HomeMy WebLinkAbout20143628.tiffRESOLUTION
RE: GRANT REQUEST TO WAIVE LATE FEE, APPROVE RENEWAL APPLICATION FOR
TAVERN LIQUOR LICENSE FROM VIPER 2, INC., DBA BORDERLINE, AND
AUTHORIZE CHAIR TO SIGN - EXPIRES SEPTEMBER 7, 2015
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, on October 1, 2014, Viper 2, Inc., dba Borderline submitted a renewal
application for a Tavern Liquor License, for the sale of malt, vinous and spirituous liquors, after
the expiration date of September 7, 2014, and
WHEREAS, on November 3, 2014, the Board deemed it advisable to continue said
matter until November 10, 2014, to allow adequate time for the Applicant to be present, and
WHEREAS, pursuant to Exhibit 5-H of the Weld County Code, said applicant has paid
the sum of $175.00 to the County of Weld for the renewal of the existing license, as well as a
request for waiver of the $500 late application fee, which the Board deemed advisable to grant,
and
WHEREAS, said applicant has previously exhibited a State Liquor License for the sale
of malt, vinous and spirituous liquors for consumption by the drink on the premises only, outside
the corporate limits of any town or city in the County of Weld at the location described as
follows:
68947 U.S. Highway 85
Carr, Colorado 80612
WHEREAS, the Licensee shall host "responsible vendor" training every six (6) months
as agreeable to the Colorado Department of Revenue Liquor Enforcement Division, and this
training shall be open to other area licensees. Each employee shall be "responsible vendor"
trained, and the Licensee shall provide documentary evidence that each employee has been
"responsible vendor" trained to the Weld County Sheriff's Office within thirty (30) days of the first
available "responsible vendor" class after hiring. Evidence of such shall be included in the
referral report submitted by the Sheriff's Office at the time of annual renewal.
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 License Number 2014-23 to said applicant to sell malt, vinous and
spirituous liquors for consumption by the drink on the premises only, only at retail at said
location; and the Board does hereby authorize and direct the issuance of said license by the
Chair of the Board of County Commissioners, attested to by the Clerk to the Board of Weld
County, Colorado, which license shall be in effect until September 7, 2015, providing that said
place where the licensee is authorized to sell malt, vinous, and spirituous liquors for
consumption by the drink on the premises only, shall be conducted in strict conformity to all of
the laws of the State of Colorado and the rules and regulations relating thereto, heretofore
passed by the Board of County Commissioners of Weld County, Colorado, and any violations
thereof shall be cause for revocation of the license.
2014-3628
C C • 5o 1212 0u 2/9)
LC0047
RENEW LIQUOR LICENSE - BORDERLINE
PAGE 2
BE IT FURTHER RESOLVED by the Board that the request to waive the late application
fee, in the amount of $500.00 be, and hereby is, granted.
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 10th day of November, A.D., 2014.
ATTEST: d
Weld County Clerk to the
B
Dep
APPROVED AS TO FORM:
Clerk tot e B
County Attorney
Date of signature: Ii12y
BOARD OF COUNTY COMMISSIONERS
WELD cQ?5 LOLO DO
uglas(Rademacher! Chair
ti Pti�l1Z�
fbara Kirkmeyer, Pro -Teem
Sean P. Conway
Mike Freeman
l
William F. Garcia
2014-3628
LC0047
THIS LICENSE MUST BE POSTED IN PUBLIC VIEW
DR 8402 (07/01/2012)
STATE OF COLORADO
DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
1881 Pierce Street, Suite 108
Lakewood, Colorado 80214
VIPER 2 INC
dba BORDERLINE
68947 HIGHWAY 85
CARR CO 80612
ALCOHOL BEVERAGE LICENSE
Liquor License Number
42078520000
License Expires at Midnight
September 07, 2015
License Type
TAVERN (COUNTY)
Authorized Beverages
MALT, VINOUS, AND SPIRITUOUS
This license 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 license is nontransferable
and shall be conspicuously posted in the place above described. This license is only valid
through the expiration date shown above. Any questions concerning this license should be
addressed to: Colorado Liquor Enforcement Division, 1881 Pierce Street, Suite 108, Lakewood,
CO 80214.
