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Home My WebLink About20163228.tiffRESOLUTION RE: APPROVE SPECIAL EVENTS PERMIT AND AUTHORIZE CHAIR TO SIGN - THE WILD ANIMAL SANCTUARY 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, The Wild Animal Sanctuary presented to the Board of County Commissioners of Weld County, Colorado, an application for a Special Events Permit for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, and WHEREAS, said applicant has paid the sum of ONE HUNDRED DOLLARS ($100.00) to Weld County, Colorado, pursuant to the laws providing therefore in payment for a County Retail Permit for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, for an event scheduled for one day only on October 22, 2016, at 10:00 AM, to October 22, 2016, at 4:00 PM, outside the corporate limits of any town or city in the County of Weld at the location described as follows: Rocky Mountain Cider Company, dba Wild Cider, 11455 County Road 17, Firestone, CO 80504; being further described as Lot B of Recorded Exemption, RE -41, being located in the E1/2 SE1/4 of the Section 5, Township 2 North, Range 67 West of the 6th P.M., Weld County, Colorado WHEREAS, said applicant has also paid the sum of TWENTY-FIVE DOLLARS ($25.00) to the Colorado Department of Revenue and has exhibited a State Special Events Permit for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only. NOW, THEREFORE, BE IT 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 Special Events Permit Number 2016-17 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 permit by the Chair of the Board of County Commissioners, attested to by the Clerk to the Board of Weld County, Colorado, which permit shall be effective from 10:00 AM on October 22, 2016, until 4:00 PM on October 22, 2016 , providing that said place where the permitee 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 permit. Cc! SOc RSA cc--Cr-H) IO(9Ct/ l(o cc c O-PPL tO!3l/tCo 2016-3228 LC0022 SPECIAL EVENTS PERMIT - THE WILD ANIMAL SANCTUARY PAGE 2 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 17th day of October, A.D., 2016. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: d4tticsA) V X‘AD;c/k• Mike Freeman, Chair Weld County Clerk to the Board ounty Attorney Date of signature: lO(Ill (C2 2016-3228 LC0022 DR 8428 (08/01/2012) COLORADO DEPARTMENT OF REVENUE 1881 PIERCE STREET, SUITE 108 LAKEWOOD, CO 80214 STATE OF COLORADO DEPARTMENT OF REVENUE VALID ONLY FOR THE ORGANIZATION AT THIS LOCATION THE WILD ANIMAL SANCTUARY 11455 CR 17 FIRESTONE CO 80504 Permit Number: 4801961 Event Manager: PAT CRAIG SPECIAL EVENTS PERMIT MALT, VINOUS AND SPIRITOUS LIQUOR VALID ONLY FOR THE FOLLOWING PERIODS EVENT 1: 10/22/2016 10 AM 4 PM EVENT 2: EVENT 3: EVENT 4: EVENT 5: This permit is issued subject to the laws of the State of Colorado and especially under the provisions of Title 12, Articles 46 or 47, CRS 1973, as amended. This permit is nontransferable and shall be conspicuously posted in the place above described. This permit is only valid during the event date(s) shown above. In testimony whereof, I have hereunto set my hand. 10/20/2016 pjr Division Director Executive Director • Pm; 4 ge rwl 0 0 N N N w H U O ru E-4-4 DC W ru z w :44 x F \TE OF COLORADO FOR A SPECIAL EVENTS PERMIT r:4 O II I, Ct 4f z r 0 4t me Z W II I, I, W ) tit CZ CZ or CZ r O r ,f U ($100.00) Dollars County Treasurer the p ci CZ cnt .:121 ,f ON r 0 rY4 IN TESTIMONY CID • ,f f • .G, U O 0 H o the Board w a o� w w 0 w U C-0 O U C: c) 0 ca) 4e w 0 w as I DR 8439 (06/28/06) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 (303) 205-2300 IN ORDER TO QUALIFY FOR A SPECIAL EVENTS PERMIT, YOU MUST BE NONPROFIT AND ONE OF THE FOLLOWING (See back for details.) SOCIAL ATHLETIC IJ PHILANTHROPIC INSTITUTION . FRATERNAL . CHARTERED BRANCH, LODGE OR CHAPTER . POLITICAL CANDIDATE l• PATRIOTIC I• OF A NATIONAL ORGANIZATION OR SOCIETY MUNICIPALITY OWNING ARTS l• POLITICAL U RELIGIOUS INSTITUTION FACILITIES LIAB TYPE OF SPECIAL EVENT APPLICANT IS APPLYING FOR: 2110 ,./MALT, VINOUS AND SPIRITUOUS LIQUOR $25.00 PER DAY 2170 FERMENTED MALT BEVERAGE (3.2 Beer) $10.00 PER DAY DO NOT WRITE IN THIS SPACE LIQUOR PERMIT NUMBER 1. NAME OF APPLICANT ORGANIZATION OR POLITICAL CANDIDATE The Wild Animal Sanctuary State Sales Tax Number (Required) 01451202-0000 2. MAILING ADDRESS OF ORGANIZATION OR POLITICAL CANDIDATE (include street, city/town and ZIP) 1946 County Road 53 Keenesburg, CO 80643 3. ADDRESS OF PLACE TO HAVE SPECIAL EVENT (include street, city/town and ZIP) 11455 CR 17 Firestone, CO 80504 NAME DATE OF BIRTH HOME ADDRESS (Street, City, State, ZIP) PHONE NUMBER 4. PRES./SEC'Y OF ORG. or POLITICAL CANDIDATE Pat Craig, Executive Director 1946 WCR 53, Keenesburg, CO 80643 303-536-0118 5. EVENT MANAGER SAME 6. HAS APPLICANT ORGANIZATION OR POLITICAL CANDIDATE BEEN ISSUED A SPECIAL EVENT PERMIT THIS CALENDAR YEAR? ✓ NO YES HOW MANY DAYS? 7. IS PREMISES NOW LICENSED UNDERSTATELIQUOR OR BEER CODE? OCK f Y tn un+ou� O NO X YES TO WHOM? L' RIC: Colnnparl-c°,. ild CGc 8. DOES THE APPLICANT HAVE POSSESSION OR WRITTEN PERMISSION FOR THE USE OF THE PREMISES TO BE LICENSED? 0 Yes ill No LIST BELOW THE EXACT DATE(S) FOR WHICH APPLICATION IS BEING MADE FOR PERMIT Date Oct 22nd, 2016 Hours From 1 gar. To 4 es.m. Date Hours From .m. To .m. Date Hours From .m. To .m. Date Hours From .m. To .m. Date Hours From .m. To .m. OATH OF APPLICANT I declare under penalty of perjury line second degree that I have read the foregoing application and all attachments thereto, and that all information therein is trucorrect, and complete to the best of my knowledge. SIGNATURE / �. TITLE Executive Director DATE 09/21/2016 z REPORT AND ROVAL OF LOCAL LICENSING AUTHORITY (CITY OR COUNTY) The foregoing ication has,b examined and the premises, business conducted and character of the applicant is satisfactory, and we do report that such permit, if granted, will comply with the provisions of Title 12, Article 48, C.R.S., as amended. THEREFORE, THIS APPLICATION IS APPROVED. LOCAL LICENSING AUTHORITY (CITY OR COUNTY) CITY Weld County, Colorado V COUNTY TELEPHONE NUMBER OF CITY/COUNTY CLERK (970) 356-4000 Ext 4225 SIGNATURE �y1,� TITLE Chair, Board of County Commissioners DATE LJ�6 OC1 1 t. U DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY LIABILITY INFORMATION License Account Number Liability Date State TOTAL -750 (999) APPLICATION FOR A SPECIAL EVENTS PERMIT Department Use Only (Instructions on Reverse Size) APPLICATION INFORMATION AND CHECKLIST THE FOLLOWING SUPPORTING DOCUMENTS MUST BE ATTACHED TO THIS APPLICATION FOR A PERMIT TO BE ISSUED: Appropriate fee. Diagram of the area to be licensed (not larger that 8 1/2" X 11" reflecting bars, walls, partitions, ingress, egress and dimensions. Note: If the event is to be held outside, please submit evidence of intended control, i,e., fencing, ropes, barriers, etc. Copy of deed, lease, or written permission of owner for use of the premises. Certificate of good corporate standing (NONPROFIT) issued by Secretary of State within last two years; or If not incorporated, a NONPROFIT charter; or if a political Candidate, attach copies of reports and statements that were filed with the Secretary of State. Vt I 0 .✓J APPLICATION MUST FIRST BE SUBMITTED TO THE LOCAL LICENSING AUTHORITY (CITY OR COUNTY) AT LEAST THIRTY (30) DAYS PRIOR TO THE EVENT. THE PREMISES TO BE LICENSED MUST BE POSTED AT LEAST TEN (10) DAYS BEFORE A HEARING CAN BE HELD. (12-48-106 C.R.S.) AN APPROVED APPLICATION MUST BE RECEIVED BY THE LIQUOR ENFORCEMENT DIVISION AT LEAST TEN (10) DA VS PRIORTO THE EVENT. CHECK PAYABLE TO THE COLORADO DEPARTMENT OF REVENUE (12-48-102 C.R.S.) A Special Event Permit issued under this article may be issued to an organization, whether or not presently licensed under Articles 46 and 47 of this title, which has been incorporated under the laws of this state for the purpose of a social, fraternal, patriotic, political or athletic nature, and not for pecuniary gain or which is a regularly chartered branch, lodge or chapter of a national organization or society organized for such purposes and being non profit in nature, or which is a regularly established religious or philanthropic institution, and to any political candidate who has tiled the necessary reports and statements with the Secretary of State pursuant to Article 45 of Title 1, C. R.S. A Special Event permit may be issued to any municipality owning arts facilities at which productions or performances of an artistic or cultural nature are presented for use at such facilities. If an event is cancelled, the application fees and the day(s) are forfeited. October 17, 2016 CLERK TO THE BOARD PHONE: (970) 336-7215, Ext. 5226 FAX: (970) 336-7233 1150 O STREET P. O. BOX 758 GREELEY, COLORADO 80632 Colorado Department of Revenue Division of Liquor Enforcement 1881 Pierce Street Division 108-A Lakewood, CO 80226 RE: WINE FESTIVAL CHARITY EVENT HOSTED BY THE ROCKY MOUNTAIN CIDER COMPANY, DBA WILD CIDER FBO THE WILD ANIMAL SANCTUARY - SPECIAL EVENTS PERMIT APPLICATION BY THE WILD ANIMAL SANCTUARY FOR BEER GARDEN WITHIN EVENT To Whom It May Concern: The Rocky Mountain Cider Company currently is an established, licensed winery. They are hosting a charity wine festival to benefit The Wild Animal Sanctuary. There will be multiple wineries attending this festival, and the Rocky Mountain Cider Company has submitted a wine festival permit application to the State of Colorado in which the applicant will be "turning off' their current license for the event date so the wine festival permit will take effect. As well, there will be a separately sectioned beer garden at the event. The attached documents have been submitted by The Wild Animal Sanctuary to license the beer garden. All proceeds from the beer garden will directly benefit The Wild Animal Sanctuary. Please see the attached application for a Special Events Permit, and applicable supporting documentation. The Weld County Board of Commissioner's approved a county Temporary Assembly Permit, and the Special Events Permit this morning, Monday, October 17, 2016. Because the event is Saturday, October 22, 2016, I am initially submitting the application via email. I have mailed the application via priority overnight Fed -Ex, and you should receive it tomorrow morning, Tuesday, October 18, 2016. If you have questions or need additional information, please do not hesitate to contact me at (970) 400-4225. Very truly yours, Chloe A. Rempel Deputy Clerk to the Board Weld County crempelco.weld.co.us SPECIAL EVENT PERMIT QUESTIONNAIRE AND AFFIDAVIT What type of an event is planned (e.g., annual, quarterly, benefit, etc.)? Beer Garden for fundraising purposes 2, Explain in detail the nature of your organization, its function, and who or what benefits from its operations (attach separate sheet if necessary). Non -Profit Wildlife Sanctuary - Please see attached. 3, Who or what organization will be the recipient of funds derived from this event? The Wild Animal Sanctuary 4 How many attendees are expected at this event? 1,000 (estimated) 5 Describe the premises at which this event will take place. Nild Cider land with designated parking, stage, seating, bathrooms and vendor sales area. 6. What type of security will be provided at this event? 6 Trained security guards, as well as staff and volunteers of the sanctuary 7. How many security personnel will be on hand? All staff and volunteers will wear safety orange attire 8. How will security personnel be identified? 9 If this event is being held outdoors, how will the exterior boundaries of the premises be marked (e.g., roped, fenced, etc.)? Fence boundaries and/or roped, coned and barriers will be used. 10. What type of entertainment will be provided, if any, for this event? Various music artists 11. What method will be used in checking identification for proper age of attendees (e.g., at the door, at the bar, etc.) and how will underage patrons be identified so as not to be served alcoholic beverages (e.g., stamp or mark on the hand, etc.) ID at the bar 2016-3228 M:\CTB\CTBFORMS\FOSPEC IALEVENT.D0CS pocia I Event 12. How will the conduct and level of intoxication of attendees be monitored and by whom? Staff and volunteers will be positioned throughout the venue to monitor attendees. 13_ Have volunteers or members of your organization been trained in the sale/service of alcoholic beverages: If yes, what training have they received and by whom? Only staff & volunteers that have worked professionally in liquor/bar/restaurant establishments will serve alcohol from booth. 14. What types of alternate beverages and food/snacks will be available? Soft drinks, water, burritos, beef entre, fruit, etc... 15. Has a State Sales Tax Number been initiated by you or a member of your drganization? If so, write that number in the space provided. 01451202-D000 16. Explain how this event will be marketed describing what kinds of advertising material will be distributed and the targeted recipients of such material. Through the organization's newsletter, website, and social media pages (i.e. Facebook) as well as billboard and print advertisements I hereby certify, underpenalty of perjury, that the information provided to the Board of County ommissioners�,of 'Weld County contained in this affidavit is true and accurate to the best of my knowledge. 