HomeMy WebLinkAbout20171168.tiffRESOLUTION
RE: APPROVE CORPORATE REPORT OF CHANGES FOR CIRCLE K STORES, INC.,
DBA CIRCLE K STORE #2709846, 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, Circle K Stores, Inc., dba Circle K Store #2709846, holder of a 3.2% Beer —
Off Premises Liquor License in Weld County, Colorado, has presented the Board with a Corporate
Report of Changes, and
WHEREAS, said corporate change is as follows: Melissa McKinley replaces Kelly
McGuire as Vice President, and Timothy Peters is added as Assistant Secretary, and
WHEREAS, after study and review, the Board deems it advisable to approve said
corporate report of changes.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Corporate Report of Changes submitted by Circle K Stores, Inc., dba
Circle K Store #2709846, 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 26th day of April, A.D., 2017.
BOARD OF COUNTY COMMISSIONERS
WELD CqUNTY, COLORADO
ATTEST: ditAvit)' ;i/k.
Weld County Clerk to the Board
BY: (1.
puty Clerk to the Board
APP 'e EDA
ounty Attorney
Date of signature: L --it lad /
Steve Moreno, Pro -Tern
Sean P. Conway
CG Ga.CFH), O PPL
6/(Cott
Barbara Kirkmeyer
C-
2017-1168
LC0013
DO NOT WRITE IN THIS SPACE
OR 4177 (04m9/08) PAGE 1
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1676 SHERMAN STREET
DENVER CO80241
(303) 2062300
REPORT OF CHANGES
CORPORATION, LIMITED LIABILITY
COMPANY AND PARTNERSHIP
Liquor and 3.2 Beer Licenses
(2355) ❑ LLC/PARTNERSHIP SEE INSTRUCTIONS AND
2350) ® CORPORATION
FEE SCHEDULE ON PAGE 2
1. CorporatelL.L.CRMIneNNp Name
Circle K Stores Inc
2. Slate Tax Account Number
21-65089
3. Slate Liquor License Number
Multiple Locations
4. Trade Name
Circle K Stores
5. Telephone Number
Multiple Locations
B. Addreas or Licensed Promisee
Multiple Locations
Oily
Multiple Locations
State
CO
ZIP Code
Multiple Locations
7. Milling Address r Mentor than above
119 S. Beitilne Rd. Ste 160
City
Coppell
State
TX
ZIP Code
75019
8. LIST ALL officers, directors (corporation) or Managing Members (L.LC.) or General Partner(s). Each
Officer, Director, Managing Member or Partner MUST FILL OUT a DR 8404-I (Individual History Record).
Position
Held
Names
Home Address DOB
Replaces
Aral. Sec.
Timothy Peters
1001 Lake Carolyn Pkwy 9530 Irving. TX 75039
None • Additional Signer
VP
Melissa McKinley
1701 Clark Lake Circle Keller, TX 76248
Nona Additional Signer
VP
Kelly McGuire
178019 Pnddla Meadow Place w. Paddle Alberta TOL two
Removed
Asst. Sec.
Kim Kwlatkoskl
7853 S. MIchele Ln. Tempe AZ 85284
Previously Qualified
1326 F,pgL4 Bend Southlake TXj6092
Previously Qualified
Mat. Sec.
Pres/Sep/DV
Dennis Tewell
TresNP/Dir
Kathy Cunninnton
14909 S 19th Place Phoenix Al 85048
Pray
onsiv Qualified
9. LIST ALL 10% (or more) Stockholders or 10% (or more) Members or 10% (or more) Limited Partners.
Each person listed Must Fill out a DR 8404-I (Individual History Record)
Stockholders/Idembers/Partners
owning 10% (or more) of business
%
Owned
Home Address
DOB
Replaces
No Change
10. Registered Agent Address For Service
Corporation Service Company 1560 S. Broadway Ste 2090 Denver, CO 80202
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REPORT OF.LgdAL LICENSING AUTti3ORIrt ;;1
The forego(ng charges have beak reed and pxeminedby the Local Licepemg Au(hoilty.
12. Local Licensing Authority For �CwMy ❑ Townk`ry
n Colons CI
P fl
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7MS
Count Gamut R910RP.TS
Date
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LIASILXTYJNFONIAATIONv.z.
License Account Number
Parll6d
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1:00 (999) .,
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COLORADO
Department of Revenue
Enforcement Division - Liquor & Tobacco
Physical Address:
1881 Pierce Street
Lakewood, CO 80214
October 19, 2016
Mailing Address:
P.O. Box 173350
Denver, CO 80217-3350
CIRCLE K STORES, INC.