In testimony whereof, I have hereunto set my hand. 11/17/2014
Ooduon
Division Director Executive Director
THIS LICENSE EXPIRES NOVEMBER 10, 2015
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NON -TRANSFERABLE.
DR 8400 (Revised 09/01/12)
COLORADO DEPARTMENT OF REVENUE
LIQUOR ENFORCEMENT DIVISION
SUBMIT TO LOCAL LICENSING AUTHORITY
LIQUOR OR 3.2 BEER LICENSE
RENEWAL APPLICATION
RECEIVED
OCT 01 2014
COMMISSIONERS
Fees Due
Renewal Fee
Storage Permit $100 x
Optional Premise $100 x
Amount Due/Paid
Make check payable to: Colorado Department of Revenue.
The State may convert your check to a one-time electronic
banking transaction. Your bank account may be debited as early
as the same day received by the State. If converted, your check
will not be returned. If your check is rejected due to insufficient or
uncollected funds, the Department may collect the payment
amount directly from your banking account electronically.
• .. .-.w r as urun r c MLL IIVCUKMA IION BELOW
/
RETURN TO CITY OR COUNTY LICF NSIN6 AUTHORITY RY DUE
kicepsee ame
license
PAIR
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Stregt Address
Type /�yy '' 11
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1. Do you have legal possession of the premises at the street address above? I YES ❑
Is the premises owned or rented? ❑ Owned Cil Rented' 'If rented, expiration date
NO
of lease} r7 "1Q�rj
2. Since the date of filing of the last annual application, has there been any change in financial
or organizational structure (addition or deletion of officers, directors, managing members or
and attach a listing of all liquor businesses in which these new lenders, owners (other
directors, managing members, or general partners are materially interested. ❑ YES
NOTE TO CORPORATION, LIMITED LIABILITY COMPANY AND PARTNERSHIP APPLICANTS:
officers, directors, managing members, general partners or persons with 10% or more interest
and return immediately to your Local Licensing Authority, Form DR 8177: Corporation,
Report of Changes, along with all supporting documentation and fees.
3. Since the date of filing of the last annual application, has the applicant or any of its agents,
(other than licensed financial institutions) been convicted of a crime? If yes, attach a detailed
4. Since the date of filing of the last annual application, has the applicant or any of its agents,
(other than licensed financial institutions) been denied an alcohol beverage license, had an
revoked, or had interest in any entity that had an alcohol beverage license denied, suspended
explanation. ❑ YES tt3;r( NO
5. Does the applicant or any of its agents, owners, managers, partners or lenders (other than licensed
or indirect interest in any other Colorado liquor �icRnse, including loans to or from any licensee
yes, attach a detailed explanation. ❑ YES NO
6. SOLE PROPRIETORSHIPS, HUSBAND -WIFE PARTNERSHIPS AND PARTNERS IN GENERAL
must complete and sign the DR 4679: Affidavit — Restriction on Public Benefits (available
attach a copy of their driver's license, state -issued ID or valid passport.
interest (new notes, loans, owners, etc.)
general partners)? If yes, explain in detail
n licensed financial institutions), officers,
NO
If you have added or deleted any
in your business, you must complete
Limited Liability Company or Partnership
owners, managers, pa er or lenders
explanation. ❑ YES NO
owners, managers, partners or lenders
alcohol beverage license suspended or
or revoked? If yes, attach a detailed
financial institutions) have a direct
or interest in a loan to any licensee? If
PARTNERSHIPS: Each person
online or by calling 303-205-2300) and
AFFIRMATION & CONSENT
I declare under penalty of perjury in the second degree that this application and all attachments are true, correct
and complete to the best of my know/edge.
Ty
or Prin
Name of plica
thorized Agent of Business
,q
j—
Sig a re
'REPOR
Dll
�' I Li
T A 11 RVAL OF CITY OR COUNTY LICENSING AUTHORITY
The foregoing applhsaudn has been examined and the premises, business conduct-.. art
that such license, if granted, will comply with the provisions of Title 12, Articles 46 ��,; .I ire applicant
P � �� y�J iRE
are APPLICATION , and we Rdhereby report
THIS IS APPROVED.