4,, AppliC hesra gnature .r STATE OF COLORADO COUNTY OF WELD ) ss 1 09/21/2016 Date Subscribed and sworn to before me this qMP.0 day of Witness my hand and official seal. R BEKAH ERNST Notary Public - Stale of Colorado Notary 10 20164033127 My Commission Expires Aug 20, 2020, Notary Public My commission expires: set 201( Vi , IOW M:1CTB\CTBFOF MS\FOSPEOIALEVENT.DOCspecialEvent To Whom it may concern From Mark Bix do 11455 CR 17 Firestone, CO 80504 I hereby give permission for Wild Cider to hold the 2016 Carbon Valley Wine festival on my Property on October 22 2016, The applicant swears, (affirms) that, the statements contained above are true and correct. Owner Mark Birkin 11455 CR 17 ti Firestone. CO +1495 3t5,5-0 91 ierAfeiziers/mievici Printed Name Mark Biricin Owner Signature of owner SUBSCRIBED AND SWORN TO BEFORE ME THIS n DAY OF 2016. WITNESS MY HAND AND OFFICIAL SEAL. My Commission expires Oft is 2.0 11 may. CktA, _____ N gTA' Y PUBLIC IC OSjii • •F I �f r� ti' R 7fi r T: l }• .,;859 k %'9 'l °.R'a ' ' "".wit' 3 To whom it may concern, 10/5/16 I am the property owner € irectly north and adjacent to the property where the Carbon Valley Wine Festival is proposed. Legal description is, PT NE4 5-2-87 DESC AS BEta NE COR SEC 30D25W 515,23' 0D2.5W 1211.03' TO TPOB TH 60D25'W 108'1.24' TO Eall COR SEC N89D21'W 1330.08' N0O43'E 1399.71' 87'5O50'E 136►1.62' TO WOE PT LOT B RE -4884 I give consent to park vehicles on the above mentioned property for the wine festival on 10/22/16 S OFFICE OF THE SECRETARY OF STATE OF THE STATE OF COLORADO CERTIFICATE OF FACT OF GOO STANDING I, Wayne W. Williams, as the Secretary of State of the State of Colorado, hereby certify that, according to the records of this office, The Wild Animal Sanctuary, a Colorado Non -Profit Corporation is a Nonprofit Corporation formed or registered on 07/27/1995 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 19951094721 . This certificate reflects facts established or disclosed by documents delivered to this office on paper through 09/21/2016 that have been posted, and by documents delivered to this office electronically through 09/23/2016 @ 09:55:43 . I have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, and issued this official certificate at Denver, Colorado on 09/23/2016 @ 09:55:43 in accordance with applicable law. This certificate is assigned Confirmation Number 9849656 Secretary of State of the State of Colorado *********************************************End of Certificate `***`************************************** Notice: A certificate issued eleeimnic:ally from the: Colorado Secretary of Slates if'eb site is Ws, ,Writ inunatatelv valid and effective: However, as an option, the issuance and validity of a certificate obtained electronically may be established by visiting the Validate a Certificate page of the Secretary of State's Web site, htipAiiww.sos:state.co.us/biz/CertificateSearchCriteriaxio entering the certificate's confirmation number displayed on the certificate„ and following the instructions displayed. Confirming the issuance of ' a certificate. is merely colon rl and is. trot necessary to .he valid and effective issuance of a certificate For more information, visit our Web site, hap:!! www.sos.state ,co.us/click "Businesses, trademarks, trade names" and select "Frequently Asked Q stion s. " DR a1 sM (0216/11) COLORADO DEPARTMENT OF REVENUE DENVER CO 802614015 THIS UCENSE IS NOT TRANSFERABLE • • e CHARITABLE SALES TAX LICENSE USE ACCOUNT NUMBER la LIABILITY INFORMATION for all references 01451202e0000 • VALID THROUGH armir 03.4206-075 100110 Dec 31 2017 ROCKY MN'1'N WILDLIFE CONSE 1946 WELD COUNTY ROAD 53 KEENESBURG CO 8)643 ROCKY' MNTN WILDLIFE CONSERVATION CTR INC 1946 WCR 53 KEENESSURO CO 80643 S. A Detach Here A Important Verification Process Executive Director Department of Revenue VERIFY that all information on your charitable sales tax license is correct, Modify and update any errors you identify on the Internet through Revenue Online. Access your tax account, file returns, submit payments, verify sales tax licenses and view sales tax rates through Revenue Online at www. oolorado.gcv/RevenueQnllne All the information you need to get started is on this document; have it with you before you begin. Follow these easy steps. 1. Go to VAw. Colorado. go v.MevenueOnifne 2. Click on Sign Up (individual or Business) link on the right , Click on Continue. Now click on: Enter Taxpayer Information. Click on the down arrow in the Account Type list and select Other. Use the first 8 -digits of the account number shown on your license. Complete the rest of the screen.Next click on: Enter Login Information and complete the screen (this is information YOU get to create for the as nt). Next click on: Enter Account Information and complete the screen. Your Letter ID is: L1548517408 . Then click the Submit button. You will see a confirmation page on your screen, You should receive a confirmation email from the Colorado Department of Revenue. If you do not check your Junk email folder. Once you have your Authorization Code return to Revenue Online via the link in your email. Enter the Login ID and Password you created, 1. Click on the Login button. 2. Enter the Authorization Code from your email (first time only). 3, Click Login. You should then be in your mount. NOTE: 11 you have additional tax types registered under the same Account Number, such as withholding, you will be able to view those tax types through the account You do not need to create separate Login IDs and Passwords for each tax in your account. Filing Returns To file a return, go to Revenue Online(www.tolorado.gov/RevenueOnline). You must file a return for each reporting period, Ii you have no tax to report, file a `zeros return. Tax reporting and payment are your responsibility. To avoid late penalties and interest file online on or before the due date. It you discontinue sales, you may close your business location through Revenue Online. Learn more and avoid unnecessary errors by attending our free sales tax classes! Sign up at www. TexSeminers.stete.co, ors ACORIO CERTIFICATE OF LIABILITY INSURANCE DATE CM MOD/ YY) 4/26/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the po l icy(Ies) must be endorsed. If SUBROGATION CS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such a ndorsementjsI, PRODUCER Arthur J. Gallagher Risk Management Services, Inc. PO Box 4190 Estes Park CO 80517 INSURED Rocky Mountain Wildlife Conservation Center dba 1946 Weld County Rd 53 IKeenesburg CO 80643 COVERALGES ROCKMOU-34 CONTACT NAME: PHONE as .0,70_586-4407 E-MAIL ADDRESS4 I FA. Hc)1, 970-586-3370 INSURERS I AFFORDING COVERAGE INSURER A: National Casualty Company INSURER B ;Artisan & Truckers Casualty Company _ INSURER c : Pinnacol Assurance Company INSURER D :Owners insurance Company INSURER E : INSURER F : NAIC # 11991 10194 41190 32700 CERTIFICATE NUMBER: 830819968 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT ' 11TH RESPECT CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY PERIOD TO WHICH THIS ALL THE TERMS, INSR LTR I TYPE OF INSURANCE AODU I IN.SD SUBA MOr POLICY NUMBER POLICY EFF' I smminortyyyl POLICY EXP SISIIIOPTCP LIMITS , , A X COMMERCIAL GENERAL LIABILITY KKO0000020180200 4/1/2016 4/1/2017 EACH OCCURRENCE $1,000,000 DAMA PR EEMISE_Sge E TO -RENTED occurrence) $300,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ Excluded $1,000,000 PERSONAL &ADV INJURY GENERAL AGGREGATE $None GET IL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGOG $5,000,000 � POLICY 4 EC JECTT LOG $ OTHER: EAUTOMOBILELIABILITY t 1,000,000 iJ1457146- 4/1/2016 4/112017 fCMBINErtLELJPI1T BODILY INJURY (Per person) $ ANY AUTO ALL OV NED x SCHEDULED BODILY INJURY (Per accident) $ PROP'E W,DMI, jeer =Went) E $ NkRED AUTOS NON -OWNED AUTOS $ $1, 000, 000 A UMBRELLA LIAR X OCCUR M(000000201 80300 4/1/2016 4/1/2017 EACH OCCURRENCE $1,000,000 X EXCESS DAB CLAIMS -MADE AGGREGATE DED RETENTION $ $ r ' Y 0WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 4082811 7/1/2015 7/112010 SPER TATUTEI OTI R Y I N $100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N A EL, EACH ACCIDENT FOFFICER/MEMBER EXCLUDED'? $100, 000 (Mandatory In NH) el DISEASE - EA EMPLOYE If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $500,000 D Commercial Auto 4872885400 4/1/2016 4/1/2017 CSL 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedute, may be attached if more space is required) General Liability extends to: Summer Safari Fundraising Dinners 5/14/16, 6/18/16, 10/1/16 and "Into The Wild" Running Festival 6/3/16 6/4/16. - CERTIFICATE HOLDER CANCELLATION Weld County Weld County Commissioners 1111 H Street Greeley CO 806320758 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4 ACORD 25 {2014/O1) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,CORD CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/'YYYVI 9/23/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT' If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Arthur 3 Gallagher Risk Management Services, Inc. PO Box 4190 Estes Park CO 80517 INSURED TH EWI LD-01 The Wild Animal Sanctuary, A Colorado Non -Profit C 1946 Weld County Rd 53 Keenesburg CO 80643 CONTACT' NAME: PH ONE .Fr.,v�. E970-586-4407 E-MAIL ADDRESS: INSURER(S1 AFFORDING COVERAGE FAX Itit 970-586-3370 INSURER A ; National Casualty Company INSURER B :Owners Insurance Company INSURER c : Pinnacol Assurance Company INSURER D INSURER E NAIC # 11991 32700 41190 INSURER F COVERAGES CERTIFICATE NUMBER:. 1770814719 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS 'I INSR LTR ACOL TYPE OF INSURANCE INSO UBi MO POLICY NUMBER PQLI :Y EFF iMOODJYYYX POLICY EXP ,& IDD ff y LIMITS A x COMMERCIAL GENERAL LIABILITY K1(00000020180200 4/1/2016 4/1/2017 EACH OCCURRENCE $1,000,000 iiTANIAGE150-RENTED PREMISES (Es ;v. r gnceo, -- $3O0,OO0 I CLAIMS -MADE X OCCUR MED EXP (Any one person) $10,000 PERSONAL & ADS' INJURY $1,O00,OO0 $ GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 5,O0O,OO0 X POLICY PRO- JECT LOG OTHER: $ = AUTOMOBILE LFABILIW 4872865400 4/1/2016 4/1/2017 ?IILE LIMIT $1 O00,0O0 BODILY INJURY (Per Person) $ ANY AUTO BODILY INJURY (Per accident) $ Ath8NED SCHEDULED IS PIWPE (Per accident} `�1�'I MAGE $ - HIRED AUTOS NON -OWNED AUTOS $ A UM s RELLA LIAR X OCCUR XKO00O002018030O 4/1/2O16 31 ,CO0,0OO 4/1/2017 EACH OCCURRENCE AGGREGATE $1,0O0,00O X EXCESS LIAR CLAIMS -MADE $ OFF) I RETENTIONS C WORKERS COMPENSATION AND EMPLOYERS' LIA :ILITY Y N 40828'11 7/1/2O16 N /A 711/2O17 PER ST TUT - I 0TH ER - E L EACH ACCIDENT 31,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEIv1 UEFA EXCLUDED? E L. DISEASE - EA EMPLOYEE; $1,0OO,00O (Mandatory If yes, DESCRIPTI.OR describe In NH) under OF OPERATIONS below E L DISEASE - POLICY LIMIT $1 ,0OO,00O DESCRIPTION General and Wild OF Liability Cider OPERATIONS extends Festival / LOCATIONS - to: Summer 10/22/16 I VEHICLES Safari (ACORD Fundraising 101, Additional Remarks Schedule, Dinners 5/14/16, may 6/18/16, be attached II' more 10/1 /10, space "Into Is The required) Wild" Running Festival 6/3/16 - 614/16 CERTIFICATE HOLDER Weld County Weld County Commissioners 1111 H Street Greeley CO 806320758 USA CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATLVE er-ot 01988-2014 ACORD CORPORATION. All rights reserved.. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD A CORO CERTIFICATE OF LIABILITY INSURANCE DATE (MM!DD/YYYY) 9/23/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is en ADDITIONAL INSURED, the policyties) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s . PRODUCER CONTACT - Arthur J. Gallagher Risk ManagementServices Inc. NAME. NEFAX P G 41 rA„ Ito, Ex11N 970-586-4407 (A Ca.Nc�� 970-586437 E- MAIL 0 Estes Park CO 80517 DDRESS: INSURED THE ILDfr01 The Wild Animal Sanctuary, A Colorado Nona -Profit C 1946 Weld County Rd 53 l eenesburg CO 80643 INSU FtER1SS AFFORDING COVERAGE INSURER A :National Casualty Company INSURERS: Owners Insurance Company INSURER C : P'i ri nacol Assurance Company IN SURER D INSURER E INSURER F NAIC iP ;11991 32700 41190 COVERAGES CERTIFICATE NUMBER: 1770814719 REVISION NUMBER: THIS INDICATED, CERTIFICATE EXCLUSIONS IS TO CERTIFY NOTWITHSTANDING MAY BE AND CONDITIONS THAT ISSUED THE POLICIES OF INSURANCE ANY REQUIREMENT, OR MAY PERTAIN, OF SUCH POLICIES. THE LIMITS TERM INSURANCE LISTED SHOWN OR BELOW HAVE BEEN CONDITION OF ANY AFFORDED BY MAY HAVE BEEN THE REDUCED ISSUED TO THE INSURED CONTRACT OR OTHER POLICIES DESCRIBED BY PAID CLAIMS. NAMED DOCUMENT HEREIN ABOVE WITH IS SUBJECT FOR THE RESPECT TO POLICY TO WHICH ALL THE PERIOD THIS TERMS, MISR I LTA! TYPE OF INSURANCE AWL INSD SUBR' POLICY EFF WVD POLICY NUMBER IMMIOD!YYYY) POLIt QLI MIPD/YYYY)r ' EXP LIMITS A x COMMERCIAL GENERAL LIABILITY KKO0000020180200 4/1/2016 I 4/112017 EACH OCCURRENCE -r34MAGErro $1,000,000 RENTED PREMISES (Ea occurrence $300,000 I CLAIMS -MADE X OCCUR 4 IVIED EXP (Any one person) $100000 PERSONAL & ADV INJURY $1,000,000 GEN`L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $5,OOC,00O X POLICY PROS ACT LOC $ OTHER: $ AUTOMOBILE LIABILITY4872885400 ANY AUTO ert5MDNS SINGLE LlI ,$ 4/1!2016 4/1/2017 (Ea ac�cklent) 1,000,000 BODILY INJURY (Per peen) $ BODILY INJURY (Per accident) $ ibT S I EIRENHULED -PROPERTY ,DAMAGE (Per ctccl lent) $ X HIRED AUTOS X NON-Mel/NE° AUTOS $ A UMBRELLA LIAB X OCCUR K00000020180300 4/112016 4/1/2017 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $1,000, 100 DED RETENTION _ - $ C WORKERS COMPENSATION 4082811 711/2016 7/1/2017 iTtJTE ER 1 $1,000,000 AND EMPLOYERS' LIABILITY If IN ANY PROPRIETOR/PARTNER/EXECUTIVE A EACH ACCIDENT OFFICER/MEMBER FFICER/ME BEF EXCLUDED? I ? f lEl. 1 $1,00Or°01 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE. If �ytes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT ,; $1.O00,0UC , DESCRIPTION OF OPERATIONS General Liability extends and Wild Cider Festival / LOCATIONS to: Summer -10/22/16. / VEHICLES 4ACORD Safari 101, Additional Remarks Schedule, Fundraising Dinners 5/14/16, may be 6/18/16f attached 10/1 if mare space is required) /16, "Into The Wild" ld" Running Festival 6/3/16 - 6/4116 r -- CERTIFICATE HOLDER CANCELLATION Weld County Weld County Commissioners 1111 H Street Greeley CO 806320758 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF? NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE etlate aiaidocliget 341wakilmst do 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25 (014/0'11 The ACORD name and logo are registered marks of ACORD MOUNTAIN VIEW FIRE RESCUE 3561 N. Stagecoach Road, Unit 200 • Longmont, 00 80504 (303) 772-0710 • PA (303) 6514702 To Whom It May Concern; In regards to the Carbon Valley Wine Festival at Wild Cider, to be held on October 22, 2016 at 11455 WCR 17, Firestone CO 80504, Mountain View Fire Rescue has been advised of this event and at this time does not require medical personnel to be dedicated to this location during the Festival. The event organizers have been advised of pricing options for medical staff, should they wish to provide dedicated medical coverage. Respectfully, -ilea (:/ t. Keith Long Assistant Chief of Operations ww.nivtzpd,org tracye Feu SJa Emergency Services Plan 10.22,16 Wild Cider Is excited to be hosting the First Annual Carbon Valley Wine Festival (O1INF) on our property' We are committed to insuring a safe and fun event for our patrons and vendors! Festival Information: '■ Name: Carbon Valley Wine Festival presented by Wild Cider a Address: 11455 WCR 17, Firestone, CO 80504 • Date: October 22, 2016 ■ Festival Time: 11:00 am to X4:00 pm (aicohoi served) a Gates Open: o VIP 10:00 am o General Admission 10:30 am • Anticipated Patrons: 1000 • Vendors: tier, mead, Wine., Beer, Food, Other products, Live music Emergency Services • Mountain View Fire Protection 5Miles O 303 7710710 O Notice of event emalled ! edougias@mvfpd.org UC Health Emergency Room 0 2,9 Mies o 303,678.4340 o Open 24 Hours o Notice of event emalled - infoQuchcoloradorcom Carbon Valley Wine Festival presented by Wild Cider 11455 WCR 17 Firestone, CO 80504 law Enforcement Jurisdiction: ` Weld County Sheriff's Department Email to: kcogswell@co.weld.co.us 9.20.16 • 911 Contracted security, services: • Big Al's Security Team o Address: 2649 E Mulberry St A-11, Fort Collins, CO 80524 o Phone: 970.825.5991 o Email: admin@bigalsecuritv.com o Contact: Michael Vermillion/ Project Manager o First Aid Certification o CPR Certification Wild Animal Sanctuary Volunteer and Staff: o Wild Anima' Sanctuary Staff will be monitoring all patrons for intoxication • Will not allow service of alcohol • Will offer additional non-alcoholic beverage n lieu of alcohol • Will call lJ BER or ZIP Car if intoxicated person does not have a ride • Communication Within Festival Perimeter: ✓ Sanctuary Staff members will have radios to communicate as needed o Cell Reception is available on property to contact Emergency Personnel if needed o ALL Volunteers and Wild Cider Staff will have a designated hat to insure easy recognition to guests • Patrons and Vendors can easily identify and contact as needed • Emergency Needs • Security Needs • Other If you have any questions or need further clarification please contact one of the following individuals: Pat Craig/Executive Director -The Wild Animal Sanctuary pat@wildlife-sanctuaryr.org 5003=53118 Lynn Va rger/Event Coordinator events@wilddider,com 303.517.2428 Becky I laitlen/Development- The wild Animal Sanctuary becky@wildllfe-sanctuaryr,org 303=S36-0118 - Adam Gorove/Owner adarn@wildciciercorn 303.994.7723 Mark Birkin/Owner rni@wwildcider.com 480.818.2337 Carbon Valley Wine Festival presented by Wild Cider 11455 WCR 17 Firestone, CO 80504 +i�cia!"