D/B/A CIRCLE K STORES
1199 S. BELTLINE ROAD, SUITE 160
COPPELL, TX 75019
Re: State Master File for Circle K Stores, Inc.
Account # 2165089-0000
Dear Sir or Madam:
This is to advise you that the Colorado Liquor Enforcement Division ("Division") has, at
your request, revised the "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-I) for the following persons:
Darrell Davis
Dennis Tewell
Geoffrey Haxel
Kathy Cunnington
Kim Kwiatkowski
Melissa McKinley
Tim Peters
2. Fingerprint cards bearing the names and birth dates of the persons listed
in paragraph 1, above. All the fingerprint cards have been submitted by
us to the Colorado Bureau of Investigation. The CBI and FBI have
checked the prints and reportedly found no record of any criminal history
for those listed above.
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
DR 4041B (06/11/14)
submitted such documents to the Division. This letter will serve to inform the local
authorities exactly which documents you have already submitted to the State
Enforcement 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-I)
if manager's registration is required.
Sincerely,
Patrick Maroney
Division Director
2 DR 4041B (06/11/14)
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"), for the company operations in the State of Colorado, 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:
Geoffrey C. Haxel
Kathy Cunnington
Dennis Tewell
Darrell Davis
Melissa McKinley
Kim Kwiatkowski
Tim Peters
President and Secretary
Treasurer and Vice President
Sr. Vice President
Sr. Vice President
Vice President
Assistant Secretary
Assistant Secretary
3. The following persons have been elected as directors until their
successors shall be elected and qualified:
Geoffrey C. Haxel Director
Kathy Cunnington Director
IN WITNESS WHEREOF, I have hereunto set my hand as Assistant Secretary
and affixed the corporate seal of said Corporation this 01st day of August, 2016.
Assistant Secretary
Circle K Stores Inc.
. y. �F
fits,.
•
Lj
•
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OFFICE OF THE SECRETARY OF STATE
OF THE STATE OF COLORADO
CERTIFICATE OF FACT OF GOOD STANDING
I, Wayne W. Williams, as the Secretary of State of the State ofColorado, hereby certify that,
according to the records of this office,
CIRCLE K STORES INC.
is an entity formed or registered under the law of Texas , 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 19871038658 .
This certificate reflects facts established or disclosed by documents delivered to this office on
paper through 08/31/2016 that have been posted, and by documents delivered to this office
electronically through 09/02/2016 @ 1425:33 .
1 have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, and issued this
official certificate at Denver, Colorado on 09/02/2016 @ 1425:33 in accordance with applicable law.
This certificate is assigned Confirmation Number 9819805 .
Secretary of State of the State of Colorado
End ofCertificate
IJotlac_A certificate Lashed eledroriconv from the Colorado Seaeary of 8ate'sWeb Ste Is fully and immediately valid and effective. However.
as an option, the issuance and validity of a certificate obtained electronlcalty may be established by visiting the Validate a Certificate page of
the Sxvetary of Sala s Wab ate, hnp://tvww.sos.state.co.us/blxerefcateSearchCrlterla.do entering the certlfleata s cod oration number
displayed on the certificate, and following the Instructions displayed, Confirming the issuance of a certificate Is merely optional and is not
necessary to the valid and effective issuance of a cenifione For more information, visit our Web sae, http:/Annv.sosstate.ro,us/ click
"Businesses, trademarks, trade nem" and sided ° FreyuantlyA.ced Questions"
DR 8404-I (06/10/10)
COLORADO DEPARTMENT OF REVENUE
Liquor Enforcement Division
(303) 205-2300
Individual History Record
To be completed by the following persons, as applicable: sole proprietors; general partners regardless of percentage ownership, and
limited partners owning 10% or more of the partnership; all principal officers of a corporation, all directors of a corporation, and any
stockholder of a corporation owning 10% or more of the outstanding stock; managing members or officers of a limited liability company,
and members owning 10% or more of the company; and any Intended registered manager of Hotel and Restaurant, Tavern and
Lodging and Entertainment class of retail license
Notice: This individual history record requires information that is necessary for the licensing investigation or inquiry. All questions
must be answered in their entirety or the license application may be delayed or denied. If a question Is not applicable, please indicate
so by "N/An. Any deliberate misrepresentation or material omission may jeopardize the license application. (Please attach a
separate sheet if necessary to enable you to answer questions completely)
1. Name of Business
Circle K Stores, Inc.
