1-4 located on page 1
El Section A
To Register or Change Managers, check the appropriate box in section B and complete question
9 on page 4. Proceed to the Oath of Applicant for signature (Please note: Hotel and Restaurant
licensees are required to register their managers).
❑ Section B
Fora Duplicate license, be sure to include the liquor license number in section Don page 1 and
proceed to page 4 for Oath of Applicant signature.
El 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 3 and complete question 7. Submit the necessary information
and proceed to page 4 for Oath of Applicant signature.
5) For Optional Premises, go to page 3 and complete question 7. 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 8. Submit the necessary information
and proceed to page 4 for Oath of Applicant signature.
7) For a Bed and Breakfast Permit, go to page 4 and complete question 10. Submit the neces-
sary information and proceed to Oath of Applicant signature.
DR 8442(06/02) Page 3
.. 5. Retail Warehouse Storage Permit or a Wholesalers Branch House Permit
K ❑ Retail Warehouse Permit
W ❑ Wholesalers Branch House Permit
a
W Include full address of storage premises.
Ifgranted,will the proposed warehouse or branch house be in compliance with local building and zoning laws?P P P Yes No
O Name and title of Person in Charge of Premises ❑ ❑
to
❑ Attach a lease/deed and a diagram of storage premises.
R a 6. Change of Trade Name or Corporation name
i ❑ Trade/DBA Name Change only
w
ZG ❑ Corporate Name Change(Attach a Certificate of Amendment from Colorado Secretary of State)
U Old Name New Name
O
7. Modification of Premises or Addition of an Optional Premises to an existing Hotel/Restaurant Liquor License
(a) Describe change proposed
U,
w
(b) Will the proposed change result in the licensedpremises now being located within 500 feet of P Po 9 any public
▪ K or private school that meets compulsory education requirements of Colorado law, or the principal campus
of any college, university or seminary? Yes No
y (If yes, explain in detail and describe any exemptions that should apply) ❑ ❑
a
s (c) When will the proposed change
a.n0 Start (mo/day/year) End (mo/day/year)
u
CO (d) Is the proposed change in compliance with local building and zoning laws? Yes No
▪- ❑ ❑
p (e) If this modification is for an additional Hotel and Restaurant Optional Premises, has the local authority
Cauthorized by resolution or ordinance the issuance of optional premises? Yes No
(f) Are such changed premises owned or leased? ❑ Owned ❑ Leased ❑ ❑
(Attach a signed copy of deed or lease in the name of the licensee only)
(g) Attach a diagram of the current licensed premises and a diagram of the propesed changes for the
licensed premises.
8. Change of Location
(a) Address of current premises
City County ZIP
2 (b) Address of proposed New Premises(Attach a copy of the deed or lease that establishes possession of
0 the premises by the licensee)
8 Address
-� City County ZIP
u.
O
W (c) New mailing address if applicable
Address
t) City County ZIP
(d) Attach a diagram of the premises showing the area where alcohol beverages will be stored, served,
possessed or consumed. Include food preparation facilities for Hotel and Restaurants.
DR 8442(06/02) Page 4
9. Change of Manager or to register the manager of a Tavern or a Hotel and Restaurant liquor license.
w (a) Change of Manager(attach Indhividual History DR 04-I H/R only)
Former manager's name v6( an ufh
4 New manager's name l(4/r, Mae- Darla I
u. - (b) Compensation of Mgr. (f GD/tr leek Date of Emp. 10/U 3 Exp. Date /I.9
to Has manager ever managed a Liquor-licensed establishment? ❑ Yes At-No
Does manager have a financial interest in any other liquor licensed establishment? ❑ Yes '®'No
V If yes,give name and location of establishment
•
10. Bed and Breakfast Permit
• Attach a copy of a deed or lease in the exact name of the applicant only, reflecting possession of the permitted area
for at least the minimum duration of this permit(1 year from date of issuance).
• Attach a diagram of the premises which accurately reflects the area where alcoholic beverages will be stored, served,
possessed or consumed.