+fki�'Kdll �i�Mtiyia�e- , Presentedby Security Plan 1022.16 Name: Beer Garden - as part of • Carbon Valley Wine Festival presented by Wild Cider • Address: 11455 WCR 17, Firestone, CO 80504 • Date: October 22, 2016 * Festival Time: 11:00 am to 4:00 pm (alcohol served} • Gates Open: AN]JYIAL_A-LLLtLIsccYN o VIP 10:00 am o General Admission 10:30 am "` Anticipated Patrons: 1000 • Vendors; Cider, Mead, Wined Beer, Food, Other products, Live music • Festival Grounds Delineation; o Wine Festival: * Orange Perimeter Fencing and Barbed Wire, staked • Two {2) gates manned at all times * •curity-tine {1) o Identification o Crowd Control o Security • Volunteers - Two (4 o Ticketing o Wrist Bands o Crowd Control o BeerGarden: • Orange Perimeter Fencing, staked • Gate manned at all times * Security- One 11) o Crowd Control o Security • Volunteers - Two (2} o One (1) on each side of entrance law Enforcement Jur'is+di tion: • Weld County Sheriff's Department • Email to kcogswell@corweldcod's 9,20,16 ` 911 Carbon Valley Wine Festival presented by Wild Cider 11455 WCR 17 Firestone, OD 80504 Contracted Security S€Moes: • Big Al's Security Team o Address: 2649 F Mulberry St A-11, Fort Collins, Co 80524 o Phone: 970.825.5991 o Email: adrraIriabioaisiocuritv.tom o Contact: Michael Vermillion/ Project Manager • Contracted Services: o Six (6) unarmed security guards or 2/350 patrons- estimated 1000 patrons c 9:30 am to 5:00 pm o Bonded and insured o Easily identified by SECURITY on clothing o http:jibigalsect ritycorrt,/ • Deployment of Six (6) Security Guards; o Two (2) at CVWF entrance gates - identification, Crowd Control, Security • VIP Gate • General Admission Gate • U1 (1) I\ beer garxie\'\ - Crowd Control,. Security o Three (3) patrol wine festival grounds - Crowd Control, Security Credentials and Additional Training of Security Team: o Military, security and law enforcement background o TIPS (Training for Intervention Procedures) Certification o Concealed Weapons Training o Identification Fraud Training o First Aid Certification o CPR Certification o P PCT training o Multiple non -lethal trainings ings as well as other weapons tiainings n ings o Bi-annual refresher training in all areas • Threat Assessment Visit: o Perform a threat -based security analysis of event prior to even * Based upon this analysis, a security plan is formulated addressing the client's security needs and any additions will be put into place Wild Animal Sanctuary Volunteer and Staff: • Alcohol Service: o ALL alcohol vendors participating in the festival must utilize TIPS (Training for Intervention Procedures) Certified staff- no exception a Patron must be wearing a festival wrist band to be served - no exception Age and Identification at gate by Security Team o Wrist band is then issued All vendors will be issued wrist bands Wild Cider and Animal Sanctuary Staff will be monitoring all patrons for intoxication Will not allow service of alcohol Will offer additional non-alcoholic beverage in lieu of alcohol Will call UBER or ZIP Car if intoxicated person does not have a ride • Communication Within Festival Perimeter: o Four (4). Wild Cide, d e, Staff members will have radios to communicate as needed n Cell Reception is available on property to contact Emergency Personnel if needed Carbon Valley Wine Festival presented k Wild Cider 11455 WCR 17 Firestone, co 80504 ALL Volunteers and Wild Animal Sanctuary Staff will have a designated safety orange shirts to insure easy recognition to guests • Patrons and Vendors can easily Identify and contact as needed • Emergency Needs • Security Needs • Other If you have any questions or need further clarification please contact one of the following individuals: Pat Craig/Executive Director- The Wild Animal Sanctuary peat@wildlife-sanctuary.org 303-536.40118 Lynn Yarger/Event Coordinator events@wirdcider.com 303.5 17 , 2428 Becky Maitlenf oevelopment -The Wild Animal Sanctuary becky@witdlife-sanctuary.org 303-536-0118 Adam Gorove/Owner adarn@wiIdcrder.com 303.99'4.7113 Mark Birkin/Owner mitry wiIdcider. em 480,818.2337 Carbon Valley Wine Festival presented by Wild Cider 11455 WCR 17 Firestone, CO 80504 tit M trC �! r' Pre5�naketi bar , Sheriff Steve Reams 1950 0 Street Greeley:. CO 80631 Re: Carbon Valley Wine Festival Please accept this as formal notification and information for your file forme Carbon Valley Wine Festival presented by Wild Cider Festival Information: - Name: Carbon Valley Wine Festival presented by Wild Cider • Address: 11455 l rCR 17, Firestone CO 80504 Date: October 22) 2016 ▪ Festival Time:11:00 am to 4:00 pry' (laikohoi served) - Gates Open: • VIP 10:00 am o General Admission 10:30 am • Anticipated Patrons: 1000 • Vendors: Cider, Mead, Wine, Beer, Food, Other products, Live music Contracted Security Services: • gig Ails Security Team • Address: 2549 E Mulberry St A-11, Fort Collins, CO 80524 a Phone: 970.825.5991 • Email: aclmrn rbigalsecurity om ► Contact Michael vermillion f ? royect Manager IF you have any questions or nOe+d further ddariftcaticn please contact one of the following individuals: Lynn VargerlEvent Coo rdinaito r events9DvAliCtCader,ccn 303317.2428 Cheers I Lynn Yarger Wedding and Special Event Coordinator The Cider Mill at Wild Cider 303.517.2428 Ackm Gorove/Owner adameilwilddder.cprn 30x.994.7723 Mark Birkin/Owner rri l@y Cider .coirn 480.212.2297 Carbon Valley Wine Festival presented by Wild Cider 11455 kiVCR 17 F restanee, CO 50564 United Me Services 91 Coloracip. M 8018E 68 AVE Commerce City, CO 80022 Tali Free: 888-232.8081 Local: 303-885.018' Fax: 303-985-1428 Quote Na,: 414,722417 Sell To: MIND CIDER LYNN Y. RGER 11455 CR 17 FIRESTONE. 00 80504 Gust #: US$434503 Phone: S03-517-2428 Lilem Deluxe Rest^o; rn Delivery, Setup, Removai Environment/Energy/Compliance Deluxe Restraom Subtotal* 2 Station Sink Dean very, Setup., Removal/INCL. Env renmenVEnergy/Compliance 2 Station Sink Subtotal: Accapied: - - 4000Pir 4 i -=.- 1,-.. 4., it t Site Service Quotation Curate Date: 08123/16 Sa k spa gp �CC jct Ronald P. Kelley Mobil0: Office: 308-22Z-7023 x27023 Fax: 408-578-8284 Roneld.Kelt ey@ u ni tedeltetervicea sc om Quote Explies: 00(22/16 Ship To: WILD CIDER 11455 CR 1i FIRESTONE. GO 80504 ASV: LYNN VAPIGGII Pltane; 303-517-2428 Terms: Due Upon Receipt Unit _ Quantity, From f itru _ Unit Price EA 2u 10122,119 10fr22115 80.00 EA 1. 10/22/16 10/22/16 0.00 EA 4 10/21/18 10124/16 1 10/21/16 10/24/16 Cale: Ramiro: UnttS Site Sarni , PO Sax f32Gi, Phoenix. 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D'irectx O4Raftriont d Revenue A CO WO CERTIFICATE OF LIABILITY INSURANCE QI%T6 (MA /11INI vrtI' tl9!O2/2O.3 6 THIS CERTIFICATE IS ISSUE° AS r:4 MATTER OF WFORMATIOh1 ONLY AND CONFERS NO RIGHTS UPON Tile CORTIRC'ATE NOLDER, THIS cER•3`IFICAIE DOES NOT A'FFIRMATIVMY OR NEGATIVELY AMEND, EXTEND OR ALTER TYNE COVERAGE AFFORDED THE POLICIES SELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REFRESZNTATWE OR PRODUCER., AND THE CERTIFI .ATE HOLDER. IMPORTANT; if the cerIlliciAte holder is an ADDITIONAL IN -MIRED, ttta polMy{ies, must be endorsed, ft SUBROGATION IS W.A1VDC3, subject to We moan arid conditions' <If II1w potty, cep 4 0 policies may require, no andorskrnenl A statement art thI; certificate does not confer r1gh1s to the 4cnillcala h osr Lit lieu al such antlersenr11tnf1'y. rs1}oaUC.ER .. - Veracity Insurance Solutions, O.(;. 2fl0 South 2500 West, Suits 30 Pleasant f, rove UT 04062 ammo Mile High LabtterShack, Ot3A Mime High Lobster Shack 5S2 STRACHAN ORtVE FORT COLLINS CO 80525 fi FLIP Program; Srrmpnrl root Acipaylrf,bl r'i # I YI i`+ q emir r;ghr 9I R! ILIU$Iu MrWOW C04VtIRMIL Ari:►t�r4�P•M_ end 4At-inul!wird UPI Ainc+r14randoetntilt rat. Lkx#,r q. 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Schwt+rk if rictLit 4p,nrml, rwiradl C$rttficate holciei had been added os additional insurrad regarding the abovt� mtchtioned policy jiet-attat;lle+� Additional - 0e -signaled Person or Organization (UU2U 26, CD. 01 13) C IE.TIFlltrATE kfolaei t _ - - CA CC extA IwTKIN Wit L3 CIDER 11455 WM 17 FIRL:S'i''ONE sHAUI_r) ANY OF Fate ABOVE DP -SCRIBED POUC►E3 BE CANCELLSO BEFORE THE CXFIFATICM DATE nuirtf CF, NOTICE WILL se DELIVERED IN ACCIOFlr5At•ICE WITH TILE F owe pR o vi6cd4.t. CO 80504 lurMtoll}i • atttatrlir J IMI-Dili ACOPS CpeRFORAwrier. A0 rights Teawved 1 ACORT) 75 (2014101) The IkCO RL1 name and Saga sat ciliaferad marks of AGGRO IN` O if -0141T! r s DEPARTMENT Or PUBLIC HEALTH AND ENVITI0NMENT `t:555 North 171'Y Avenue Creole CO 8067,31 Web www wart l(d pr!!r t i i•,ii% is, auiEs.. li ( } I e 1111 �i0rs ;06: L. s02?'1 ;(M -1,-o4 k5 rac t,a,1 - • J4 -r4 i t \'f j N IDO R A, P' P IR.' AT ()] FOR R. 1" t -;.,'w1 f't) R l\ t fir` FOOD OD Li 'tpV' L N I S • . .I .b04 b [tvennt Name; + l':\ 14, V 'I �I�,'� la"Ita: a compjete the fullow-iiiag lnkrrnttiirrca I &ic:tt ii (�tciiir;e%%I f I�itjt of E:�fc:tit r.. C.'" I •yy I .Q r ...1.1:17-1:-.1.,„:._ it,,„:� • • . • • : M IL �::k \c- .i • � , 4 ^ I`our ittitttl' Rcr:�wi riot' I t.ih .f1;wiyuuak1wt Nttrn42 \Viiich ccluilt% is.'; icd your 1rc. p,c (' urttnet Nzun e II•il . 9 -I iii,sa. s . ..i__ 1. ' Lit { re[eph►one Ntin then ( Prior 141 went): L. Q mailing. Atidrt s wr LiSjail,„:1/4.duz___:.1tAi s," loe_t Ses, ` 0 youth)! 6 ...J 1 1. L Y {s iI 111 .. - raj m awls •I j L: -Iq;t J, &:. yj1 ylr ?d�) f r. I. X11ci ;i; a," Li 1i ew- I o . Y r C j ai �j 1-iI1l:i r 111:111:1 u ' I' -kilt!- -, i ' i vSkive:. fir: L' -Atli fli it ti -..1'.. 's.. /{.. � ` r : J IrrIe� L t. 1• ifI 4! �``aY 5l l.`la'� •.?5 MI volition; III4J, 4 to+t°ide iikitiutat trE itino of fiee l!i.hre or t14IIR1-_i y(it s*atii _ Typc of Vendor'; - O1 !1p i.itirilltg hirx I t 11a8e mamlztch, t� ct� cullJ duewnentadicen L iCtil %ttl�I 'rely ly e(ll aty t vent lyren oi� d - — _ I it,:wisedMobil!: Unit 3rin1-i)rolpt (iIrt...4 icie tliftunicft tti«ii) Lei S Q at S [ ' s uu don't hold {* Fv'uinoi'-an [vent : titi R hall. F, Lf Estalifibihnient kun It- pfegise contact the Health l trl)alrtltitft- t 115. Please Hsi any additional events, and dales that you plan on participating in l .'a id :`nuts#•' 'era name } _ T��.iz4 I_c'►olkl.tflt . 1I.•• e... •-- FOR HEALTH I) PAR`P'MEtN`T tISEE. J icenRed N".,{eods tl license Ncinalit'ol it _� --- - 11%?yR(lk.I ' (.'S 'NY). 1'. )ar cc, 1. .% ►N /P/eo a crtirrc 1 crre"c.�ttltr tirt,� ��i��c'x. co; fc•c°t' V cir'%: a Initf. t! list all rood products and We specific source plan 101 1] ihciiis ( name of Y}int:I�r y chain_ whrskinaler, etc.) Bt.; sure to include items tircii ►&S tonping6 and condiments inodl usual BBrjn1 Items Etsirru kk.:: Hamlour ers_ I.s;riiii,l Onions l . , . ~ _Eck' 2. 7■ 9, R • 10. 11 I, cgici i ii vr'!lit y I trl1trr i neil (. rocIh r -c' Noire ii. Chain Strain! II :),a • k '2, -- — � r —a se:■ 4 It 11. HANIJ b-N'rtNH j 1 A\' 1' FOOD i. ANDLI Nx A hand -t'c'i hint; st;abyi,n 'ATI I IR each ht intij tar twit M;• R Lk II(J i) unless only prepaeam,cein y i i g Preparation and . { ri- tO411( li g :u Q10 I'*r1 soak, etd, Plei rsc: vI rt, ;k the space hcitm that r..ijipli s to your booth, wn 1. ❑ I Win Ka: ; eryiH tink pi'c'pack.liz•t4 ftnuJ ; that iv.clti.r't Iltt pr��?irra ik"113 l�il11�11111 ! `-lttci'N lliti Ili; be ser'v iatg i tiiods t l c lr t req u i re pet pu ra l i OAS., hind )ing, 4ftdror t oidk 1 1 t� mud will pro % rcl l: Liu: fi filt�+.�rit14 fir livid-wu hinm: 1.) a ram:limiting' ur ' ".alJc'oris pH\ artn pntublc w atec that must tic rein 't.i lictckd soap ct 4unLEiincr'fa hit a 'liands-L -cc' spigot .7 2.) odap 3 ) p[rper ttrski. N 4,) 5gallon bucket (i i nimur ) Co catch and cumizttn v a:44:ific atc.'J' until it is pri pr rIy' di .p i;itr� A.•t`'E ''•cuarrtl_ttes we .\-'O ewe accepinhh c' Ni.thisfifide /.{,r 1%V/fretI hared'-%rr,x/l rig ';t 1-ar/c icnj 14 ii] you ptvvent hare Ziongs 1•'ood-irwndcs t Deli riksucs. Other f list) 1i5 turn() contact with t'INI{ . to ea 4 1rn►r1s fat bath the commissary x4111 ail the Inert) Jisrat s -title ■ iUc S (Nutt: if gh )vics artir changed haiihis innru'*t be a c)tchhed) 1 IIf, Foot) PR E Q' RA tiON A 1i CO, %IM1SS A RV Preparation at Approved !acuity or Commissar Before Event Cheek which prep:minion procedure eat.•h menu lion requires Food I t p te: Iiam n r•gtn E t, p•ie:Ontions 4. - 1m 1��L iy sk� � r, 1r, per. , ^1� �j �.V� , "f �� 1 e .'a.{.yti.'tii.+.r.'i, " — 1...4iii - S. , r 7, - .m -o "ohagel Feint' Womb Cook) Rake x 9. 10. l x .9 1 o 6 S• r Cool Reheat- eheat- I ('4)I4l - nut u t 'folding IlokhnG , x 4 1 =d, .311 p What as the name and location of your commissary? (Compleku C"ontmissar • rkgrceinesi t too i1u .w 7) Ntune or C:on,, nisi:u' ., ;` .•. �,4,,,,Li Address {IC ( unimik,sars City Slate/Z.ip 03 4. 'ovum t�t� ; - - -- Protlatcey l toy. , tit'i1i peochtce h'. pvepat'..vJ PLiul• to use? ((mirk all that :rppi ) .ry Cr' t. s 4+s.• 1 M f. 1:1 Vv t<,c,4a produce in ?-uod preparation :5mfw (� Buy pruchiet Fii c.4w. acted and COL at c om71n1 ksttr \ ' BUS: product pre•-wc,wa.shed ind pre-cut p (Hillis (specify) y) [� Not \ Natil F� �t3,1�.• Thawing- i l t foods teed to be i ik a '- d at the commissary? V rti es, ansiz et- question b: claw I low will rrozcn roods be tliawed`' lniur; all thus apply) {� Under rel`'igtiration Q Under t-iiol cunning Water' As part Of'the cooking process. O Other (specirof) 0 Not A ppi iczth le Colt.. Holding -- Will foods ha cold held at the commissary? % krtici It' yes, answer question below, Flow will roods be held at 41'1= or h&ow? (mark all tfirst " [ Walk-in cooler nr freezer Reach -in cocilvr or- t'n zer in hi cooler wCAI) ieu irranedintel; 'r tttmsporl to site Otlicr (SNCi y Hoyt Holding - Will fowls be hot held at the commissary? it If yes, answer question below. How svii ill roods he PwId at 135 degrees or ; aw'' (mark %iII that dq;l)NN y o Steam table El Reach -in hoot hox 0 Oven CI Other (speeif\ ) 0 Grill Cooling. Will fonds be cooled at the commissary? V griti _a it yes, answer question below. Flow win foods be rapidly cooled to 41.:.F or beirro,'? (mark all that apply) Q Shallow pans (Ie5s than 4"i in rii,'t'rigcratur or cooler Q Using an ice -bath to cool the tbod product Q tee paddle or wand o Other (specify) Reheating-- Will foods be reheated at the commissary? V N , I r, e3, answer question below. Flow will foods be re -heated to at least 165 degrees F? (mark xrirrhnt apply) a Microwave p Hot Plate o Grill O Oven p Other (specify) MOP Transport Please provide the distance that you IA ill be transporting food to the event? What equipment will you use to control temperatures during transport? 