Local Licensing Authority For .�
Weld County, Colorado r on�1
DV 0 2014
Si � ri � r lr
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ature : Do gla acher
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.Chair Bo rd o• Mot
County Cn �. �„ 1'''"'
L.aar_�
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unIhAa lin--i
Clerk to
he Board
2014-3431
September 28, 2014
Re: Viper 2, Inc.
DBA: Borderline Cantina
Liquor License Renewal Application
To Whom It May Concern,
RECEIVED
OCT 01 2014
WELD COUNTY
COMMISSIONERS
It has appeared that our liquor license paperwork/ renewal application must have been lost in
the mail this year. We never received the paperwork to renew our liquor license therefore we
are submitting our paperwork and payment now. We have been in operation for 10 years and
this has never happened to us before. We have been in contact with Rafaela Martinez
regarding submitting our payments and renewal application. She has been extremely helpful.
We understand there should be a late fee assessed to our company. We are asking with
complete consideration that the late fee be waived due to our previous history with the State
and County being in great standings. We have never had this happen before and feel it was
completely a mailing mistake.
We appreciate your considerations and are more than willing to answer any questions you may
have.
Regards
4.
Kimberly Chavez
President of Vip
Borderline
720-937-6151
RECEIPT DATE /0-/ -c,2)/4 NO 87773
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BY
DATE 10-/-2o1'/ No 87774
V youo2, tint. dbarimytadmiti &i.t&noJ
Rafaela Martinez
From:
Sent:
To:
Subject:
Frank Piacentino
Wednesday, October 01, 2014 12:46 PM
Rafaela Martinez
RE: Liquor License Renewal - Viper 2, Inc, dba Borderline (Cantina)
Rafaela,
Building Inspection Department has no concern with the renewal of liquor license.
Frank Piacentino
Building Official
Weld County Building Inspection
970-353-6100 Ext 3531.
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: Rafaela Martinez
Sent: Wednesday, October 01, 2014 12:08 PM
To: Brad Yatabe; Bob Choate; Roy Rudisill; Janet Lundquist; Lisa Carpenter; Mark Mellon; Frank Piacentino; Bethany
Pascoe; Dan Joseph; Deb Adamson
Subject: Liquor License Renewal - Viper 2, Inc, dba Borderline (Cantina)
In accordance with the procedure for Liquor Licenses, please review all records on the following document for any
associated reports/incidents during the last year 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 Approval and renewal
of the Applicant's Liquor License.
PLEASE RESPOND NO LATER THAN: October 15, 2014
Applicant: Viper 2, Inc., dba Borderline (Cantina)
File Location: LC0047
Thank you!
Rafaela .7!. .Martinez
Deputy Clerk to the Board
1150 O Street P.O. Box 758(Greeley, CO 80632
tel: (970) 336-7215 X5226
Rafaela Martinez
From:
Sent:
To:
Subject:
Janet Lundquist
Thursday, October 02, 2014 11:49 AM
Rafaela Martinez
RE: Liquor License Renewal - Viper 2, Inc, dba Borderline (Cantina)
This is an existing location. Public Works doesn't have any comments at this time.
Janet Lundquist
Traffic Engineer
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: Rafaela Martinez
Sent: Wednesday, October 01, 2014 12:08 PM
To: Brad Yatabe; Bob Choate; Roy Rudisill; Janet Lundquist; Lisa Carpenter; Mark Mellon; Frank Piacentino; Bethany
Pascoe; Dan Joseph; Deb Adamson
Subject: Liquor License Renewal - Viper 2, Inc, dba Borderline (Cantina)
In accordance with the procedure for Liquor Licenses, please review all records on the following document for any
associated reports/incidents during the last year 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 Approval and renewal
of the Applicant's Liquor License.
PLEASE RESPOND NO LATER THAN: October 15, 2014
Applicant: Viper 2, Inc., dba Borderline (Cantina)
File Location: LC0047
Thank you!
Rifaela .4.Martinez
Deputy Clerk to the Board
1150 O Street/P.O. Box 758/Greeley, CO 80632
tel: (970) 336-7215 X5226
MEMORANDUM
To: Rafaela Martinez, Deputy Clerk to the Board October 1, 2014
From: Bethany Pascoe, Zoning Compliance Officer, Dept. of Planning Services
Subject: LC0047
Review of the following liquor license renewal by the Department of Planning Services shows the following:
42-07852-0000
Viper2, Inc.
dba Borderline
68947 Highway 85
Carr, CO 80612
Zone District: A (Agricultural)
This use is permitted through an Amended Use by Special Review (AmUSR-1096) permit.