Home Phone Number
N/A
Cellular Number
2. Your Full Name (last, first, middle)
Peters Timothy William
3. List any other names you have used
N/A
4. Mailing address Of different from residence)
1199 S Beltline Rd. Ste. 160 Coppell, TX
Email Address
tpeters2@circlek.com
5. List current residence address. Include any previous addresses within the last five years. (Attach separate sheet If necessary)
Street and Number
City, State, Zlp
From
To
Current
Previous
541 Slattery
Shreveport, LA 71105
04/01/13
07/01/15
6. List all employment within the last five years. Include any self-employment. (Attach separate sheet If necessary)
Name of Employer or Business
Address (Street, Number, City, State, Zip)
Position Held
From
To
Circle K Stores Inc
1199 S Beltline Rd. Ste. 160 Coppell, TX
DlrectorofReal Estate
04/01/12
Current
Circle K Stores Inc
3656 Southern Ave. Shreveport, LA 71106
Development Manager
06/01/15
05/01/16
Cornerstone Carwash
215 Gordon St. Gainesville, TX 76240
Owner
01/01/08
04/01/12
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
None
8. Have you ever applied for, held, or had an interest Ina Colorado Liquor or Beer License, or loaned money,
furniture, fixtures, equipment or Inventory to any licensee? (If yes, answer in detail.)
t♦ Yes 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 United States? (If yes, explain in detail.)
■ Yes
.4 No
10. Have you ever been convicted of a crime or received a suspended sentence, deferred sentence, or forfeited•
ball for any offense In criminal or military court or do you have any charges pending? (If yes, explain in detail.)
Yes F3 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 (] No
12. Have you ever had any professional license suspended, revoked, or denied? (If yes, explain in detail.)
■ Yes
No
Personal and Financial Information
Unless otherwise provided by law, the personal information required in question #13 will be treated as confidential. The personal
information required in question #13 is solely for Identification purposes.
13a, Date of Birth
b. Social Security Number
c. Place of Birth
Tulsa, OK
d. U.S. Citizen ®Yes O No
e. If Naturalized, state where
f. When
g. Name of District Court
h. Naturalization Certificate Number
I. Date of Certification
J. If anAlen, GlveAllen's Registration Card Number
k. Permanent Residence Card Number
I. Height
6'1"
m. Weight
205
n. Hair Color
Sait&Pepper
o. Eye Color
Brown
p. Gender
Male
q. Race
Caucasian
r. Do you
®Yes
have
•
a current Driver's License/ID? if so, give number and state.
No #
14. Financial information.
a. Total purchase price or Investment be ng made by the applying entity, corporation, partnership, limited liability company, other.
$ N/A
b. List the total amount of the personal investment , made by the person listed on question #2, in this business Including any
notes, loans, cash, services or equipment, operating capital, stock purchases or fees paid. $ N/A
• If corporate Investment only please skip to and complete section (d)
**Section b should reflect the total of sections c and e
c. Provide details of the personal Investment described in 14b. You must account for all of the sources of this Investment.
(Attach a separate sheet if needed)
Type: Cash, Services or Equipment
Account Type
Bank Name
Amount
N/A
d. Provide details of the corporate investment described in 14 (a). You must account for all of the sources of this Investment. (Attach a
separate sheet if needed)
Type: Cash, Services or Equipment
Loans
Account Type
Bank Name
Amount
N/A
e. Loan Information (Attach copies of all notes or loans)
Name of Lender
Address
Term
Security
Amount
N/A
Oath of Applicant
I declare lit d oe ry that this application and all attachments are true, correct and complete to the best of my knowledge,
Authorize I Print Signature
Timothy William Peters
Tide
Director Real Estate
Date
08/01/16
DR 8404-I Attachment
Timothy William Peters
Previous Residential Addresses
- 6051 Roma Dr., Shreveport, LA 71105
- 215 Gordon St., Gainesville, TX 76240
7/2012 — 4/2013
12/2010 — 07/2012
DR 8404-I (08/10118)
COLORADO DEPARTMENT OF REVENUE
Liquor Enforcement DMsion
(303) 205-2300
Individual History Record
To be completed by the following persons, as applicable: sole proprietors; general partners regardless of percentage ownership, and
limited partners owning 10% or more of the partnership; all principal officers of a corporation, all directors of a corporation, and any
stockholder of a corporation owning 10% or more of the outstanding stock; managing members or officers of a limited liability company,
and members owning 10% or more of the company; and any intended registered manager of Hotel and Restaurant, Tavern and
Lodging and Entertainment class of retail license
Notice: This individual history record requires information that Is necessary for the licensing investigation or Inquiry. All questions
must be answered in their entirety or the license application may be delayed or denied. If a question is not applicable, please indicate
so by "N/A". Any deliberate misrepresentation or material omission may jeopardize the license application. (Please attach a
separate sheet if necessary to enable you to answer questions completely)
1. Name of Business
Circle K Stores, Inc.