0 Coolers with ice O ('aunbros for coil foods o (-umbras far hot foods jZ Other ( specify � _. ,�., ti ti s__ Jte -1-1/2/a1. C trfEl erg 10, 4. IV. Fond Handling_ at the Uvont/Event List all menu items. inclbd i tt a beverages, to be served from the zemporar3 food booth, Chock vs hid) food handling procedure each menu item requires at the booth. Food Cold Holding Reheat' ('wik1 Grill Example: Hamburger Exam, ic; Onion I X .X flot x Asseaua h1e Sias- Crata.king ;ii ,lcit t��lt9�i� of Fluid ((ems I I. I IOW ww ill these limas. he coked undlor reheated at the site? (mark all that upply ) *Grill CI I lot plate 0 \dot \pplicabic El [deep fryer 0 (hen ,❑ M ierim Ltvfe 0 Other (seer -ill ) 2. How will lint foods be held at 15 F or above at the event? (mark all that apply) (Stern° burners are prop ibi!ti d ) Q itot holding unit 0 Steam ttihle ❑ No Applicable ID Held under lic tt lamps isicsScrsia timitediatcls lifter cook ilia ❑ Crock -pot p Held on :aril C until served O Other (sp►ec i l y) What utensils will you use to dispense or seat e the bin items? ID fangs deicr s) Not Applicable 0 Spatula ClOti Fund Items I . ! low will cold tkuads he held .at 41°F or helmti at tlw event'? (murk all that uppl ) Refrigerator t freezer ❑ Not Applicable p lee chest - "me se he drearracrble find finiels urtn • nuf he • /Cc& i n crn uric. / with the ice nr1 ti_e Met' t' wv packaged and vwwaled p Other (speeirv) 2. What utensils will you use to dispense or serve the cold items? on s 0 Ladle Spatula ,p 'Other (spec i h ) '' Y41 • y 3. What kind of food thermnineier (O-220°Fj tin k(o1) halve' fetal stern probe D Thermocouple 0 \jll \ppiic ble ` V. Cleaning and Related What type or Sa nitizer will you use at the booth? ig Bleach at 50 -?till PP' �I Quaternary Ammonia at 200-400 ppm �❑ Other: _ Note: Test strips for sanitizer in use must be provided and he i n-slie Where will utensil washing take lIiace? ❑ Commissary 3 comportment sink ❑ Commissary dish machine CI Commercial 3 -compartment sink Unit (part of unit) 'hat type or sanitizer will you use in the 3 compartment i,tk,? 'I leach O Quaternary Ammonia d °the i O Not Applicable- using dish machine Where will washnvutcr from hand washing :Mid cleaning be disposed ol? ,❑ Corumis ;ar; ❑ Appro. ell onesitc receptacle at event O t thci 6t ;see waver CANNOT he dumped on the ,gro roil or into von'' eiremnS ti `a/CF must he placed m t ppre;itt7I receptacle or .tianitary. wirer Please litre NM from C %'tflhn cofafl ehirifrtt' r 'here ii,t.s r.w' fin -at& tier• eat' ti ererr/ What is your booth plan for flying insects and dust control, if applicable? ROOM.LAYO`M ■ AND MAP Provide r drawing of the Tia:niiiisra The map shall include the following: ❑ Cooking equipment D Hand Washing facilities ❑ Food and Single Service storage El Customer Service area t e Food Establishment. Identify and describe all equipment, ❑ Hot and Cold Holding, equipment L Work surfaces ❑ Garbage containers 0 Summary Paragraph: Write a paragraph or two about how !our rnperatiun %%darks, What is your booth plan for flying insects and dust control, if applicable? , ir ` r' de- irI 1.4 Ik re BOOTH LA.VOIJT AND MAP Provide a drawing of the Temporary Food Establishment. Identify and describe ail. equipment. The map shall include the following: �'/ WCooking equipment rHot and Cold Holding equipment :jelland Washing Ga'il'ities or, pork surfaces po Pond and Single Service storage t: u rthuge containers ?Customer Service area 0 iatior ;�+ 1.1 i4 r — 61,34ar,,M-9ti o `L 4 ce c/ usi I t3t A oe.f. a - ID tAicor Ore. 5 -cite ic .. t:' ent ` seij iCr`tijiCf46,f tr.? m,‘,/ AVMt�\ ` y C a� 4-% k ' e; (effr"()r i \Lrg (.c. F. Les (in Tlie* + ,b , i _,O 1 2_1 aleSa I 4 I -co, w-kt-tpbo • rl Sat., t+..S 44 Li , ti S I 1 its ---1-k it 7 7)1 is ail, rise r T •0 4 f` (lc!! s,) I_-Cr' if r- 4 • 1—, .y ``\ in..2 eh__ hit (4 r L de K� t t rs K5, ,' _ r+p%.� G • 1'J '4+i Ilkti'I1-r`' 1,.'1'i1liLrhtiht4i .1 1111 1L 'i+.it,li1l fl 1�� el. i 1. Wad? diktat I,it /14 1 t fie ti(d.lerfrupo 1rtr.'Jddl'� 1+111'- I )�I' ,'.(rlltl{,-llt +11 Itld!', II J I I�111 dItLI J fit It till I '.,, , / I" •, - � t11�4'il `•14111 I ,t ! • Lat.I I I II hall 1/411- SI Yti F1 tlF ltl 1+I + ,'1 , ll FA( I I 't: I tiCt16l:.IIltmt1 IIIti t11+Ik'• !I IYt1! lire_ , Itlt'i1tti L.111t111 �tl`111°t;t'�li !tlt'Illlitt H I}I1 HA 1t 11kI t i'111!.I,ft' It `+ ,•, !'tt`11'I; ,•1 I I '•, ti SIM,.`til .+'''l.1t•' 11 11"1.11` "11 '- I L• :t :YI'l1Y it It" ' lM \ { ;II?rL'.1 \jyth„.`, ( ' V"! V ati:'I'•I it :111'. t` \141t'1!t.!'1 I I•I'II I ?iI ?ohIYIIIt'lll Y $' I : ' 1 : Iii <Illt11111 �1I Id'' illt` 1�1L t� . 11+It.',` :i1Ir1Y-• +tit;. 11r I ',. Ie Vt'I 1i: .I a \. I.:I:IIlI-Willi rt. l,'t'q' 'UL' tlltdtidY'F,t�t.,ti'ilt f IU 11L,J 111 I'ICISI-111 'Jeri It Ill C Il1l,;..1 71101042' 42' 1111 i I1]il'II i LL-ril!�<.It • ,, I�ICt! Ship • r1 f 1,:1111 • 'Hillis* (iii,'It)`L±.I(IiI I'..{1111:: iI'f(ti1'tlk t-'+,i %%lilts.' • , 411 ,` , 1lt; ':Itic M :t"°Ii? . I!" t' .. (ll::tit.'11t1. 111ud1 hill I 'Aril'' I1.'ll•ti I11,,:+ 'L' 1 :li': L•Itl,l hit• \ I;IItilu111,1. Ito lie/ �l 111 _ `fit ,Ud •+1 •• I •I l rl. 1'1111 1 I 111}l L.' I o 111 11L' 1.1,' .tic I. ill 1•,_1'1-.I- h.iIII111_1{, I 'dt+£d141I '',IAN I1_ 1•1.11'I.,- I 11111111141111 4tti IL ''ti IrSk ISI d III; t di' ; 144b. 11/1- I. ii i' 1 J �k t• -I 1 •! 11}1 I Hid 1tt I Ji It I •i, 1 r, - 11• M II t A FFI DI I T - RESTRICTIONS ON PI MAC BF N I: I I s I;-. sk s+ 1/4 ' t LOA, tN IIIL' ‘M'Isll• '; I •Iii'r.ttls/ V`1.:1 I1 111,1 ", i j I111, ,l t II11c;ti1 `0,Yt, • •1 17 (, -At III +I Idt'IIIV.IIJC11! I•.;: II?4 I "C..' '+'.t;, • lilt �iik1 IItIF\ Atli" I:1i+ tll 1111' I Iiil•,:Li "+iiiI F',la''1. Elul 'I' I .+(l'i•( 11' , I tIZIiii.i tl:Iiill II; .II list . 1ti'Iii +l.l',.i:t4."I • I'' tl•.jkill l c't'7 + I ,'1 I.tl c'•. ' ' .1 I YI 11111411.'1\1:11)t1 tli.il "I+IIL I.IN% l';.i,11.11d!'+- 141;- II' 1+III\ i L' 1'114, I dl1,,l: I t,ll •,, ' Ljd :I 1 1[1 1'l'ct:-1 i III III, rIII7:; !'ellt•rrI 1 'III 1'11.'1 1..,0191•><1 itI'_.. 1` J Il :11_ Ii 11 .4 CIl1:IIiCIll ++1 IC`I11'L'-+L'fltLt11/+II III II 1.• totillrl Ill'tLit it -, ski 5 1,11 ' ''',''• 1111 Llof It 1+1'1'1{11.4 !II IIIt• .0ct'I O1'_'rt•t Intl : �flf11ii1Jl I'11.'11�t' .+Li" 1111';' 1 r • � • r 1 J Y 111111 ', I L''?':11 ++,. ; 1111 : itin 5 Sik' \ti fr .%- J - I I e1+ Ink's.'" 184Y." I'll 1;16 ''491``1= S• Ir.illltlii: 'Y'i R iyI!�i� w AIM .I r !r; • I I I I'ld1:n Ii W• Olt 11' ' I•I +tl 1.1 -• rl...l II r .:1 "I 1 HealthTri-C Department COMMISSARY AGREEME T y_,_ 1iipbiI ' Food Facility fDA I Mobile Food Facility Owner :'1 # 6 Address I Pit'1.c T' Co mrni..xar r URA mi jitawitssary Owner'' i' NYaille , 4 rr,d .C 11 r r 7f^ r' Address�... �...� ' u # 1 ' ' `t II Phone. MilMis t ip; states ihdt het/she has your taeinli sion to use your conimi s31y/food facifliy'hasc! of Koperations Ibr !ha purpose of wiring food and supnlios used for the mobile food faciliLy, necessary preparation of rood, farm, unit will pntahIc writer, cleaning of rifo. malt, anti damping of viastewatcr from storage tanks, This is in accordance with the kmg gOVernin g mobile retail food establishments 0r pug 1 eartt; as stutc.I in the t.:alrar-tardri 4ta1tVolni SUiIttt1l Rion and kliw.riI'u irrtpi r, cttrm �y,,atar7i. To qualify in an approved commissary, you Taw: I. Pros ide approved, food grade hoses for potable \It UI el" sup p Iv CA: mobile wins `} Pr'ovride al) aptalavecl arca i`cIf the storage and pt eparofiot of food products and iuppJies, with :approved, properly ITi installed equipment. nt. . Provide an approved ai.0a with an appItnietl ;-compaitalent sinkkli hwaslrrj fbi' the washings ii11sit;g, and sanitizing of' utensils and ttquipment 4. Provide :llt appraiqed mod with IlooI citilins fur dkauittip+ 4 ikl lllu iutella'It {; off; €ilc: II L1b1 ' food ticBitty_ 5. Provide direct rlc'ce:3s w an approved floor sink for pope] waste.cval l Espos i fn nn holding. tanks. 6. Main t. Fn u valid Retail Food Establishment Li tense: C rer Qt3Mit Sary /load ti eU hty . 7. Post aid Maintain a daily log (cheek-iilrout) sheet, the mobile food facility owoer must sign daily that tf3ey are usi It1g your comma ssait. and you ni wt sign daily verifying that the mobile food facility fuses your coi11mi gsaay _ liviairtiain yew eo c Ii nissat 3D in sat i l ate to :D condition as determined Lw dw Local Department. Once the Are in& food ac/li y has been approved fi?r //eerr,'i ng, you must r /so agree to nosily the Tcr-CSi uv Ifealt a Department f� f the above formic( rted mobile .food facility hitt two` Wilfred yourfacilitr. u itiq a!rreq, afile three (. a r.gn,Lic'rulrv'c days. roil rr1 ust lr&o cent)" r tinder penalty of perfidy ',hat you, ore the legal of viler artde'r3a- raptr'ratIIr of OR fu rsrd. (etch& and wilt oubiettr kv the conitiin of this tcuer, Sitattiure/. _ Print ilarno z Dam -C 'Y >.,■ Al.1111,EIRMENTLET E V '..w11$.r BE UPDATED I\NB L SU 11M'TTEO ANN' -7 [RILLS: renn ;Iii lit,‘ 5 31 r►Q] STATE OF COLORADO DEPARTMENT OF P Untie HEALTH AND ENVIRONMENT 255 �U ag LICENSE TO OPERATE A RETAIL FOOD ESTABLISHMENT AIUCC3tJlNI NtJhWIFF} ____! all rl00.7.0R;.Sn 1•f 11 i L4el Ie1rY 1NF ��F+ih.rlik fti?t� ri ry 1• 31214 r'1-611011 14 MD I " 04 THIS LICENSE MUST [ E POSTED AT THE FOLLOWING LOCATION: M T F OS CATERI • ; MOBILE F'l..-AMINC SIB'S ll'lA I:' V 3515 CAR4WiS I, F.\ COLORADO WRINGS* ( 1) MD917 .a . 1 , "i•"K)L' aIle NIT IP 1/-1,120 m• ..e IC1ENhr /AL tLl 1F ; 1 29 I r1 !"1ili� i ' int hceolh .e 311! bs' i k rtlor 3uihc,Ftzn.I and :lcan ;et# ! f oncizs9t rt;,un A. r _I%flcir;11� ': r Il ie iaye and rE<, It 11 t) :5 0~ 11 x: !;;3irtrri:I f �IiR1P.11t of Puul r tr��aii1 viii„nl rrnerll Any i eru1Ie.)ira "nd fr C I�r �;t.+= avttl autotnapt.Ati(I .i, ivy ►r�lll 311r1 . g);(1 POST IN A CONSPICUOUS PLACE CE U'. EICATE of tNSU N V --- ry ISSUE DATE I_ 'Tait t_b RTIF1cATti< P13 ISSUED AS A MATTER OF INFORMATION ONLY AND CCNF ns NO Flit-l7s U(VIQ THE CER1'.IFICXJE HOLDERS THIS ECERT1FIcAJ'E DOES NOT AVFIRMATIVELY OR ME.aAnua:Pr AMEND, EXTEND OR ALTER 'ME CDvERAGE AFFORDED BY THE POUCaES BELOW. THIS CERTIFICATE OF INSURANCE 00ES NOT tONSTIT'UTE A C©mTRAct SETwEEN THE ISBU1PJ13 JWEURER(s). AUTMORLZED RCPR.ESENTArtVE OR PRODUCER, AND THE CERTIFICATE HOLDER. JMPORTAt 7°• IF TP4E. CERTJCATE I30LDER IS AM ADDITIONAL 1NSUil q THE POLICY4IFS) MUST E ENbORSEa IF SUBROGATION IS WAIVED, C �=1 TO TIME %IThIS ANC CONDilioNg ME Pal.CY, CERTAIN ph:31.1CIn it.AV REQUIRE AN ENDORSEMENT. A STATEMENT ON THIS E+t'I`IF1cATE DOE.s NOT C:CIWIFER RIGHTS To Pig* CERTIFICATE HOLDER IN LIEU OF $ ICtI ENDORSEMENT,(Si, PRODUCER Northeast Agencies, Inc 4467 Main Street - Suite 104 'Mlliarn ville, NY 14221 at.,64,71o16 Maine MINIM 1NSUR.ER(S} AFFORDING COVERAGE INSURER Al Scottsdale. Insurance Company 1NSt3RER B: 11A INSURED INSURER C: Matthew Spain , dibla Mateo's Ca'ta ing 3515 Car•ou,sel Lane Colorado Springs, CO 80t3-17 INSURER 0: INSURER E . N/A VERACIES THIS IS TO CERTIFY Y THAT Tii4 14C CCIis OF FW IIRANCE !AWED FillskalIA1 PIAVF Mail ISSIJfl1i,. i) T1F a$1SLIkal NAMED ABOVE r tR -tPI POLICY PERtiikU INDICATED. NOTW1THS TARDIKG ekFi'lr REQUIREMENT,, TERM DR COtanniON of ANA CONTRACT OR OTHER DOCUMENT Vim PV SPE CJ TO WHICH 'THIS CERTIFICATE MAY 9f ¶S&UED OR MAY PERTAIN, iwE INSUR*ICE AFFORDED SY THE LCCIES or-ScR a :� 1,11REIN is SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITION -a OF SLlr i-1 POI,9CIFS LIMITS SHOWN MAY WAVE PaEER REoucEn, ay PAID CLAMS - IN _.a LTR 'GENERAL „LIABiLi FY TYPE OP POLICY INSURMQE AIVVMEIER. f PS24, 400 FFERSONLAL LlAEOLTY EXCESS L)M3ILITY await I POLICY EFFECTIVE I ATE 5/1/2016 POLICY LI wMI EXPIRATION DATE 5(1/2017 GENERAL A4GGRESAW, PRGuucTSCON rcp AGG . fpeRsrmett 4 • C V ri+rltilt₹Y EACH OCGURRE;NCE DAMAGE PREIA RENTEll TO litU MED. EXPEN%. IlAny'me Damon) PRoef pr? t icAltvItiPa r `(u ra!+ 'my , I 4attmi t ry iTEJh4 1 2,1100,000 1,000,000 I COO 000 1,OO0.OO0 100.0000 FOOD COMBlra€o SINGLE i4MI r MEDIt.I. 1. PAYMENTS TO GTHERS ECHOeC:tI RENGE. AG iGATE BU!1,D1N(1 CCNTE/CS E3ut±NESS Pucome r _ Sore Push Carl Wild Cider and The c arrbrort Vai'Iey Woo frslival ,am cam:! nddiliarid irwfet+s with r-Etsped tq general 'aability r CERTIFICATE HOLDER 1+lld Ckier and The Carbon Wiley Wine Fes1M! 114551r1WCR 11 firestone, CO 8O5O4 Ann An PJ r 11�rE AaiYiru- bE5t Htev Rotas .ice cMica[ SE oae "Ir E .XPIRA i DATE tHERUDF, NOTICE WILL, HE FDEJ NERED IN ACC.O11411OO4.1E E. WITH 114E POLICY iti ' ISa , : AID T k i R.42 o S LIVA TIME deaavaidev, Department of Public Health & Environment 1555 N4 17`h Ave.; Greeley, CO B0631 Phone: (VCI) 304-6415 Mobile Unit Inspection Form Dote; length of Inspection: Pagel of , s'tab1ishmertt: Type of Inspection: ttegulp r / Follow-up Items circied below Identify viotaittong to be corrected lc round raw animal mooch ;torrid above ready to eat feuds. All raw animal foods chaff be stored below r-eady to ear foods 7c Obtaiwel erripioyea :haraging glervet without ;washing ltnrrd; in-ieetareeri donning new gloves. Food employees ;hall clean their handstand' envied portions rF choir arms Immi dialeiy ':refore donning Single -use glove.& for working with rood, and etween removing gloves and putt ng un ;:lean glom II Corrected Omite eourlst employee dfinkfs on - _ - _ _ An emplogyre'e may drinK from a clean1 closed bevSrag,e lion Winer' i i it Stored to prevent contarnin tian of Food, food contact surfaces, equipment and 51r+eta. Sfertii'ice articles. t� bserved employ/Be touching ready to eat fond with here halms fare hard wnoet % MO ;lady to ria i grid! prchtb'r~; ed. Ic e 3f re,eurrd hazardous /nada citiall be WO sot 135 iegrensF or above boars, = The temperature of potentially Tami'*a, -2 PIP F 11 temperature for more than 4 Pnw'rd ----�, F [he temperature rr1 patenti ally n.azat slam `cods shall tie held at 41 degrees F Or below Fetid was ra rxff 13Ff temperature far snare chart A hurt Found do fr}od probe rrt1t mi?Iur an �lte A calibrated lox, thermometer with a numerical Some 0113-220 F ;hail bt! praktitierl and acs es5rttie at Alt ttrrie-ti / Found Ito thin rna$4 pr:)0d thermometer cm tirte. A thin mass pi'ddkiur !htM;=K.rrrr+kir� sh dI Gip i►4tlr riti if cps krr!! thin r t. 3q.« .mod i �, � s �"-Y u- l_ ttiritr�Ss .i.�rfti How: 9 4' i maid! ateiy toned 1 1 _ fiit�+dt 3g Facility round op -crating with irr.achaquate equipm nt to maintain ternperat+ure :q irltaUatt equ uwwrn in&iI a t plot/idea to nwrncain !area temperaturrar ? Facility tiorzs not htitve aiiet}trite c!quiktrt en1 ro prct?r.t food Crum Ccnrannnatton ;nod preparation shalt occur at r:orrIRtisi>~ar y and "tart rcWWSite 56 Found no wit vault r' •;:qiii .tap at hand sink at ,fnle of crisp ctiwrn teat acrd cr l water she I( be prnvi led at all Lima( to RACLIN Or,}p r viann,rr , OA take caJace *AC 6c Found via rt.11+-r - Titelq ti%11 at parrd slim Handl iwxs shalt tie; Eulitalkydhufrfl 3n adequate iupply r1lt soap 3r e! paper towS at MI times r i uund Ian -Meer green ter 2a0 p}3m 'at r,,hlclrbnfi. aattilti;er SI;i I Ile bit:MRCP 50 2M pprn Found sanili rer greater than .I@U ppm cat quaternary amrnunla Sea niliz+er shall be behvnen LSO -400 pp i l tit Found no rest Strips for 38 nicker l!st -Wigs for $anixtia r moll %1e ailadie for U-st at all times. 12d Found sanR12er utket 10th tats than 50 pprr of r:hioririe Sanitizer shall tie between .5tflOt) rpm Found 5aruittzir bucket wrth l,e5S tarsi l50 porn ;k ,uratetrnantarrnonia. Sanitifor slat! tuu between 150-dICQ rrt. 1111 • Single use utensils found with food contact surface facing CttstQrny/3 Single use uten5iis shall be stored ir, a manner Ls, he re : he handle faces Mt, cuctalrs-let 14a fslumbin - found Iaaklfig Jt, time of inspection lalurr,t�it�g;laait '7181 n la&rted Ica s t d rP.t77 h .kdcittlonal inspc?cUgn remarks: I Si -r Environmental fiealtli Specialist Rec eived By flnvr_d no Om iti;ilescion this day the 'NIT'S crtcied d►!rttilie tbt ytoLAtloit m crperabcr: rn lacnires that mint ce roarerteii Isy !hie rely;! out.ne inspection or cuch shorter,pertoc Gf rim a as irli? lfe ;pecifiN 1 in wiling ryg the rngcrlatnne 3umorit r F.iiiirr= to {rxrnpib geilh arty they limits'ou sar[ecttans ;pacified a 'Ate notice may i rmuir rp r ess:Ouan at your low, eenrr:v capc''raticns DEPARTMENT OF INTIM HEALTH AND ENVIRONMENT 1555 North it Avenue, Greeley, CO 80631 Web; w, unk al'th.orr Etwirctinwntal Health Services (9701-304.