Based upon my computer and case files, staff is not aware of any active zoning violations on the above
mentioned property.
SERVICE, TEAMWORK, INTEGRITY, QUALITY
To: Weld County Board of Commissioners
From: Deputy Lisa Carpenter
Date: October 7, 2014
RE: Viper 2, lnc./DBA Borderline
Dear Commissioners,
I have researched and found no reported calls for service to Viper 2, Inc./DBA Borderline
located at 68947 Hwy 85, Carr, CO 80612 for the Calendar year of 2013 to present day.
During the inspection to the Viper2, Inc./DBA Borderline, I noticed that there are no
meals or snacks available, other than the chips and candy bars located in the vending machines.
I do not recommend approval for the renewal of the liquor license, until proof is shown
that appropriate meals and snacks are available.
Respectfully Submjed,
Deputy Lisa Carpenter
Community Resource Officer
Weld County Sheriff's Office
1950 "O" Street
Greeley, CO 80631
WELD COUNTY SHERIFF'S OFFICE
Communit}+ResoLice Office
LiquoR ENFORQENtENT WORKSHEET
1950 O'Street
Greeley, Colorado 80631
Voice (970) 3554015 • Fax (970) 304-6467
Inspection Report
Incident Roport
Lrcw.ue T:aae Name: ' ( ',
license Name:
License. # I Type: TT� c !L
Dale of Report l lnadtnt
/6
7- /4/
Address:IQR �/7 f„ ,,e
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Person Contacted. l
4d,,,,,,_'�//�T/Q`�✓
City, State, Zip.. 1 /2 �C J
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Telepl;cne 8: -
C C'
State Liquor License Posted
=
1
Manager Registered
State Sales Tax License Posted
,
Licerse in Control of Premises
County Liquor License Posted
'-
Trade Name Properly Registered
,.-
Federal Form 11 ' Call (800) 398-2822
✓
Premises Physical Control Adequate
41'
Food Service License Posted
Acceptable Dispensing System
✓
Minor Warning Sign Posted
4�
►f
Off Premise Storage Licensed
✓
Meals and Snacks Available
Only Permi I d Items Sold
✓
Cleanliness Adequate
Alcohol F Permitted Source
Books & Invoices Available
✓
Discus ales of Liquor ors
'--
.
j
Alcohol Beverage Stock Acceptable
,/
Disc s Sales to Into ' Perms
✓
[]Warning OFollow-Up inspection
6/en
Violation:
I Dade:
I Time.
Subcot:
I DOE: tIgt:
Wgt: 1 Eyes:
11-Laa:
Collung
DL 110>:
Stale:
Address:
.
City:
Slate:
7,p:
Evidence: Yes NO
Hnti Phone M:
Summons #:
Court Date:
Photos: Yes NO
Narrative: `f c. 8 S, - UC1oO
Deputy:
#: Jti e 6 Date:
Rafaela Martinez
From:
Sent:
To:
Subject:
Rafaela,
Dan Joseph
Monday, October 13, 2014 8:45 AM
Rafaela Martinez
RE: Viper 2
We have never seen food products like burritos, pizzas or soups there. Most of what we see
is a quart of milk (for coffee). The kitchen is available, but most of their equipment isn't
turned on. The few coolers that are on are for another person who uses that facility as a
commissary (he does BBQ).
They haven't had much for violation from us because they do so little. Generally we check
out things like soap and paper towels at sinks, etc., but during our visits there is usually
one person selling lotto tickets, and that is all they do while we are up there.
Dan
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
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: Rafaela Martinez
Sent: Thursday, October 09, 2014 2:15 PM
To: Dan Joseph
Cc: Lisa Carpenter
Subject: FW: Viper 2
Good Afternoon Dan,
Normally I try not to bother you with requests, especially for Liquor referrals, but since
this referral from the Sheriff's Office came back with a recommendation of denial, I wanted
to request one from you as well. Could you please send me a Referral response for Viper 2,
dba Borderline (Cantina)? This is a liquor license renewal. Please see the attached Sheriff's
Office referral response.
Thank you!