2. Your Full Name (last, first, middle)
Mckinley, Melissa Ann
4. Malang address Of different from residence)
199 S Beltline Rd. Ste. 160 Coppell, TX
5. List current residence address. Include any previous addresses within the last five years. (Attach separate sheet if necessary)
Home Phone Number
3. List any other names you have used
Melissa Ann Schroeder
Email Address
mmckinley@circlek.com
Cellular Number
Street and Number
City, State, Zip
From
To
Current
Virginia Beach, VA 23456
06/01/11
06/01/16
Name of Employer or Business
Address (Street, Number, City, State, Zip)
Position Held
From
To
Circle K Stores Inc
1199 S Beltline Rd. Ste. 160 Coppell, TX
Vice President
05/01/16
Current
Dollar Tree Stores, Inc
500 Volvo Pkwy., Chesapeake, VA 23320
Zone VP
05/01/11
05/01/16
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
None
8. Have you ever applied for, held, or had an interest in a Colorado Liquor or Beer License, or loaned money,
furniture, fixtures, equipment or inventory to any licensee? (if yes, answer in detail.)
CI Yes ®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 United States? (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 ❑ Yes
bail for any offense in criminal or military court or do you have any charges pending? (If yes, explain in detail.)
In 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 ID No
12. Have you ever had any professional license suspended, revoked, or denied? (If yes, explain In detail.)
• Yes IN No
Personal and Financial Information
Unless otherwise provided by law, the personal information required in question #13 will be treated as confidential. The personal
information required In question #13 is solely for identification purposes.
13a. Date of Birth
b. Social Security Number
o. Place of Birth
Brownwood, TX
d. U.S. Citizen
Yes O No
e. If Naturalized, state where
T. When
g. Name of District Court
h. Naturalization Certificate Number
I. Date of Certification
fir GiveAlien's Registration Card Number
k. Permanent Residence Card Number
I. Height
5'-4"
m. Weight
198
n. Heir Color
Brown
o. Eye Color
Brown
p. Gender
Female
q. Race
White
r. Do you have a current Driver's Llcense/ID? If so, give number and state.
Yes ON if A62157088
Financial Information.
a. Total purchase price or investment being made by the applying entity, corporation, partnership, limited liability company, other.
$ N/A
b. List the total amount of the personal investment , made by the person listed on question #2, in this business including any
notes, loans, cash, services or equipment, operating capital, stock purchases or fees paid. $ N/A
* If corporate investment only please skip to and complete section (d)
•* Section b should reflect the total of sections c and e
c. Provide details of the personal investment described In 14b. You must account for all of the sources of this investment.
(Attach a separate sheet if needed)
Type: Cash, Services or Equipment
Account Type
Bank Name
Amount
N/A
d. Provide details of the corporate investment described in 14 (a). You must account for all of the sources of this investment. (Attach a
separate sheet if needed)
Type: Cash, Services or Equipment
Loans
Account Type
Bank Name
Amount
N/A
e. Loan Information (Attach copies of all notes or loans)
Name of Lender
Address
Term
Security
Amount
N/A
Oath of Applicant
I declare under penalty of periu that this application and all attachments are true. correct, and complete to the best of m knowiedae.
Auth Signature /
/�,�q
Print Are
Melissa Ann Mckinley
Title
, Vice President
Date
8
08/01/16
MEMORANDUM
TO: Weld County Attorney's Office April 11, 2017
FROM: Weld County Deputy Clerk to the Board
Chloe A. Rempel
SUBJECT: Corporate Report of Changes — Circle K Stores, Inc.
Per State of Colorado, Department of Revenue, Liquor Enforcement Division: Circle K Stores,
Inc. is a master file, and thus, paid fees totaling in $500.00 ($250.00 per addition to corporate
directors) directly to the State of Colorado.
2017-1168
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