-64i V ax (970i-3044411 VENDOR APPLICATION FOR TEMPORARY FOOD EVENTS All veucloss must complete and 413f)rut to Event `door thrtaior fat each event in Weld County Lim teams, alai no ctquiprnent change is occu rjug from one ecrezu f.0 another, the cc rripieted original may be copied. Please attach a copy of y rm r current tcnlpontry e tout or mobile Una C n l orudo Retail F pock E atablishm already titans -eat Event Name: Caidten \b'k "JJ'Apk-in\ Date(s): Cap -ft Pb Location of Event (address); R s 'lease comptele the following Inl ation: Hours of Event_ Temporary Retail Food 'EMMA nName; _.. . i_ousieo iFL 0 c( Truck: Whichcounty issued your license Contact. Nagle.; s foke.,e/ u Telephone Number (Prior to Event): Nettatt EllAg ddress: ri ry: State: ' ij► Cbsicskacco Crier( ie_ *Marna _ vn , Trf COUV i LOL,uc.ouvl+rj, Lid I i di) kletisalYnOdaa 1 I CO ni Cell Number (During Evt nt): 3 cg.j r- 7 .R. *MI vendors shalt have the original Colorado Retail Food Establishment license on premise at ail times* . -ten don nest provide. documentation Ut ttettamite or non runt starts T. t~ of Vender; _ , Check appropriate box ! have attached copy of clooriapata.tion Licensed Tezn r E-vE rt Vender 1J _. Liter sett abile'Dui t '' A •on Pi()Et (provide documentation) ._ J !yon dinft hold a Tens, rare '.v'ext or Mobile Retail F e Establishment La easeplease contact the Health Department at 970404-64.15 Please list any additional events and dates that you plan on participating in Weld County Event name Date Location --t7'ai. FOR HEALTH. DEPARTMENT USE Licensed Needs a Eiders Nonprofit ER Specialist Signatun - APPROvEt) Ycs No 1- sa -- i Date k MENU (Please attach additional sheet, as necessary) Please list all food products and the specific source of all food items (name of grocery °limb, wholesaler, etc.) Be sure to include items such as t ppings and condiments. Food and Drink Items Location where obtained - - Example: Hamburgers Groc Store A Ex .. i , Onions ChainStore B 1. iho SAP1S road qs_ , S• r�[y'p� 7. Iriti-SY ` N . 9. W. 12 1.3. 14. - - - - HANDWASHING AND FOOD TIANSILM A hand -washing station wranN each booth or unit is REQUIRED unless only prepackaged foods requiting no preparation and I or cooking are to be served. Please check the space below that applies to your fit / unit t will' be senring only prepackaged foods that require no picvaration, handling, iind&or cooking. r will be serving fonds that require preparation, handling, and/or cooking and will provide the following fair hand -washing. 1..) a minimum of 2 gallons of warm potable water that must be relied as needed U, a container with a 'hands -free spigot 2.) soap 3) paper towels 4.) 5 gallon bucket (minimum) to catch and contain wastewater until it is properly disposed NOTE; .hand isanitizers' are NOT an acceptable substurte j r required hand -washing set-up_ How will you prevent bare band contact with ready to eat fads (at both the commissary and in the booth)? Dugs Rind- rude disposable gloves (Note if gloves are changed hands must be washed) 9 Deli tissues El Other (list) Page , c LEL FOOD PREPARATION T COMMISSARY Preparation at Approved Facility or Commissary BcfpLej Event Check which preparation prcicedure each menu item requires. 11114W Cut/ Wash Assemble Cook/ Bake Coo Reheat i Cold Holding I Hot RoJddit Food , !Xi Exam le: flsniburr exs -, X Example: tsdn X SrCtraW d 3, Vitt ii _. 1 s. •a L i �` _�$!f S i i i __._ Y a 6r • # _ 1 -,lit What is the name and location of your commissary? (Complete Commissary Agreement on page 7) of Commissary okit Man. Address of Commiss q0`bq M%id'nd City/State/Zap of Commissary: Produce How will product 13C prepared prior to use? (mark sal that apply) Wasi.r produce rn food preparation sinit 0 Buy froduet pre -way hed and cot at curn-rnissary 0 :.8try product pre -,washed and pr'ercut 0 Other (specify) rt sth ..e0 Thawing- Will foods need So he thawed at the commtsur1y? V Flow will frozen foils he thawed? (math all that apply) )(filmier refrigeration O Under cool running :ing water As part of the cooking prods CI Other (specify) (LS ( 4) Not Applicable if yes., answer ;question below. a Not Applicable Cold Holding Wall too& be cold held at the commissary? V How will foods be held. at 41T or Beim? (mark ail. that apply) -i cooler or freezer ❑ Reach -in cooler or freezer to In vooler with ice drum, diateIy be tr _ $port to site O Other (specify) N' 1ktir Oct Ps c i r if yes, aas wer question ifelow. )111ktetiftejfiey'll Hot Molding —Will foods be hot held at the commissary? Y How will foods be held at 135 degrees or above? (mark all that apply) o Steam table ❑ Reach-ain, hot box ❑ Oven Cl Other (specify) _ ❑Grill If yes, answer question below. Cooling— Wilt foods be cooled at the commissary? ' i If yes, answer question below. How will roods be rapidly cooled to 41°F or below? (mart. all that apply) Q Shallow pans (less than 4") in refrigerator or cooler ❑ Using an lee -bath to cool the food. product ❑ Ice paddle or wand ❑ Other (specify) Reheating— Will foods be reheated at the commissary? V If yes,, answer question below. How will foods be re -heated to at least 165 degrees F? (mark all that apply) Microwave O Hot Plate U Grill O Oven �! Other (specify) Transport Ple tse provide the distance that you will be transporting food to the event? What equipment will you use to control temperatures during port? eb‘r Coolers with. ice 0 Cainbros for cold foods D Cambms for hot fonds Other ( ) r rwtFwd ffti the B sot.ea List all menu. items, including beverages, to be served from the temporary food teat . Check which ibvd handing procedure each menu item requires at the booth., ' +a — - 6 Cold Holding Reheat Kook/ Grill pa lc flatnhe F le:Onion 1. cat )12 ei �y i,i r iK w ,ifs' 4. J ' , 6. i it ''r (,A+5 7. 8 ' 99 10. L Rot Olti X Mumble le fl pu4cInt aln4 flpt d[ t lnw ul loud ,tet t Y How will these fob be- cooked arni/of reheated at the site'" (mark all that Fly) rrll �1 Hot plaW 0 Nat Applicable Deep Itytr 0 Oven u Microwave Other (spcct fy) 2. How will hot foods be held at 133'F or above the event? (mark all that. apply.) (Sterne burners are prohibited) 0 Hot holding unit 0 Stearn table C Not Applicable Held under heat lamps c Serve -d immediately after cooking Crock --pot Gk:l on grill twill. -dyed YOther (specify) StiSsztjuin 3. What utensils will you use to dispense or -ervc t1u hot items? Tongs L ad1 e 0 Not Appti.eab.le Spawla 0 Other ( er d ) Cold Faint items 1. How w cold foods be held at. 41°F or below at the event? (mark all that apply) *'lkciligeratzt Ifeeeziut 0 Not Applicable ni let: el t - must be (trainable and flat may twit be kept in contact with the ice unless they are packaged and sealed. Other (specify) rex I- _ 2. What niznsils will you u ;e to dispense or serve the cold items? twigs ladle 0] Not Applicable pate Wa O Other (, p eify) ._._.s_Il Mole 3. What kind of food thermometer (0-220W) ) do you have? iem.stern probe Therr2pocutipie '.l 0 Digital T 4 C' nin2 itI�!JI +t' �a!e What Iype of San titer will you use at the booth? Bleach at 50-2C10 ppm O (Nate:tarp Ammonia at 200. 00 ppm C� Ober: - - Note' Test strips for sanctizer in use mast be provided nut be citt4kite Where will utensil washing take Placer O Cotruuisssry 3 compartment sank o Coinrnissaty dish machine Commercial 33-catnpartutent sink unit (part of mobile ut3 t) What type of Sanitizer will yuu use in the 3 .compartment sink? EIeach O Quarernary Ammonia Other Not Applicable- using machine Where ill Wasteuter from hand witAiug aad cleaning be dimmed o Commissary O Approved on-sio: receptacle at event 0 Other - - Wane water CANNOT be dumped on the ground or into storm drains. Water must be placin approved receptacle or sanitary sewer Please /Mil outfrom event coordinator where this is located for each event. What is your booth Sian for flying insects and dust control, if applicable? .Q' =: ai. WPM_ LAYOUT AND MAP Provide a drawing of the Temporary Food Establishment Identify and describe all. etlit1pmeaet The map shat! include the following: Cooking equipment # Band Washing facilities O Food and Single Sege storage Customer Service area Yot: (� Hot and Cold ilotd g equiptnet t Work }surfaces , a Garbage etstsinen t- veoctim Summary Paragra ; Write a paragraph or two about how yourop t works. iq bdharteir rood Aro?. 7 .O5V11 itkr4 V‘ecas -Q0M4 CW04-ta ‘ColiCaQi scr42cJj tn. og-ncteneters and 44f9tzQC on. bcr Hite r,ohi uoil'its- 010, emotid isassen101 poi on t ( -ti -dire trotaike. tA t Ov-vt.'ordered • tPHA o -P. is 1 foitregiy-urc ttneritAcmcdto,4 lett o1/41.1A-s, and vtolr- hold alter ps Dn. '; 0 ci4ach uSitAit acres_ erviervvw itAiAtt. r . &c. Jitter: -traia.M201 ITA,- .. a cbt-si o44j (94cV10'f COMMISSARY EMET ffiling Date Fatkii Elorta,„ Qictt ivkan rafts ft (Owner/Operator) tabii .ent Name) a at 3oS`1, Marc h.aIf _ CJt_(Ah&tmt1tthr1 CO (Address ofEstablishment) " .•onto Lewco 0d TroeL- (Nzrne of Mobile Unit/Pushcart/Temporary to use my � lines to perform the following: vir Preparationof foods such as vegetables or its, cutting meats, king, cooling, reheating. viej Storage of food% mijt 1t service items, awl cuing agents —7— ervice and cleaning of the equipment hIli Commissary ''a Supply? Commissary nit Seerservice? Municipal unci/ tic Vi Ware washing 'e Filling wafer tacks dfr -moping waste water Other (list below) indicarc the equipment available at the commissary fortheixopooed use Hand sink de Prep Si Mop 11.1( xiet Three bay sink tre" Dish machine Refrigeration meter Mawr V Cooling - p t Dry Storage se" I am a self cod#sbed mobile aft and do at require are of a commissary This C am] aV a thIS e Phone Number f Page 7 of it 3gz3 SALES TAX P 80008210 STATE OF COLORADO DEPARTMENT OF PUBLIC HEALTHAND ENVIRONMENT LICENSE TO OPERATE A RETAIL FOOD ESTAEILISHMENT . ACCOUNT NUMBER L1A8MA'R31.11E TuTY INF ri SDATE LICENSE 'Al ID TO use rot i1I1 f*i7rii'.'�i1J�_ urn �RA WL u�l �� -ieox POO MUM- ' ieer L I::Ef 2551)0 !.__.,. 2:7Wi'' Q4 THIS LICENSE MUST SE KAM AT THE fottoWi 13 tOCABON; Loweountry ILLC 12875 Clarkson Or Thornton, CO 80241 Mtt ri40 tedi 1) rflJ JME$T or ctEVENUP O K CQ t :26 I-.aO13 Lowcountry - Mob Mobile Thornton. CO 80241 This LICENSE IS NOT TRANSFERABLE `t ATE COUNTY COLORADO ADAMS' _ Mat coked USE ACCOUNT ILIABluri' INFORMATION I tam far: NUMBER fi 1 zitI referencesI"d'y'tJl j �7 W�Sr° J �.r -lr RTD/CO This ;Thai licenses 4PQ*)1 1*00 to authorized tirsii MIeale �n butimanns In aretiordaitc. with I1* Eowtslons co ma taw alita regulations ct e for 'Claostlinitinl 41 Pelle Heath t cl environment Aay seura kins Made ash liMnr *1 arderrIsticaRY ,rake k 3110.1 and YOWL •111 - POST IN A cotaPICIJOILIS PACE LIC ENSE _?77 r 1179140X) M2-0044-011 liana LICEASE MST tE POSTED AT THE AntioWING t-OCim 1*4 A CQSterIC $ PtACt 12878 CLAWSON CM T l NTON CO 80241 -NM ISSUE DATE rnlei I 7 r t C54391 5I Jon LOINCOUNTRY, LLC A : STACEY `xrATE:S 128Th CLARKSON CR THORNTON Oa" z30Z41-3966 io6 It °di ci LICENSE VALID TO DECi�� a} l �iTr. 1 2017 INKS LICENSE'S Nat TRANSFERABLE 153 Eirecu1iv3 Director tp;wtvrIerti of +vea l A coati CERTIFICATE OF LIABILITY INSURANCE 0A3E M YYYI I 9/8/2018 This CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS K9 RIGHTS UP MN THE CERTIFICATE HOLDER. TWA CERTL ICATE DOES NOT Aff #RMATW LY OR NE(IATIVELY AMEND, Ear Nti OR ALTER THE COVERAGE E AFFOSQEO SY THE POLICIES BELOW, THIS 'CER'TIFICAT'E 1f INSURANCE. DOES MOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER,(S), AUTHORIZED I REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER - la !ii1APTAt1»t'1': i1 is cartN nake hokks is tin ADDITIONAL INSURED, the ciacsi(tsN min is wndarsact I1 SUBROGATION 1er WAIVED, s ci.10 the isms and-tadI'den. at Ova may, catis+irt polickiss may require an ensforaernaga, A statement on tills aeistiftce4a does nut °enter rights tO Ohl. i,s, Ifc+Ete tkolchirin nCW of IWO *ndvt*nnofttlli. _ MC041C ER Mobile rood Vendors Insurance 11200 Doll u'it1Rd . yea TX 719 59 WM= STAMP PATES OSA WV= FOOD 'MLitt 12875 CLARKSON CIRCLE THORNT0N CO S0241 a4s44a4_cotisuwovr.th 4'' creek ;080) lyT9--63811 .5randanC4wham eating .Qom souseross APOORO NQ COVERAGE artatiams., :Eno vex r itz an ttn Ttcia.i Biongifit ttta 1S4Q ;I'Fii{1_ 4 T'. COVERAGES - CERTIFICATE MUM rtRpLi1 S 12 3419 0 56 REVISION, NLJ'ER: TI -03 IS r) CERTitrf THAT THE POLICIES OF iNSUIRAPACE LISTED laelKIVW ,RAVE BEEN ISSUED TO ME INSURED NAMED ABOVE Peli THE pave pcRIUD INOtCA'T'ED NOMITTHSTANDINC ANY REQUIREMENT, rathil OR CONDITION OF ANY CONTRACT OR OTHER IJOCAIMENT ti l RESPECT T i rit trl MIS CERTIPICATE MAY $E ISSUED OR MAY PERTAIN, Die IfiSt ANCE AFFORDED laY THE POLICIES DESCRIBED I4FRF_INI IS-UBJECT TO ALL TIME TERMS, EXCLUSIONS AND CONDITIONS StJCMPOLICIES, LMTS ,SHOWN MAY HAVE BE€N REMJC:EL BY PAID CLAIMS. wicyc palipigirrnil,1 tytut OP WoritkIneNIRI GENERAL LIAMITT ANY AIJT[J AU. 0161.14D AUTOS WIRED AU P s LA ERMA UM flee 90 alba WOOKINNICariPlaisA-11044 AND tortuvERst imistsf lrf Y1 N E. 7(E LA INS -Ni/C4i lair: UR I Y PF�t�Rpi�:.':iF�fF7Mi'Mat�rk?4 CU {1i ondt city In NW Ir si#lgtLe tlivartd � ift3;ds hettar MrA rznirosifl]0 AIROJILS.,59 137 S/al; 261 /1't/2!115 LJ17/2OtS t,T OCUPRAINCE rap 'Mr Mut +urm snot"; PERSO Mt. 4 (CV 44,1U PLY 4 4 . 000 r 000 4 kriFACRAL A'iaflWAVE _s t'RG1)1C1S COMP/OP ACCI COMINED SAW bLt LIMIT LEAKCIFIES ___ _ .z_. _ l301)ILY ?wdUrn' (Pear { 114 n) troeVF 41- 2+000,00 4OOO.DDGr S BODILY IRRMY (fir + ) $ ,tai► nll,_ Mmilicui menu s X11)0 Uini-4 MCA RENCE s i Air Mattis I TO t -t44 1. A LL' PLC WENT EL DMASE ateiOYEI al— =Car POLIQO 11W It M OI plt Tilt srS1 Lt rvous rWHIC4_ i AliCOU la P. a&WSW atirfillan 4chinikalrsr min If .+a r,qrhti The aemaral Stabit, sty and .into Vidag44.iity policies -!Include a Sia.nks t a atosstie additilmsl insured endorsement that par onelos ad:Lasttonal S,ntuk-i4, micata3 to tint .t'ti i atsr h, ltiax only elan bbere is II writtan contract betweerx ths teamed insured and the aartiticists hclder that eequires such 4sitatu.$. Marino to HER CANCELLUON Wild Cider and Cazhon Valley Nine festival aHOULD ANY OF 7115 AUOVE DESCRIBED.POLCIES se CASCELLED BEFORE Ttit E%PIR.ADOW 01141E "Thy€OF( $OT1 Mt1 E ofarvERED AGOORDAPite WITH THE 'OtlMY PROVISIONS. AUTNORIZED REPRESENTATIVE i tak I Oi rtOnu 5-WCO s-,. �•i-_ Jam^ i't-r}�..rm ACOIW 74 (2010/135, IiiliAnwi not R5 tti 0 114}11-2010 A 'I. P ORA I i. rirA tts rewva rl T'la�. Aencil Nam,*:n4 lesten area r sitie*,ffYelt4e rk43 rt4 nn'no'n Vendor Information List ■ r Contact number (() Ibliefilti item at toot J A 1, i :71 et It.c Lli ji et I 1..e. i ,Ir 1I r O I. or 1 : V(1+' au (1ct!'. a 'i r+ tic' .: rr: . J Ll 1 Pit p [i[l I q I Contact Person Name JC Val (1;.1' dr ��• 51 ,i M e 1 34 el 't.I ! 