HomeMy WebLinkAbout20011001.tiff RESOLUTION
RE: APPROVE PERMIT APPLICATION AND REPORT OF CHANGES (CHANGE OF
MANAGER) FOR ROMANCE, INC., DBA CLUB ROMANCE/LUCKY STAR, AND
AUTHORIZE CHAIR TO SIGN
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, Romance, Inc., dba Club Romance/Lucky Star, holder of a Tavern Liquor
License in Weld County, Colorado, has presented the Board with a Permit Application and
Report of Changes (Change of Manager), and
WHEREAS, said change is as follows: Isidro Rodriguez replaces Ruben Rodriguez as
manager, and
WHEREAS, after study and review, the Board deems it advisable to approve said Permit
Application and Report of Changes (Change of Manager).
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the Permit Application and Report of Changes (Change of
Manager), submitted by Romance, Inc., dba Club Romance/Lucky Star, be, and hereby is,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said report.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 2nd day of April, A.D., 2001.
BOARD OF COUNTY COMMISSIONERS
//�� � ear% WELD COUNTY, COLORADO
ATTEST. //%/// ,#7 \' sa\ XCUSED
i�6dd WW��((//�/// .��/tow;
,� , . J. Geile, Cha',
Weld County Clerk to the 'doh ,`
By: trio lenn Vaad, ' .- -m
Deputy Clerk to the Board"%roctil
i >//i-.11
Willi . J ke
KAPPRO ED AS T ORM:
D v' E. Long
ounty Atto ey
Robert D. Mas en
2001-1001
!JC .' 5O/ ,lppl LC0016
DR 8442(07/97)Page 1 21
COLORADO DEPARTMENT OF REVENUE L
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN STREET PERMIT APPLICATION
DENVER CO 80261
(303)205-2300 & REPORT OF CHANGES
CURRENT LICENSE NUMBER_ au-tc hl -tea
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)321-4164 DO NOT WRITE IN THIS SPACE
1. A-p/plkant is a i z.s :� .<.�:s.
u Corporation 0 Individual Jl guc L -voc,laens—
❑ Partnership 0 Limited Liability Company
2. Name of Applicant
(
c-antt 3..�T�raade Name ^r� aur"�- !}-oOtze)
a-t-S5‘•
4. Address
`3-1 \3\ ''. i . in
City Count ZIP
S-I-ctth- a• •r• •riat- s-cti•n b-I•w -n• •r•c- - • t• th- instructi•ns •n • . s - 2.
t ~k£3 st "f3 . 5?'`<ta 1". ..s('sue s�,+`;i5,atat.3:wY` .srM ,::tit z, ,z
'?` M,t:'Tfi�9°&z,', �.� rzw„>1'`:<<�...asss;:
1)02210-100(999)Retail Warehouse Storage Permit(ea) $75.00
• License Account No. 2)❑2320.100(999)Wholesale Branch House Permit(ea) 50.00
3)❑2320.100(999)Change Corp or Trade Name Permit(ea) 25.00
❑ 3.2%On/Off Premises Only NO FEE 4)❑2230.100(999)Change Location Permit(ea) 100.00
❑ Liquor Store or Drugstore NO FEE 5)❑2280.100(999)Change,Alter or Modify Premises
$100.00 x Total Fee
` "<m I : 6)O1980400(999 Addition of Optional Premises of Existing H/R
$75.00 x Total Fee _
• License Account No._,g.\\-+e)5bal.—CJOC� 7)❑2340-100(999)Bed and Breakfast Permit 25.00
.:F:. ' g `. :,.