1. Applicant is a:
t
s ❑ Corporation (attach DR 8177) ❑ Partnership
W ElIndividual (attach DR 8404-I) ❑ LTD Liability Company(attach DR 8177)
F 2. Name of Applicant
2 3. Trade Name of Establishment(DBA)
a.
g 4. Address of Premises (specify exact location)
5. State Sales Tax Number Business Phone ( )
CO
O Pursuant to 12-47-410, C.R.S.,Applicant hereby states that it qualifies for a Bed and Breakfast Permit to serve complimentary
alcoholic beverages,and does certify to the State Licensing Authority:
O That it has no more than 20 sleeping rooms,and
to
CO 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 I FRIDAY HOURS i SATURDAY HOURS SUNDAY HOURS
From: m. From: m. From: m. From: m. From: m. From: m. From: m.
To: m. To: m. To: m., To: m. To: m.' To: m. To: m.
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/Ozy— Title G- pi Date
•
REPORT AND APPROVAL OF SING AUTHORITY(CITY/ COUNTY)
The foregoing application has been examined and th It �nducted and character of the applicant is satisfactory,and we
do report that such permit, if granted,will comply 'i e • I i. •y s of Title 12,Articles 46 and 47, C.R.S.,as amended.
THERE'C, 1gIC S APPROVED.
189 J
ocal Li using Aut rity(City or County) ('(4f —/I,/
Date file with Local Authority
04b Weld County, Colo. 1ar,' --.7`./ D'
Signature 71 f»� ''Alf re s.... ate
Chair, Weld County Board of Commissi `s:1iY:-/(r�iLa�/ ip�1,a 11/15/2004
REPORT OF STATE LICENSINa AUTHORITY a oar
The foregoing has been examined and complies with the filing requirements of Title 12,Article 47,C.R.S.,as amended.
r.
Signature r Title Date
DR 8404-I (06/02)
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, all limited partners owning 10% (or more)
of a partnership; all officers and directors of a corporation, all stockholders of a corporation owning 10% (or more)of the stock
of such corporation; all limited liability company MANAGING members, 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
4 Cc �ovkC 1 --- S (abet-- 3«e 6 Sior Ls Sx-/4 cr'vt
2.Yo r Full e(last,first,middle). O 3.List any other names you have used.
MAC 1NALD xA 1 n/NN
4.Mailing address(if different from residence) Home Telephone CPO-1-105-4e219
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
4n5 7 fill Ave ? vcxv6 CO 8Ola2 5/04 NIOW
Previous 1
2100 W C51- 129 ,�-►re�hy CO &Iig3a A103 5104
2S 25 W 2+h ,Si- X22 Givce eI 0 EB (23,4 7/01 4/os
6. -
?% D�l�V L�Yes ❑No
If Naturalized,state where When Name of District Court
Naturalization Certificate Number Date of Certification If an Alien,Give Alien's Registration Card Number Permanent Residence Card Number
8.Height Weight Hair Color Eye Color Sex Race 9.Do you have a current Driver's License?If so,give number8,state
5 / f f 45 I k l ?d I F 1W Yes 0 N
10.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 EMPLOYER
11.Have you ever applied for,held,or had an interest in a State of Colorado Liquor pr peer License,or loaned money,furniture or fixtures,equipment or
inventory,to any liquor or beer licensee? If yes,answer in detail. D Yes JX` No
12.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) n Yes k]No
13.Have you ever received a violation notice,suspension or revocation, liquor law violation,or have you applied for or been denied a liquor or beer
or a
license anywhere in the U.S.?If yes,explain in detail. O Yes No
14.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
S ri h�i I1 a5 8 live G��ei�y Cc 80L21 N(avla c✓ -3/1)3 Now
Dowiu y 2(61, II 1C-IV . -�YaLty e gel vfcv er e/02 2/03
R yip 59°O W reeley CO 80 M ro vier 51611, 1/u2
15.Financial Information.
Total purchase price$ (if buying an existing business)OR list the total amount of your investment in the new business,
including notes,loans,cash,services or equipment,and operating capital $
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 _ Where Obtained(Savings,Checking,Account,etc.) Amount
N/A — - —
Loan Information(attach copies of all notes or loans)
Name of Lender Address Term Security Amount
NVA
16.Give name of bank where business account will be maintained;name the account will be maintained under;and the name or names of persons
auth 'zed to draw thereon.
vi 2in k A vld C Cone(p)3 1 nc. DD, .3rvi(36 r1 S2 )0DVA-i
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.
Authoriz d ignature Title Date
5
1(0.70
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