1 jl R 1I I I 2 So9 C t. 1 i L G M —i 0 rap Li C �f p' Hours of Operation c'�Ir 4 'Q 0 03. I it a I - - 04 ' h 1 I �4j ) 5 I 1 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue Greeley, CO e90631 Web: www,yvvplillea11.li4cwq Envilucinleinai Fk i fth .ervk .erk (I37`ti ) ,..;04-64 Fax 1970)-1304-64( VENDOR APPLICAT i N FOR . TEMPORARY FOOD EVENTS ALA: veriCIucs ?1fASI cOflif LL:•re ,rid StlbnIl li It i 6veI a Coordinator toI' each ie'\ w; nr ld-) Weld Counter [- no mein! And fl{) equipment ehaog IS uc'e?I16)11y f ommm on.: ev y ( ' out her; _he v 3 plchi t .I ' 'copied ekas ;__lac 1 ;� �.',}��v -I L � •�1 �� Y' 1i�ll ,L.i t� � I 1 1 r �I l r r of you r curreut kin' °t'r1ry C vc nt 0; mob, lc unit Color;,do R to E •1 t . , i .- heensed. t., Gl F. 1��:�;r��,l' �t]111�.I1t L .t_.�.₹��., r� ��I�-�1�--�I�• �1�.-�.nsed. Event Name: r Lov 1 /&i I ! ,: 1 `� k4/ 1 £ Date(s):C 0 r - Iete the following information: L cation of Ever i �r ,� . Hours of Event, 4 radscteosir,Tempotar Retail Food l iit►iit rt.tin a -�eLA..0_ s , co t�:l - - 7 1 LI talioo ret 2 -0 - Which county issued your Iicensc \Ai ct Lal.) 111• e1 Name: Tglwphunc r ltrillber ( ritior ID Event) Mailing 11 AIJrc v, -s• 1 �1 - 72 tsivfi r .C4(mott Cell Number Dilrinc Even): J43C-te 7t2?$ ?Lys State *Alt vendors shall have the r{yinai Colorado Reteni Food EstabHHshmnnt license on premise at all lives' All vendors most iwrMce documetttatiurt of Ricensure or non:profit status Type of Vendor: _ N Checlateproprvo box I have attached cu1�, � ' of documentation � Licensed Temporary Event Vendor a Licensed Mobile Unit ix Non P'ro it +provide documentation) tC i if you don't hold a Tempj rnr v Event or Mobile Retail F jotl Establishment Litrease please contact the health Department at 970-3044415. Please list any additional events and dates that you plan on participating in Weld County 1 -;vent natne Date _ Location T, _ FOR HEALTH DEPARTMENT USE Licensed N eeds a license Non-profit ,ssa EH Specialist Signature ARMOVED Yes No Date I. MENU (Please attach additional sheet, as necessary) Please list all food products and the specific source of all food items (name of grocery chain, wholesaler, etc.) Be sure to include items such as _ttiat and volLd nlent&. Food and Drink Items Example: Imnhu:rc �s Example; Onions is? ce773 Lr _. CIL� ) _ r �_ - 3.r 1.- 4e dp cj f F fr, tom-. O kl �J;'. C7.e+d..3 ..�i } .�(f k! C= - e�.'T 54111:IL Litt Ca. t) "rack -vet -5 elbellel 6. Location where obtained Grocery Store _A I Chair; Story B 7- _ CD CI' C ST ten- d --A) E:P67- f { rl4jf!Lj1?aC7t 8. l is foe IL 12. 13. 14 a IL HAND "A `tHNC FOOD IIANDLINC A hand -washing station WITHIN each booth or unit is REQUIRED unless only prepackaged roods requiring no preparation and ! or cooking are to be served. Please cheek the space below that appfies to your booth / unit. C 1 wilt be serving only prepackaged foods that require no preparation., handling, andrur cooking. will be serving Ihuds Ilan require preparation, handling, and/or cooking and will provide We following for h ra41-washmg. )) a minimum of 2 gallons of warm potable water that must be refilled as needed in a container with a stands -free' spigot 2.J soap 3,) paper towels 4.) 5 gallon bucket (minimum) to catch and contain wastewater until it is properly disposed NOTE: Hand `suttit zer s ' are NOT an acceptable substitute /br required hand -washing set-up. How will you prevent bare hand contact with ready to eat (Nods (t both the commissary and ix the booth)? rig Tongs Food -grade disposable gloves (Note: if gloves are changed hands must be -washed) Deli tissues C tier (list) _ - I.II. FOOD PREPARATION AT COMMISSARY Preparation at Approved. Facility or Commissary Retort Event Check whieb preparation procedure each menu item requires. Food Example: _ Hamburgers F-xa le Onions 1. 2. _1 _ , a Coo 4 I:1 04-Ta fig 0 47.. z cewc cart 5s 0 rfir-- )L 1 r `fa 1D P 46R 7. 8. 9. 10 Thaw Cut/ Wash Assemble K r a . Coo Cool Reheat Bake J 14 a Cold Rot Holding I Holding x What is the name and locatiork of your commissary? (Complete Comm nary Agreement on page 7) Name. of Commissary: z -z - NJ _ ILL fie ft Address of Commissary: \,11 1 City/State/Zip of Commissary: Or ap,,Cu Produce How will produce be prepared prior to use? (mark all that apply) l-! Wash produce in food preparation sink Buy product pre -washed and cut at commissary Buy product pre -washed and precut Other (specify) 0 Not Applicable Thawing- Wilt foods need to be thawed at the commissary? ' ' I .N [ ' y , answer question below. HOW will frozen foods be thawed? (mark all that apply) /Under refrigeration �I Undor cool running water C� As part of the cooking process 1 Other (specify) o Not Applicable Cold Holding — Will foods be cold held at the commissary? V How will foods be held at 41°F or below? (mark all that apply) CI Walk-in cooler or freezer Reach -in cooler or freezer In cooler with ice immediately be transport to .si Le 0 Other (specify) 1 f yes, answer question below. IV. Food. liaindlifilig at the Booth/Event List all menu items, including beverages, to be served from the temporary food booth. Check which food handling procedure each menu item requires at the booth, Example: lia mborger Example: Onion 1. P.O LA k .. et -57 ( r 3. C I f ,Fj YV L L 1K Al -f co4 Reheat r Cook!' Grill Rot Holding. r ea Assemble x Coo&i.rijz and not l-laldi,n t f'Eepd (Punk 1. How will these foods be cooked and/or reheated at the site? (mark all that apply) ❑ Grill r I1 t plate ❑ Not Applicable ❑ Deep fryer einven ❑ Microwave ❑ Other (specify) __i_e.-- - __ 2 How will hot foods be heti at 35°F or above at the event2 (mark all that apply) (Stems° burners are prohibited) CI Hot holding unit 0 Steam table O Not Applicable ❑ Held tit heat tamps eared immediately after cooking ❑ Crock -pot ❑ Held on rrili until served ❑ Other (specify) What utensils will you use to dispense or serve the hot items? ❑ Tongs in Lad I e ❑ Spatula rfother (specify) ❑ Not Applicable Cold Feed Items 1 How old bads be held at 41°17 or below at the event? (mark fall that vpty) e.l rigt nr r i Freezer 0 Not Applicabie u Ice chest - must be dr a nlc ie and fora may not be kept in contact with the ice unfests they are packaged and ,sealed. ❑ Other (specie]) rr • - ,.nPsIL 2, What utensils will you use to dispense or serve the cold items? O Tongs 0 Ladle in Applicable ❑ Spatula (specify) � p j Other (specify) - 3 Whin ki O1 rod, thermometer (O.220'"F) do you have? kw' item probe 1 T herinuct up to ❑ Digital rt 1 lat Vat 3 ,a St 0 V Clem STATE CF COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT LICENSE. TO OPERATE A RETAIL FOOD ESTABLISHMENT LIA3IL- I rr ntiroftiopcnon ACCOUNT NUMBER use for all Memnon. 3003 6564KM 3289 8/2120(6 'MIS LICENSE MUST BE POSTED AT THE FOLLOVVINQ LOCATION; HOT TIN ROOF PIZZA MOBILE UNIT WELD COUNTY, CC) 8063 Owner:, ROCKY MOUNTAIN WILD CiDER i ..I PNS IN G A ULNC Y: WELD COI MCI 1' OEPAR'T IEN l' OF PUBLIC HEAL ni AND ENVIRONMENT t'REVOR itr rLr_tc NI ..; E S DIRECTOR ENVIROrtillYIENTAL HEALTEI SERVICES ISSUE LIATE march ab I LICENSE.* VALID It D(CMM®ERIi 2016 This cell:WO th St titaness Shoo hewn is att$fhru�aect acid i.lr tend to engage in eusI i a In acce,rdGnce with the pra fv*nn of me flaw and ireguhalloois of the Colorado fDtp rtment of k Wh: IIettith and Environment. Any alterations made on this itcensa will automatically make it nut? and void, POST IN A CONSPICUOUS PLACE DEPARTMENT or PUBLIC HEALTH AND ENVIRONMENT 1555 North 17") Avenue Greeley, CO 80631 Web:• eMY.Lx1�S�t�l� Etwironcratated health Services (9703-304-641 Fux 1970)-304-641 t VENDOR APPLICATION FOR TEMPORARY FOOD EVENTS AR vt1tidt,i'* must cimiiip u..ii: kind submit LO Event Coordinatoru (or each. evorli hi Weld County [lino menu. and nu equipment chance is occurring from one event Le another, the coinplkuctcr origins l ma> he copied Nease attach u copy o yorrr current ierncmnnt event or mobile unit Colorado Relaii FOCA Rctahlishrcmerit Litxrkse, if thud)" licensed Event Name: CARBON VALLEY WINE FESTIVAL Date(s): OCT. ??1,2016._ '4 ilela r M 1 17 Firestone, CO 80504 Please Lift the' i'nik)WFnJR in►torniaiion: Temporary Retail Food Establishment Name; MILE HIGH LOBSTER SHACK h i ch county i,ssaacd your I n:.. tro.-., LARIIt ER Con#aet Nat1nc; NANCY VAN REETH Wurr'thw• (Prior to Event): (207 l 72-5-ff373 (vfa iii At.14,Inssic 532 STRACHAN DRIVE AIM LLOIL (Hour; aF tveni: 'I OAM = 4' I f Email . miletilghlr3astemhac t@: crradl Cirri Celt Number (Dur3%.g Event): f .I SAME City Stare: FT COLLINSCO Zip: 80525 -Ti. kAll vendors shall have the original Colorado Retail Food Establishment license on premise at all times* Ail eudiii's must provide documentation of ticcitikkre or ,ton-eporlit status Type of Vegan -in' - Check appropa�iatu box l lmve attached cop) of ducum miat.ic it Liecitsocil Tenkporrstsy Event Vendor Licensed Mobile Unit 1 Non -Profit, (provide documentation)_ Milas if you don't hold a tpr1101111411t Reta is PoiMi*.bll.>41 rncnt Litt* a pieMs-e contact the Health fepartm etrt at 970494-6415, Please list any ad4iitionai kweirtg and dotes tikat you. plan On participating (la Feltz Coiun ty Event name Date Location • tUv--arftat- FOR HEALTH DEPARTMENT USE Licensed Needs a Uice•nse Non -faro f'i - EH Saraeci ; its( Simla/um won APPROVED Yes l Dale 12. ( ''leave auurich additional sheet, as' nece. it r ) Please list all food products and the speci f c source of all food items (name of grocery chain, wholesaler, etc.) Be sure to include items such as toppingsand t.cc i llinutn.ti. Food and Drink Items Example: Hamburgers Example: Onions _ 1. 2. PLEASE SEE A r +ACHED 3. Location where obtained - Grocery Store A Chain Store B 4. 5. 6. a 8. 9. ii. amEMIalla 13, 14, IL HA i WWASIUNG AND F000 HANDLING A hand-waNitink4sNiaikm WITHIN each booth or unit is REQUIRED unless only prepackaged foods requiring no preparation and / or cooking are to be served. Please check the space below that applies to your booth I unit. O i will be serving only prepackaged foods that require no preparation, handling, and/or cooing. 11 \its be serving foods that require preparation, handling, and/or cooking and will provide the following for hand -washing! 1.) a minimum of 2 gallons of warm potable water that must be refilled as needed in a container with a 'hands -free' spigot .) soap 3,) paper towels 4,) 5 gallon bucket (minimum) to catch and contain w atesvater until it is property. disposed NOTE: Hand 'amnia ' are NOT an acceptable ,wzibstitutre,fbr required hand was'hin, s' -u p Rove will you prevent bare hand contact with ready to eat foods (at both the commissary and in the booth)? a Toz gs aloud -grade disposable gloves (Note; if gloves are changed hands must be washed) Deli tissues Other (list) W SWIM. Aim. M. FOOD PREPARATION AT COMM 'MARV Preparation at Approved Facility or commissary Before Event Check which preparation procedure each menu item requires. Food Example: hamburgers 04110712 2. LOBSTER MEAT JrILEMONS (4' 5. Thaw Cut? Washy Cook! Cool Assemble , Bake x 6�. 7. r r X Reheat Cold , Rot Holding Holding x a x e u 8. 10. E _ I. T7 What is the name and location of your commissary? (Complete Commissary Agreement on page 7) Name of Commissary: SACKIIS HOT *la_ la CATERING Address of Comrissan}: 2649 2. MULBERRY City/State/Zip of Commissary: FT COLLINS, CO 50524 Produee How will produce be RI-epared prior to use? (mark all that apply) Wash produce in food preparation sink Buy product pre -washed and cut at commissary a Buy product pre -washed and pre-cut �7 Other (specify) tia 0 Not Applicable Thawing- Will foods need to be thawed at the commissary? Y / N if yes, answer question below. How will frozen foods be thawed? (mark ail that apply) Under reftlgeratdoTi a Under cool running water 0 As part of the cooking process ❑ Other (specify) 4 Not Applicable Cold - Will fads be mid held at the commissary? '1 / IM If yesj answer question below. How ,will roods btt he -d ni 4.1°F orMow? (mark all t Rtt apply) f Walk-in -io cooler or freezer Cl Reach -in cooler or freezer a In cooler with ice immediately be t5 sport to site 1 Other (specify) Hot Holding Will foods be hot held at the commissary? V / N If yes, answer question below. How will foods be held at 135 degrees or abc e? (mark all that apply) �I Stearn table ❑' Reach -in hot box �7 Oven ❑ Other (specify) O Grill Curling --- Will foods be cooled at the commissary? ' ' / N If yes, answer question below. How will foods be rapidly cooled to 41°F or below? (mark all that apply) ❑ Shallow pans (less than 4") in refrigerator or cooler ❑ Using an ice -bath to cool the food product ❑ Ice paddle or wand. ❑ Other (specify) Reheating— Will foods be reheated at the commissary? Y , N If yes, answer question below. How will foods be re -heated to at least 165 degrees F? (mark all that apply) o Microwave ❑ Hot Plate ❑ Grill fl Oven O Other (specify) Transport Please provide the distance that you will be transporting food to the event? 29 MILES 'hat equipment will you use to control temperatures during transport? Coolers with ice Q Cambros for cold foods ❑ Cantos for hot foods O Other (specify') IV. Food handling at 11r Booth/Event List all menu items, .including beverages, to be servod torn the tempo aty food booth, Check which food handling procedure each menu item requires at the booth. Food Cold Holding ' Reheat Coda Grill Example; pie; Hanabu ► er Example: Onion 1 ■ LOBSTER 2. HOT DOGS AND 6RATS (PRE -CO IKE 3. CONDIMENTS 4. SODAS, WATERS., IMOXIE S. CHOPPED ONIONS., PICKLES 6. SAL 1 kK UT 7 ChI PS (SINGLE SERVE) 8. CUT LEMONS X X X 8 X Hot Mudding X Assemble X X X X T t. 9. BUTTER 10. SPLIT TOFF ROLLS SHOESTRIh1'a POTATO STICKS (PREPACKAGES) `i Jfinu pawl Hot [-lddlug of Food Items I I()ly% skull these d'i'rrlr.'l be cooked ail dim O Deep fryer O Other (specify) ft reheated at the sits'? (mark all that apply) 0 Hot plate ci Not Applicable p aidevi Microwave 2. How will hot foods be held at 135'F or above at the event? (mark all that apply) (Steno burners are prohibited) O Hot holding unit aSteam table 0 Not Applicable O Held under heat lamps 0 Served immediately aster cooking O Crock -pot 0 Held on grill until served O Other (specify) 3. 'What utensils wilt you use to dispense or serve the hot items? crongs Ladle O Spatula .Q Other (specify) Not Applicable Cold _food !reins I. How will °old foods be held at 4 F or below at the event? (mark all that apply` p Refrigerator / freezer 0 Not Applicable Ice chest must be dr:athiat ie and /both may not he kepi /n contact with the ice error/es,- they are pa(*aged and sealed 0 Other (specify) - 2. What utensils will you use to dispense or serve the cold items? c3Tongs 0 Ladle 0 Spatula 0 Other (specify) 3 . What kind of food thennorneter (0-220°F) do you have? COvietal stem probe 0 T ennocouple 0 Not Applicable iglral V. CLenLud Related What type of Sanitizer will you use at the booth? i3 Bleach at 50-200 ppm p Quaternary Ammonia at 200-400 ppm C Other: Note: Test strips for sanitizer in use must be provided and be 13fnsit Where will utensil washing take place? 