1970-750(999) 0 Manager's Registration (Hotel&Rest.) $75.00
• LIQUOR LICENSE No._____ ___ _
114 Change of Manager(Other Licenses) NO FEE
2330.100(999)DUPLICATE LICENSE S 25.00
DO NOT WRITE IN THIS SPACE-FOR DEPARTMENT OF REVENUE USE ONLY
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OR 8442(07/97) Page 2
INSTRUCTION SHEET
❑ Section A
For current 3.2% On/Off premises only a Retail Liquor Store or Drugstore licensees apply-
ing to deliver alcohol, check the appropriate box in section A and proceed to page 4 for Oath of
Applicant signature.
ea Section B
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 C
Check the appropriate box in section C and proceed below.
1) Fora 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. Submit the necessary information and proceed
to page 4 for Oath of Applicant signature.
❑ Section D
For a Duplicate license, be sure to include the liquor license number in section D on page 1 and
proceed to page 4 for Oath of Applicant signature.
on)/-/OC)/
f
DR 8442(07/97) Page 3
..,._'_"I5. Retail Warehouse Storage Permit or a Wholesalers Branch House Permit
a ' ai O Retail Warehouse Permit
IttO Wholesalers Branch House Permit(Does not require local licensing authority approval)
agg1)Federal Basic Permit#__ _ __
MEI If granted,will the proposed warehouse or branch house be in compliance with local building and zoning laws? Yes No
`:; "? ❑ ❑
MS and title of Person in Charge of Premises
--------
❑ Attach a diagram of premises showing area of alcohol beverage storage
`w 6. Change of Trade Name or Corporation name
*4: O Trade/DBA Name Change only
` F` ❑ Corporate Name Change(Attach a Certificate of Amendment from Colorado Secretary of State)
!
itiA a
Old Name New Name
iiti
1 rf Modification of Premises or Addition of an Optional Premises to an existing Hotel/Restaurant Liquor License
InWEiii (a) Describe change proposed _ _ _ _ _ __________--
"'i"- (b) Will the proposed change result in the licensed premises now being located within 500 feet of any public
lit or private school that meets compulsory education requirements of Colorado law,or the principal campus
of any college,university seminary?
rIP g orYes No
1 (If yes,explain in detail and describe any exemptions that should apply) ❑ O
• a (c) When will the proposed change
Start_ __ _ _(mo/day/year) End__ _ _ _ ___(mo/day/year)
1 il
(d) Is the proposed change in compliance with local building and zoning laws?
Yes No
❑ ❑
(e) If this modification is for an additional Hotel and Restaurant Optional Premises, has the local authorityill
authorized by resolution or ordinance the issuance of optional premises? Yes No
❑ ❑
(f) Are such changed premises owned or leased? O Owned ❑ Leased
fER (Attach a signed copy of deed or lease in the name of the licensee only)
OM
(g) 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.
WS
'u 8. Change of Location
SES
MER
(a) Address of current premises
<3 >NE
ME City -- County — - - ----- ZIP -- --
(b) Address of proposed New Premises(Attach a copy of the deed or lease that establishes possession of
"' "`"' the premises by the licensee)
� `; Address _ __
Pxr:.,.:t . City
__ County _-- ______ ZIP _____ _
MAK
>S41k'ts (c) New mailing address if applicable
>\am
gial Address _____ _
City _ _ County _ ZIP __
aiat
<r <" (d) Attach a diagram of the premises showing the area where alcohol beverages will be stored,served,
"≥%z possessed or consumed. Include food preparation facilities for Hotel and Restaurants.
kaa
tat
0.200/—/CO
DR 8442(07/87) Page 4
'i`"n'': 9. Change of Manager or register manager of a Hotel/Restr.liquor license
ittEi (a) Change of Manager(attach Individual History DR 8404-I H/R only)
3_ _ Former manager's name W'S• --__—_
" s4i New manager's name S\
�y:��` (b) Compensation of Mgr._S Dat of Emp. 3" Exp.Date
:k'
iiiilikiiiiii, Has manager ever managed a L uo icens establishment? Elf Yes O No
Dal
Does manager have a financial interest in any other liquor licensed establishment? �❑ Y`es No
If yes,give name and location of establishment_ ,�\�ri1.ZL�`S �?�`� T CCI
_____
iilitiiiii 10. Bed and Breakfast Permit
NM • 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).