Rafaela A. Martinez
Deputy Clerk to the Board
1150 0 StreetlP.O. Box 758IGreeley, CO 80632
tel: (970) 336-7215 X5226
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: Lisa Carpenter
Sent: Thursday, October 09, 2014 12:51 PM
To: Rafaela Martinez
Subject: Viper 2
Original Message
From: IT-Canon(co.weld.co.us [mailto:IT-Canon(co.weld.co.us]
Sent: Thursday, October 09, 2014 11:37 AM
To: Lisa Carpenter
Subject: Attached Image
2
Rafaela Martinez
From:
Sent:
To:
Subject:
Bethany Pascoe
Monday, October 13, 2014 11:55 AM
Rafaela Martinez
RE: Viper 2
Found it... LC0047... My referral would not change. Restaurant is called out as a use under
their AmUSR.
Please feel free to contact me with any questions or concerns.
Bethany Pascoe
Zoning Compliance Officer II
1555 North 17th Avenue
Greeley, CO 80631
Office: (970)353-6100 Ext. 3555
Fax: (970)304-6498
Web: www.co.weld.co.us
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: Rafaela Martinez
Sent: Monday, October 13, 2014 10:01 AM
To: Bethany Pascoe
Subject: FW: Viper 2
Bethany,
Could you please re -confirm compliance for this location based off of this new information
(Commissary for BBQ?)
Thanks Bethany!
Rafaela
Rafaela A. Martinez
Deputy Clerk to the Board
1150 0 StreetIP.O. Box 758IGreeley, CO 80632
tel: (970) 336-7215 X5226
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
1
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 13, 2014 8:45 AM
To: Rafaela Martinez
Subject: RE: Viper 2
Rafaela,
We have never seen food products like burritos, pizzas or soups there. Most of what we see
is a quart of milk (for coffee). The kitchen is available, but most of their equipment isn't
turned on. The few coolers that are on are for another person who uses that facility as a
commissary (he does BBQ).
They haven't had much for violation from us because they do so little. Generally we check
out things like soap and paper towels at sinks, etc., but during our visits there is usually
one person selling lotto tickets, and that is all they do while we are up there.
Dan
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
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: Rafaela Martinez
Sent: Thursday, October 09, 2014 2:15 PM
To: Dan Joseph
Cc: Lisa Carpenter
Subject: FW: Viper 2
Good Afternoon Dan,
Normally I try not to bother you with requests, especially for Liquor referrals, but since
this referral from the Sheriff's Office came back with a recommendation of denial, I wanted
to request one from you as well. Could you please send me a Referral response for Viper 2,
dba Borderline (Cantina)? This is a liquor license renewal. Please see the attached Sheriff's
Office referral response.
2
Thank you!
Rafaela A. Martinez
Deputy Clerk to the Board
1150 0 StreetIP.O. Box 758IGreeley,
tel: (970) 336-7215 X5226
CO 80632
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: Lisa Carpenter
Sent: Thursday, October 09, 2014 12:51 PM
To: Rafaela Martinez
Subject: Viper 2
Original Message
From: IT-Canon@co.weld.co.us [mailto:IT-Canon@co.weld.co.us]
Sent: Thursday, October 09, 2014 11:37 AM
To: Lisa Carpenter
Subject: Attached Image
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U.S. Postal ServiceTM
CERTIFIED MAIL RECEIPT
(Domestic Mall Only; No Insurance Coverage Provided)
Postage
Certified Fee
Return Receipt Fee
(Endorsement Required)
Restricted Delivery Fee
(Endorsement Required)
Total Postage & Fees
Postmark
Here
PS Form 3800. June 2002
See Reverse for Instructions
SENDER: COMPLETE THIS SECTION
• Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
• Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
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Vqpah 2 d1,0_. bkii-ofticw
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D. Is delivery address differs •m item 1? O Yes
If YES, enter delivery address below: ❑ No
3. Service Type
Ja Certified Mails
❑ Registered
O Insured Mall
❑ Priority Mail Express-
o Return Receipt for Merchandise
❑ Collect on Delivery
4. Restricted Delivery? (Extra Fee)
O Yes
2. Article Number
(Transfer from service label)
PS Form 3811, July 2013
7004 2890 0003 5708 9844
Domestic Retum Receipt
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