12 Conirrkissary 3 compartment sink Commissary dish machine ❑ Commercial 3 -compartment sink unit (part of. mobil unit) bat type of Sanitirer will you use in the 3 compartment sink? Bleach C3 Quaternary Ammonia r Other o Not Applicable- using dish machine Where will wastewater from hand washing and cleaning be disjunct] 07 I Commi saty ❑ Approved on -site receptacle at event p Other Waste water CONOT be dumped on the ground or into ee nn drains Wate intat be placed in approved receptacle in' scrnitwy sewer Please find ow from event coordinator where this is located for each event What is your booth plan for flying insects and dust control, if applicable? CANOPY WITH WALLS NO FCC) 18 LEFT EXPOSED TO THE OPEN AIR ILLQ__sOfitiLA' (L F 444,ND MAP Provide a drawing of the Temporary Food Establishment, identify and describe iii equipment. The map shall include the following: 0 Cooking equipment 0 Hot and Cold Holding equipment p Rand Washing facilities O Work, surfaces' p Food aad Single Service garage ci Garbage containers 0 Customer Service area 0 Summary Paragraph: write a pUrag.rupih I r IWO at wut [tow you..r M.rperati n works. WE HAVE A 4? X 7' PROFESSIONAL, SiS FOOD CART THAT IS HAUL) VIA OUR TRUCK. IT HAS COLD STORAGE AND STEAM TAII3L S WITH A LARGE GRQL THAT )S POVVERED BY PROPANE AS IS THE HANOWASHING ING HOT WATER HEATER. MILE HIGH LOBSTER SNACK 532 Strachan Drive # FL Collins, CO G052 9 Nancy K. Van keeth (207) 725.6371 FOOD 8,L DRINK ITEMS Doug E. Van R.eeth (207) 240-83 75 Lobster Meat Hebrew National Dogs Guiness Deer Brats Mayo, Heinz Yellow Iviustard, Ketchup, Relish, guldens Mustard, Celery Salt. Sodas, ra4er Beater, lemons Single scree Chip Matte New England style Split -top Buns Ytilloopie Pies Dill Pickels Shoestring Potato Sticks Gluten- free Buns LOCATION WHERE OBTAINED Northeast Seafood, Denver Restaurant Depot, Denver Sktgarland, Culotta&& Springs Pepperridge Farms Wicked Cieoct Whoopics from Gardiner, WI Sam's Watmart King Soopers Ai;.` err L t {<FtC sinsCOiil5"'L _ rJ�J,.t a\ . J7'.):t Lid 5*:!5. Mtehen Rental Agreement:', ALre:7.t.:tFt i; is +� f,, d 1. c .;c' ti -.: Riti?! 3 •. r'Tt C t- i't ir4ti '( . 4 ',t k : :a...2 -.-+ :Cis -..c4.:. cociLj.. _ 4: 1[ E{yy+ are lett4c.-,.ACS] i .2!- :.t ..d`. c. • t}!ea/:iC ft{- tYR aS rett..t'net! riti`•c x`• _ tii5.ac, eft c;G :x,'� Yti.a e;r`.Cvtiie rr�ropri -' .ivtt_ i.:cles,, n, to r. g�e3f tip. _ -,ac; . ,, 5irii.. �tZc,.s, ci,.,rni, nb. "o ir,vtts.S, e4c ,{fell. ie. if i f. hap? CO udi7 „s^ i,6.,pai i : ,);A .ie--,'a....t4i..i'.:ti?:'Of 'iGpt3v,'k:°.it. Ona`•'e be ' .c-F..t ri rum, 7. 3 _ t$i?cl t4 bie €oir p virz tier .'igse.bouts, 'tou ;are required <<, ,y. ,tik ,.. d., 1,, t^ I... a:h. =1 It i ' .i.' 'irtC'.u-stajid t iat Yl12itgs k.irne '' W . h't e L r'lr-i 4te;1. x'C, ..,�z .r� ' v'---.1 ....xccCi • ,,.:h :,,. i:LV tilrollvt, wi - your financial cornnytrren' Sracn"t' a-'.!r.2u Tie .t uvitt!.741iie iti h l,ir i7s€er Sbit' . 3i ', i..` � i.h.: t:. ,. >�C..• i ,ratC'. .g ' -, 41;ni? per month I1- JX1 1) CANOPY COLD HOLDIMC. C001.'FRS CONDIMENT TRAY rill PS' sr INIVX IF ri -- -, • TABLE I FORMA LINUERN,EATI1 FUR ifsiON,PERISH Milt DAY GKJUin mint rat STAINLESS STEEL 4%? FOOT CART CC)LI) VIOLDIMG COOLER Tor 1140_0540. PRY Sr Otka ANO 11OljWATI 1 ` l '/ Ara EM= tithdolealATI4 ZAMA FOIL COLD 1+10LU1p1r A+ NON-FIRIMIABLu DRY (LOCUS waked Sibs grosalti Sir- EcODASSCL VMS. I ORDERfOOD ING m O O CI _ 03 :ek-5r—o C.) ,2 it - co a) eL -o O Z, ca Ca >-", CO 11) 0 a en C CO °L3 O o 4) m 715 eL RECEIPT DATE G f a-7 /1 NO 88913 RECEIVED FROM The. LUnd 0 G-�-C.�C�►f� ADDRESS I CiLari Co Coy n+ ctd G3 C FOR T €) c C Fl efilVtOr CASH CHEC95 KMONEY Sr" 9"4-1 lb° . ORDER RECEIPT BY CR DATE q a E-7 Co NO. 88914 RECEIVED FROM Mined (j311c4O&nirnca,) 3cxncjtiocr ADDRESS 1��1 Coon 4 Road 53 Kee- rues (our ck , CO FOR C.ti.Jl e I cl Crec6n, +' C3 bCov3 $ co* or) picric.' a, l ave.n45 Penni HOW PAID CASH d CHECKcr..' 9 5 0 too 60 MONEY ORDER ciiPic45 NOTICE PUMINUAsp Pt' lilt MiMO%Iawz Ur Hi on Ain OS ;mime IE LICIflINQ UPI ICLMS 4i 4i t. ,.�,.� TO -, ►�►rnu 'INAS( At • kdF�,�dHf �Pr'�� 4 HM 111 l ull0 Ar • .._ y :ia.,Y d1 W 8 DATE. UIkTE 01 AP#IPC*Tla*; . . 74..- �r UROE11 OF' OFFICtit ; • 4. i NOTICE PURSUANT TO THE LIQUOR LAWS OF COLORADO —Eke. uukka adrirv-' cIS a.r►e.+ air Crounint Road 53 Keerler,+bc'r ce., CoAtC'13 HAS REQUESTED THE LICENSING OFFICIALS OF LJtid ca" rCoIorcao Tot 5ptc; a 1 Eti +5 t r i+ LICENSE AT: Coun4i3 Ro,.94 ti � F7ra 5# -or. , CD '(O 5 Dpi HEARING ON APPLICATION TO BE HELD AT: �.I otrri+_+ nn. n st-ra+pan eftplei;r1.5 L ti 50 aO-54ret+ ?r tic j CO creCoSi TIME AND DATE: 9:QO am 10/17/ OF co DATE Of APPLICATION:5tpf: x , 2014 B ORDER OF:Ucid 4 0T OFFICERS:elc Ld .r;�iai * n,ar. ..+ r :', e. , w f �rl 'd _t `'1 fl_S I 11 •St,u iURri. i Cf •ie 1[ 1f a •ar r•- -•=* I WELD COUNTY COLORADO LAND RECORDS AFFIDAVIT OF INTERESTED LAND OWNERS SURFACE ESTATE 9/27/2016 9:05:41 AM THE UNDERSIGNED, States that to the best of his or her knowledge the attached list is a true and accurate list of the names, addresses, and the corresponding Parcel Identification Number assigned by the Weld County Assessor of the owners of the property (the surface estate) within 500 feet of the property being considered. This list was compiled utilizing the records of the Weld County Assessor available on the Weld County Internet Mapping site, http://www.co.weld.co.us, and has not been modified from the original, The list compiled for the records of the Weld County Assessor was assembled within thirty days of the applications submission date. Property Owners Within 500 ft of Parcel # 131105000041 Signature Date Account Parcel Owner Mailing Address R0933601 131104000006 ZADEL CHRISTOPHER • J 'R0933601 131104000000 ZADEL JENNIFER L 11298 COUNTY ROAD 17 LONGMONT, CO 805049562 R3774905 131104201002 BABCOCK LAND CORP 212 N WAHSATCH COLORADO SPRINGS, AVE STE 301 CO 809033476 R3775005 131104201003 BABCOCK LAND CORP 212 N WAHSATCH COLORADO SPRINGS, AVE STE 301 CO 809033476 R5369086 131105000041 BIRKIN MARK 11455 LONGMONT, COUNTY ROAD 17 CO805049562 R8749300 131105000057 FAYE MICHELLE ,1 R8749300 131105000057 ' FA` E DAREN T 7813 COUNTY LONGMONT, ROAD 24 CO 805049549 R8763300 131105000058 VANNOR DEL DAVID R 11335 COUNTY LONGMONT, ROAD CO 805049562 17 R8763400 131105000059 ALLEN JENNIE L 11371 COUNTY ROAD 17 WELD COUNTY COLORADO LAND RECORDS AFFIDAVIT OF INTERESTED LAND OWNERS SURFACE ESTATE 9/27/2016 9:05:42 Al l THE UNDERSIGNED, States that to the best of his or her knowledge the attached list is a true and accurate list of the names, addresses, and the corresponding Parcel Identification Number assigned by the Weld County Assessor of the owners of the property (the surface estate) within 500 feet of the property being considered. This list was compiled utilizing the records of the Weld County Assessor available on the Weld County Internet Mapping site, http://vvww.co.weld.co.us, and has not been modified from the original. The list compiled for the records of the Weld County Assessor was assembled within thirty days of the applications submission date. Property Owners Within 500 ft of Parcel # 131105000041 Signature Date Account Parcel I Owner Mailing Address LO N G M O NT, CO 805049562 86770077 131105100004 C/O PO GREELEY, BOX LOAN 337060 OPERATIONS CO 806330618 DEPT CACHE BANK & TRUST 7 R6 84757 131105100012 SCOTT LA R R - P6784757 131105100012 SCOTT TO NI I J 3312 GREELEY. 66TH AVE CO 806349628 INS PROPERTY OWNERS (STATE I POSTAL CODE 1C 180504-9562 11455 COUNTY ROAD 17 litONGMMtON T ICO 180504-9562 7813 COUNTY ROAD 24 LO NGIYIONT ICO +80504-9549 g12 N WAHSATCH AVE STE 301 'COLORADO SPRINGS ICO 180903-3476 1.1335 COUNTY ROAD 17 ILO NGMONT lCQ [20504-9562 N to ul Cicl ee� p u5 0 t__ 3312 66TH AVE G REE LEY CD 30634-9628 IGR.EELEY (C[3 UI 11288 COUNTY ROAD 17 I LONGMONT he notification requirements oaf Weld County in the U nirted States Mail, postage prepaid First CI is 17th day of September, 2016. the 27th day of September, 2016. Chloe A. Rem pel Deputy Clerk to the Board ADDRESS 1 11371 COUNTY ROAD 17 LAST NAME 'COMPANY t O LOAN OPERATIONS DEPARTMENT w r,1 C CC ' uu. IBABCOCK LAND CORPORATION VAN NORSDEL d n FIRST NAME ICHRISTOPHER AND JENNIFER MARK DARE N AND MICHELLE et CACHE BANK AND TRUST JEtsINIE TONI NOTICE Pursuant to the liquor laws of the State of Colorado and the Weld County Code, a public hearing will be held in the Chambers of the Board of County Commissioners of Weld County, Colorado, Weld County Administration Building, 1150 0 Street, Assembly Room, Greeley, Colorado 80631, at the time specified. If a court reporter is desired, please advise the Clerk to the Board, in writing, at least five days prior to the hearing. The cost of engaging a court reporter shall be borne by the requesting party. In accordance with the Americans with Disabilities Act, if special accommodations are required in order for you to participate in this hearing, please contact the Clerk to the Board's Office at (970) 400-4225, prior to the day of the hearing. The complete case file may be examined in the office of the Clerk to the Board of county Commissioners, Weld County Administration Building, 1150 0 Street, Greeley, Colorado 80631. Petitions and comments may be fried in the office of the Clerk to the Board of county Commissioners. E -Mail messages sent to an individual Commissioner may not be included in the case file. To ensure inclusion of your E -Mail correspondence into the case file, please send a copy to crempel@co.weld.co.us. HEARING DATE: October 17, 2016 HEARING TIME: 9:00 a.m. APPLICANT: The Wild Animal Sanctuary 1946CR53 Keenesburg, CO 80643 EVENT: Wild Cider Wine Festival to Benefit The Wild Animal Sanctuary 11455 County Road 17 Firestone, CO 80504 DATE OF APPLICATION: September 21, 2016 REQUEST: To grant a Special Event Permit for the sale if malt, vinous and spirituous liquors, for consumption by the drink on the premises only. LEGAL DESCRIPTION OF NEIGHBORHOOD SERVED: Rocky Mountain Cider Company, DBA Wild Cider, 11455 County Road 17, Firestone, CO 80504; being further described as Lot B of recorded exemption 1311-5-4-RE4I located in the e2se4 of the section 5 T2N, R67W of the 6th P.M., Weld County, Colorado. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO DATED: September 27, 2016 Chloe Rempel From: Sent: To: Cc: Subject: Chloe Rempel Monday, September 26, 2016 5:07 PM Roy Rudisill Frank Haug RE: TEMPORARY ASSEMBLY - Rocky Mountain Cider Company DBA Wild Cider I do not believe that they will have an ambulance on site. They have an agreement with both medical and fire - both have been contacted and are on call, but neither plans to be at the event for the entire time frame. Chloe A. Rempel Deputy Clerk to the Board of Commissioners 1150 0 Street Greeley, CO 80531 / PO Box 758 tel; 970-400-4225 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. Original Message From: Roy Rudisill Sent: Monday, September 26, 2016 4:51 PM To: Frank Haug cfhaug@co,weld.co.us>; Chloe Rempel <crempel@co.weld.co.us> Subject: RE: TEMPORARY ASSEMBLY - Rocky Mountain Cider Company DBA Wild Cider I think this is a low key event or low risk, I'll confirm with the Fire Department and make sure they will have folks available for response. The Medical Transport could be another concern if they are not going to have an ambulance on site. Roy Rudisill Director Office of Emergency Management 1150 0 Street 970-304-6540 Office 970-381-0417 Cell Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return i e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited, original Message From: Frank Haug Sent: Monday; September 26, 2016 4:46 PM To: Chloe Rempel <crempel@co.weld.co.us>; Roy Rudisill crrudisill@co,weld.co,us> Subject: RE: TEMPORARY ASSEMBLY - Rocky Mountain Cider Company DBA Wild Cider I think that as far as the fire personnel, they need to have an alternative plan, and we need to make sure that OEM, the Sheriff, and the local fire are okay with the alternative plan before we send it to the board, does that sound consistent? Frank N. Haug Assistant Weld County Attorney 1150 0 Street Mailing Address: P.O. Box 758, Greeley, CO 80632 tel: (970) 356-4000 x4394 fax: (970) 352-0242 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. Original Message ----- From: Chloe Rempel Sent: Monday, September 26, 2016 4:45 PM To: Roy Rudisill <rrudisillco.weld.co.us> Cc: Frank Haug <fhaug@co.weld.co.us> Subject: RE: TEMPORARY ASSEMBLY - Rocky Mountain Cider Company DBA Wild Cider Roy, I spoke with the County Attorney and I believe that in past events, we have approved alternate plans for fire and medical personnel. As long as the fire department and hospital have been made aware of the event, they are located close to the event, and they are on standby in the case of emergency, the County will consider its terms met. If this isn't the case, let me know and I can make further requests to the applicant. Page 62 was part of my personal notes at the beginning of the application process. I apologize that I included that page in the pdf. Originally, they estimated attendance to be closer to 2,000 people, but have since downsized. 2 Thank you Roy! Chloe A. Rempel Deputy Clerk to the Board of Commissioners 1150 0 Street Greeley, CO 80631 / PO Box 758 tel: 970-400-4225 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Roy Rudisill Sent; Monday, September 26, 2016 4:37 PM To: Chloe Rem pel ccrernpel@co.weld.co.us>; Dan Joseph <djoseph@co.weld.co.us>; Deb Adamson <dadamson@co.weld.co.us>; Bethany Pascoe <bpascoe@co.weld,co.us>; Jose Gonzalez cjgonza lez@co.weld.co.us>; Paul Wood cpwood@co.weld.co.us>; Janet Lundquist <jlundquist@co.weld.co.us>; Frank Haug <fhaug@co.weld.co.us> Subject: RE: TEMPORARY ASSEMBLY - Rocky Mountain Cider Company DBA Wild Cider Hi Chloe, a couple of items I noticed, the application makes reference to the Fire Department not requiring medical staff on site for the event. This is a requirement of our code and not a decision the Fire Department can make, The applicant will need to make sure they meet the minimum conditions as outlined in 12-1-30, The other item I noticed is in the application they estimate 1,000 people attending but in the notes on page 62 they indicate attendance at 2,000 plus. Let me know if I can help with anything. I will call the Fire Department and talk with them further. 