iiiiiiMig • Attach a diagram of the premises which accurately reflects the area where alcoholic beverages will be stored,served,
possessed or consumed.
iiiiiii"'iiiiii
>' 1. Applicant is a:
O Corporation (attach DR 8177) D Partnership
)>silt ,e: O Individual (attach DR 8404-I O LTD Liability Company
.qui? ) P Y(attach DR 8177)
.H._in„' 2. Name of Applicant ___
" ^, 3. Trade Name of Establishment (DBA)_
i "r:' 4. Address of Premises (specify exact location)L.
igt _ Business Phone _5. State Sales Tax Number_ _ _ __ __ ( )_— _ ___
�y..s�. Pursuant to 12-47-410,C.R.S.,Applicant hereby states that it qualifies for a Bed and Breakfast Permit to serve complimentary
Rao alcoholic beverages,and does certify to the State Licensing Authority:
!:'`>.:': ii __That it has no more than 20 sleeping rooms,and
Pit` ;` _____That it provides at least 1 meal per day at no charge other than for ovemight 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:
iiiiiiiigig
iin 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: m.
To: m. To: m. To: m. To: m. To: m. To: m. To: m.
t' sc tgg4pp .' ..
t#SK u+ I0 f atSOM. hstir@ s N #E s1 timi f tlt'(e gt'e + agro,,ar epic iootio# its
+ t f r 'tt? ?I"f ottre ////."t rititatio mfm $'Y tSign ur42 IfTtci<
.-. Date / L O
G
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Qa t for (t3amt: 1617+raft ooso ; [y7At'w r atootoj 4 r F ritiate.�'ak ,4,OO :G tt'.5•e�YirSser(o
iS AA1rtefF1 �
Local Licensing Authority(City or County) Date filed with Local Authority
Weld County, Colorado 03/29/2001
Signature Title Chair Protem, Weld County Date
Board of Commissioners 04/02/2001
1
MA
IIIIR '.may .y�.�y}�{gyp yyy { yi , si �t R yam,{/ .i,,a iiv:i:i, „. > s{. �m} y� u .y,y��igkK
:.:"•Y• WC`ryS+004* W00010F' �teS! YM tn***fI R E{eanti S2/y�tSS4Z RA: 004140* :
OMiiiiaminadaMEMERMOSENEMESSMamaniaMig
Signature Title Date
0'203/ -/60/
DR 8404-I (02/94)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1375 SHERMAN STREET
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,or other limited liability company members with a 10%(or more)
ownership interest in such company and all managers of a Hotel and Restaurant license.
NOTICE:This individual history record provides basic information which is necessary for the licensing authorities investigation.ALL questions
must be answered in their entirety.EVERY answer you give will be checked for its truthfulness.A deliberate falsehood will jeopardize the
application as such falsehood within itself constitutes evidence regarding the character of the applicant.
1.Name of Business D'e Social Security Number(s)
r cit\co.'S�c,, &Ca Qvk c�, \o\
2. ur Full Name(last,first,middle 3.Also__ __
Known As(maiden name/nickname,etc.)
4.Mailing Addres different from residence) Home Telephone
S\3 t.. 4-IM 4\4 t, \-Q"ctrairei, Coy 4&n3 -'sla-s‘iaS
5.Residence Address(street and number,city,state,ZIP)
6.Date of Birth Place of Birth 7.U.S.Citizen?