3 Roy Roy Rudisill Director Office of Emergency Management 1150 0 Street 970-304-6540 Office 970-381-0417 Cell Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged/ confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chloe Rem pel Sent: Monday, September 26, 2016 4:02 PM To: Dan Joseph <djoseph@co.weld.co.us <mailto:cljoseph@co,eld.co,us> >; Deb Adamson <dadamson@co.weld.co.us <ma ilto:dadar nson@co.weld ,co.us> >/ Bethany Pascoe <bpascoe@co.weld.co.ors <mailto: bpascoe@co.weld ,co.us> >; Jose Gonzalez <jgonzalezco,weld.co,us<rnailto:jgonzalezco,weld.co,us> >; Paul Wood <pwoodco,weld.co,us <mailto:pwood@co.weld.co.us>>; Janet Lundquistqunclquist@comeld.co.us<mailtoUlundquist@co.weld.co.us>>; Roy Rudisill <rrudisill@co.weld.co.us <mailto:rrudisill@comeld.co.us>>; Frank Haug <fhaug@co.weld.co.us <mailtolhaug@co.weld.co.us>> Subject: TEMPORARY ASSEMBLY - Rocky Mountain Cider Company DBA Wild Cider Hello, 4 In accordance with the procedure for processing Temporary Assembly Applications, please review all records on the following document/establishment for any associated reports/incidents and return your report to the Weld County Clerk to the Board's Office within two weeks. Your report will be used by the Board of County Commissioners in considering the Applicant's Temporary Assembly Permit. PLEASE NOTE: The applicant has applied for a wine festival permit, which is an application that is processed solely by the State. The festival is a charity event, in which all proceeds will go to the Wild Animal Sanctuary. Additionally, the Wild Animal Sanctuary is currently working on a Special Events Permit because they will have breweries at the event, which are not covered under the wine festival. Please let me know if you have any questions. PLEASE RESPOND NO LATER THAN: Tuesday, October 4, 2016 Applicant: NAME AND ADDRESS: EVENT: File Location. Sincere regards, Chloe A. Rempel Deputy Clerk to the Board of Commissioners 1150 O Street Greeley, CO 80631 / PO Box 758 tel: : 970-400-4225 Rocky Mountain Cider Company DBA Wild Cider 11455 County Road 17 Firestone, CO 80504 Wild Animal Sanctuary Wine Festival LC0022 5 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited, 6 Chloe Rem el From: Sent: To: Subject: Jose Gonzalez Tuesday, September 27, 2016 11:35 AM Chloe Rempel RE: Special Events Permit - The Wild Animal Sanctuary No concerns from building division Thanks Jose Gonzalez Asst Building Official Building Department 1555 N.17thAve tel: : 970-400-3533 jgonzalez@welclgov.com Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chloe Rempel Sent: Tuesday, September 27, 2016 9:36 AM To: Dan Joseph <d joseph@co.weld.co.us>; Deb Adamson <dadamson @coaweld1co, us>; Bethany Pascoe <bpascoe@co.weld.co.us>; Jose Gonzalez <jgonzalez@cotweld.co.us>; Paul Wood cpwood@co.weld.co.us>; Janet Lundquist cjlundquist@co.weld,co.us>; Roy Rudisill crrud isi ll @co. a Id.co. us>; Frank Haug <fhaug@coeweld.co.us> Subject: FW: Special Events Permit - The Wild Animal Sanctuary Hello All, Please see the attached document (Special Event -- ADDITION TO APP — Wild Animal Sanctuary) in reference to the below Special Event Permit Application. The attached document should be used in addition to the original document from the below email. Please let me know if you have any questions. Thank you, Chloe A. Rempel Deputy Clerk to the Board of Commissioners 1150 O Street Greeley, CO 80631 PG Box 758 tel: 970-400-4225 Chloe Rempel From: Sent: To: Cc: Subject: Chloe and All, Paul Wood Tuesday, September 27, 2016 1:18 PM Chloe Rempel; Dan Joseph; Deb Adamson; Bethany Pascoe; Jose Gonzalez; Janet Lundquist Roy Rudisill; Frank Haug Paul Wood; Sam Kaneta III RE: Special Events Permit - The Wild Animal Sanctuary As this Special Events Permit is in conjunction with the Wild Cider's Temporary Assembly Application. The Weld County Sheriffs Office does not see an issue with the issuance of this permit. if you have any questions or concerns, please feel free to contact me, Thanks! Sergeant Paul Wood Animal Control/Municipal Policing, S chow Resource Units Weld County Sheriffs Office 1950 "0" Street, Greeley, CO 80631 pwoodCc co.wcJ.c 7'co,u Ofc: (7o) 356-4015 Ext. 2838 Direct (970) 400-2838 Fax: (97°) 304-6468 ill rill ‘ to old uK 44 e LAW; r w,nn "be Strong and Courageous." From: Chloe Rempel Sent: Monday, September 26, 2016 5:05 PM To: Dan Joseph; Deb Adamson; Bethany Pascoe; Jose Gonzalez; Paul Wood; Janet Lundquist; Roy Rudisill; Frank Haug Subject: Special Events Permit - The Wild Animal Sanctuary Hello, In accordance with the procedure for processing Special Event Permit Applications, please review all records on the following document/establishment for any associated reports/incidents and return your report to the Weld County Clerk to the Board's Office. Your report will be used by the Board of County Commissioners in considering the Applicants Special Event Permit, Please see in conjunction with Rocky Mountain Cider Company, DBA Wild Cider's Temporary Assembly Application, PLEASE RESPOND NO LATER THAN: Tuesday, October 4, 2016 Applicant: The Wild Animal Sanctuary 1946 County Road 53, Keenesburg, CO 80643 Event Address: 11455 County Road 17, Firestone, CO 80504 1 Chloe Item el From: Sent: To: Cc: Subject: Hi Adam, Chloe Rempel Thursday, October 06) 2016 9:30 AM 'Adam Gorove' Frank Haug Wine Festival Event I am still awaiting the documents that our County Attorney requested on Tuesday regarding the additional parking on an adjacent lot. Just as a reminder, we need a copy of a signed letter from the property owner that states you are allowed to use their property for parking, We also need a map that shows how/where cars will be parked, and the access point between the two properties for people to walk back and forth from (people cannot walk back and forth on the county road). Let me know if you have any questions. Thank you, Chloe A. Rempel Deputy Clerk to the Board of Commissioners 1150 O Street Greeley, CO 80631 PG Box 758 tee: 970-400-4225 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication, Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 1 Chloe Rempel From: Sent: To: Subject: Works for me. Michelle Martin Planning Manager 1555 N 17th Ave Greeley, CO 80631 mm artin@co.weld.co.us PHONE: (970) 400-3571 FAX: (970) 304-6498 Michelle Martin Friday, October 14, 2016 12:25 PM Chloe Rempel RE: Temp Assembly - Wild Cider AND Special Event - Wild Animal Sanctuary -- Wine Festival and Beer Garden Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chloe Rempel Sent: Friday, October 14, 2016 10:55 AM To: Dan Joseph <djoseph@co.weld.co.us>; Deb Adamson <dadamson@co.weld.co.us>; Bethany Pascoe <bpascoe@co.weld.co.us>; Janet Lundquist <jlundquist@co.weld.co.us>; Michelle Martin <mmartin@co.weld.co.us> Cc: Frank Haug <fhaug@co.weld.co.us> Subject: Temp Assembly - Wild Cider AND Special Event - Wild Animal Sanctuary -- Wine Festival and Beer Garden Hello All, Please see the attached updated application packets. I believe the most notable additions are in relation to overflow parking. The applicants have secured the neighbor's property for extra parking. They have provided a letter from the adjacent property owner providing permission to use their property, a photo of the gate between the two properties, and a map showing the parking plan. This is up for review on Monday's agenda. Can you all please send me your recommendations asap? Thank you, Chloe A. Rempel Deputy Clerk to the Board Weld County 1 1150 O Street Greeley, CO 80631 tel: 970-400-4225 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chloe Rempel Sent: Monday, September 26, 2016 4:02 PM To: Dan Joseph <djoseph@co.weld.co.us>; Deb Adamson <dadamson@co.weld.co.us>; Bethany Pascoe <bpascoe@co.weld.co.us>; Jose Gonzalez <jgonzalez@co.weld.co.us>; Paul Wood <pwood@co.weld.co.us>; Janet Lundquist <jundquist@co.weld.co.us>; Roy Rudisill <rrudisill@co.weld.co.us>; Frank Haug <fhaug@co.weld.co.us> Subject: TEMPORARY ASSEMBLY - Rocky Mountain Cider Company DBA Wild Cider Hello, In accordance with the procedure for processing Temporary Assembly Applications, please review all records on the following document/establishment for any associated reports/incidents and return your report to the Weld County Clerk to the Board's Office within two weeks. Your report will be used by the Board of County Commissioners in considering the Applicant's Temporary Assembly Permit. PLEASE NOTE: The applicant has applied for a wine festival permit, which is an application that is processed solely by the State. The festival is a charity event, in which all proceeds will go to the Wild Animal Sanctuary. Additionally, the Wild Animal Sanctuary is currently working on a Special Events Permit because they will have breweries at the event, which are not covered under the wine festival. Please let me know if you have any questions. PLEASE RESPOND NO LATER THAN: Tuesday, October 4, 2016 Applicant: NAME AND ADDRESS: EVENT: File Location: Sincere regards, Rocky Mountain Cider Company DBA Wild Cider 11455 County Road 17 Firestone, CO 80504 Wild Animal Sanctuary Wine Festival LC0022 2 Chloe A. Rempel Deputy Clerk to the Board of Commissioners 1150 O Street Greeley, CO 80631 / PO Box 758 tel: 970-400-4225 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chloe Rempel Sent: Monday, September 26, 2016 5:05 PM To: Dan Joseph <djoseph@co.weld.co.us>; Deb Adamson <dadamson@co.weld.co.us>; Bethany Pascoe <bpascoe@co.weld.co.us>; Jose Gonzalez <jgonzalez@co.weld.co.us>; Paul Wood <pwood@co.weld.co.us>; Janet Lundquist <jlundquist@co.weld.co.us>; Roy Rudisill <rrudisill@co.weld.co.us>; Frank Haug <fhaug@co.weld.co.us> Subject: Special Events Permit - The Wild Animal Sanctuary Hello, In accordance with the procedure for processing Special Event Permit Applications, please review all records on the following document/establishment for any associated reports/incidents and return your report to the Weld County Clerk to the Board's Office. Your report will be used by the Board of County Commissioners in considering the Applicant's Special Event Permit. Please see in conjunction with Rocky Mountain Cider Company, DBA Wild Cider's Temporary Assembly Application. PLEASE RESPOND NO LATER THAN: Tuesday, October 4, 2016 Applicant: The Wild Animal Sanctuary 1946 County Road 53, Keenesburg, CO 80643 Event Address: 11455 County Road 17, Firestone, CO 80504 File Location: LC0022 Thank you, Chloe A. Rempel Deputy Clerk to the Board of Commissioners 1150 O Street Greeley, CO 80631 /PO Box 758 tel: 970-400-4225 3 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 4 Chloe Rempel From: Sent: To: Cc: Subject: Janet Lundquist Friday, October 14, 2016 12:22 PM Chloe Rempel Frank Haug RE: Temp Assembly - Wild Cider AND Special Event - Wild Animal Sanctuary -- Wine Festival and Beer Garden Public Works doesn't have any concerns with the changes or this event. Janet Lundquist Support Services Manager Weld County Public Works Dept. P.O. Box 758, Greeley, CO 80632 Tele-970.356.4000 ext 3726 Fax- 970.304.6497 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chloe Rempel Sent: Friday, October 14, 2016 10:55 AM To: Dan Joseph; Deb Adamson; Bethany Pascoe; Janet Lundquist; Michelle Martin Cc: Frank Haug Subject: Temp Assembly - Wild Cider AND Special Event - Wild Animal Sanctuary -- Wine Festival and Beer Garden Hello All, Please see the attached updated application packets. I believe the most notable additions are in relation to overflow parking. The applicants have secured the neighbor's property for extra parking. They have provided a letter from the adjacent property owner providing permission to use their property, a photo of the gate between the two properties, and a map showing the parking plan. This is up for review on Monday's agenda. Can you all please send me your recommendations asap? Thank you, Chloe A. Rempel Deputy Clerk to the Board Weld County 1 Chloe Rempel From: Sent: To: Cc: Subject: Attachments: Bethany Pascoe Friday, October 14, 2016 3:19 PM Chloe Rempel Frank Haug RE: Temp Assembly - Wild Cider AND Special Event - Wild Animal Sanctuary -- Wine Festival and Beer Garden LC0022.2016.doc Please see staff's attached Referral Response. Thank -you Bethany Pascoe Zoning Compliance Officer II Department of Planning Services 1555 N 17th Ave, Greeley, Co 80631 970-400-3555 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chloe Rempel Sent: Friday, October 14, 2016 10:55 AM To: Dan Joseph <djoseph@co.weld.co.us>; Deb Adamson <dadamson@co.weld.co.us>; Bethany Pascoe <bpascoe@co.weld.co.us>; Janet Lundquist <jlundquist@co.weld.co.us>; Michelle Martin <mmartin@co.weld.co.us> Cc: Frank Haug <fhaug@co.weld.co.us> Subject: Temp Assembly - Wild Cider AND Special Event - Wild Animal Sanctuary -- Wine Festival and Beer Garden Hello All, Please see the attached updated application packets. I believe the most notable additions are in relation to overflow parking. The applicants have secured the neighbor's property for extra parking. They have provided a letter from the adjacent property owner providing permission to use their property, a photo of the gate between the two properties, and a map showing the parking plan. This is up for review on Monday's agenda. Can you all please send me your recommendations asap? Thank you, Chloe A. Rempel Deputy Clerk to the Board Weld County 1150 O Street 1 MEMORANDUM To: Chloe Rempel, Deputy Clerk to the Board October 14, 2106 From: Bethany Pascoe, Zoning Compliance Officer, Dept. of Planning Services Subject: LC0022 Upon review of the Special Events Permit and Temporary Assembly Permit by the Department of Planning Services shows the following: TEMPORARY ASSEMBLY PERMIT INFORMATION: Owner: Mark Birkin 11455CR17 Firestone, Co 80504 Rocky Mountain Cider Co Dba Wild Cider 11455CR17 Firestone, Co 80504 SPECIAL EVENTS PERMIT INFORMATION: The Wild Animal Sanctuary 1946 County Road 53 Keenesburg, Co 80643 Dates: October 22, 2016 10 AM — 4 PM Maximum number of people: 1000 (Temporary Assembly) 1000 estimated (Special Events) PROPERTY INFORMATION: Zone District: Agriculture Upon review of my case files and computer, no active violations were noted. There is an existing Use by Special Review (USR13-00119) for a Winery (Cidery and Tasting Room) and Breakfast Facility. This USR also referred to Special Events occurring on -site. SERVICE, TEAMWORK, INTEGRITY, QUALITY Chloe Rempel From: Sent: To: Subject: I just spoke to him. Frank Haug Monday, October 17, 2016 8:39 AM Chloe Rempel roys okay with it Frank N. Haug Assistant Weld County Attorney 1150 O Street Mailing Address: P.O. Box 758, Greeley, CO 80632 tel: (970) 356-4000 x4394 fax: (970) 352-0242 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 1 Chloe Rempel From: Sent: To: Subject: Roy Rudisill Monday, October 17, 2016 8:52 AM Chloe Rempel RE: Temp Assembly - Wild Cider AND Special Event - Wild Animal Sanctuary --Wine Festival HI Chloe, I just talked to Frank and let him know that I have talked with the First Responder agencies that have jurisdiction and they have no issues with the event. Mt View Fire will take the lead on an incident action plan if it meets their requirements but at this time it looks like they will just monitor the event. No concerns from OEM. Roy Rudisill Director Office of Emergency Management 1150 O Street 970-304-6540 Office 970-381-0417 Cell Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Chloe Rempel Sent: Friday, October 14, 2016 10:49 AM To: Roy Rudisill <rrudisill@co.weld.co.us> Subject: Temp Assembly - Wild Cider AND Special Event - Wild Animal Sanctuary --Wine Festival Hi Roy, Please see the attached updated application packets. Also, now that you've had a chance to speak with Frank, would you mind sending me an email with your recommendation to the board? Thank you! Chloe A. Rempel Deputy Clerk to the Board Weld County 1 Chloe Rempel From: Sent: To: Subject: Here you go. Frank Haug Monday, October 17, 2016 8:50 AM Chloe Rempel FW: wild cider wine festival Frank N. Haug Assistant Weld County Attorney 1150 O Street Mailing Address: P.O. Box 758, Greeley, CO 80632 tel: (970) 356-4000 x4394 fax: (970) 352-0242 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. Original Message From: Dan Joseph Sent: Monday, October 17, 2016 8:49 AM To: Frank Haug <fhaug@co.weld.co.us>; Deb Adamson <dadamson@co.weld.co.us> Subject: RE: wild cider wine festival Nope. They are good to go. Dan Joseph CP-FS Food Program Coordinator Weld County Department of Public Health and Environment 1555 North 17th Avenue Greeley, CO 80631 phone: 970.304.6415 x 2206 fax: 970.304.6411 1 ru H H N C co ru Ui H c0 X O) W U a3 E L Z l¢� "To most locations. 12 V co V ) co 0- E' W PULL AND RETAIN THIS COPY BEFORE AFFIXING TO THE PACKAGE. NO POUCH NEEDED. 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