` iY%� �(. kutut ❑ Yes 1/J No _
If Naturalized,state where When Name of U.S.District Court
Naturalization Certificate Number Date of Certificate tan Alien,Give Alien's Regevadon Card Number Permanent Residence Card Number
8.Height Weight Hair Color Eye Color Sex Race 9_.._0 You Have a current Driver's License?If yes,give number,&state
S` \10 `1cGMv ](owv- M Present Employer 11.Type of Business or Employment
cacNu‘o l!_ tlik.. '*'ce css v cx\t'aox 'lC�� (\A
12.Address of Business Where Employed(street number,city,state,ZIP) Business Telephone
.2aCt\ � \\. St \,gams*' Io °tit\11\a am- ?,5aettPoo
13.Present.`s `Position
V cste V
14.Ma•at Status 15.Name of Spouse(include maiden name if applicable)
'c .dfi kA.- .:3.-e x,064%fist:L.. \—\s.0.7.\-0% L L.
16.Spouse's Date of Birth Spouse's lace of Birth
�
�1``a4SIS"`CS4 .L12
17.Spouse's residence address,if different than yours(street and number,city,state,ZIP) .
`.ZCV E-. f s tit _
18.Spouse's Present Employer Occupation
19.Address of Spouusssee. en
Spouse's Present Employer
20. List the name(s)of all relatives working in or having a financial interest in the liquor industry.
NAME OF`RELATIVE RELATIONSHIP TO YOU POSITION HELD NAME OF EMPLOYER LOCATION OF EMPLOYER
`
k�S. Q A.abC Sn�-e�a--ti CMSC1r.0• kZe-S' w y�vr (L
21.Do you now,or have you ever held a State of Colorado Uquor or Beer License,or loaned money,furniture,fixtures,equipment or inventory,to any Colorado Liquor or Beer
nsee?If yes,answer in detail Lil
Yes 0 No
•
CONTINUED ON REVERSE SIDE �-1
c2c'' 7 — (c/
•
DR 8404-I(2/94) Page 2
22.Have you everbeen convicted of a crime,or received a suspended sentence,deferred sentence,or forfeited bail for any offense in criminal or military court?(Do not include traffic
violations,unless they resulted in suspension or revocation of your driver's license,or you were convicted of driving under the influence of drugs or alcoholic beverages.)If yes,
explain in detail.
O Yes eNo
23.Have you ever received a iolation notice,suspension or revocation for a liquor law violation,or been denied a liquor or beer license anywhere in the U.S.?If yes,explain in detail.
❑ Yes No
24.Military Service(trench) From To Serial Number Type of Discharge
25.
List all addresses where you have lived for the past five years. (Attach separate sheet if necessary)
STREET AND NUMBER CITY,STATE,ZIP FROM TO
5VJ -4� S c Lan�rr � 'W\ _5\���rcse]C\
26.
List all former employers or businesses engaged in within the last five years.(Attach separate sheet if necessary.)
NAME OF EMPLOYER ADDRESS(STREET,NUMBER,CITY,STATE,ZI ) POSITION HELD FROM TO
we -. L 'o 8�i(c311k..\1
�'�r--tAsh4c MCLYNOcg 313 • 4'ln.Wc., . 8 5b6 P A-
27.What is your relationship to the applicant?(sole owner,partner,corporate officer,director,stockholder,member or manager)
Yta
28.If stockholder,number hares owned beneficially or of record Percent of outstanding stock owned
29.If partner,state whether 0 General ❑ Limited Percent of Partnership Owned If Limited Liability Company(percent owned)
30.Total amount you will invest in this business,including notes,loans,cash,service or equipment,and operating capital.(Reg.46-106.1 and Reg.47-107.1)
Amount$ 2oce' TeAr �x� .a5".
31. Identify the sources of all funds you will invest in this business as listed in 30 above. List all bank names,
account numbers and the amount derived from such source.Also identify all persons authorized to sign on,
or who are part owners of said account. (Attach copies of all your notes or loans used in or for this business.)
Amounts Sources -Account Numbers Names on accounts or person who can
sign on this account
$ 20i 00OLC3curti kYSk--Caw. I
$
$
$
Oattr of Appl cant
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 Signature Title Date
C� e� Xakti 3\i-ek\i
cQro/- /oo(
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