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Home My WebLink About2004-09-15 LLA MEETING MATERIALSLIQUOR LICENSING AUTHORITY AGENDA ITEM NO. 1 a) DATE: September 15 , 2004 REASON FOR COMING BEFORE THE AUTHORITY: a) Telephone Poll of September 1, 2004 NAME OF BUSINESS & ADDRESS COMMENTS: Consideration of Minutes LIQUOR LICENSING AUTHORITY AGENDA ITEM NO. 2a) DATE: September 15 , 2004 REASON FOR COMING BEFORE THE AUTHORITY: NAME OF BUSINESS & ADDRESS a) Englewood Elk's #2122 3690 S. Jason St. New Treasurer -Richard C. Carlson Change of Corporate Structure TYPE OF ACTION REQUIRED: _X_APPROVE OR DENY __ RESOLUTION COMMENTS: SET HEARING DATE -- __ INFORMATION ONLY All forms have been received. No fees required for Clubs due to the constant change of their corporate structure. DR 81,7 (051 PAGE 1 CC'LOR>" DEPARTMENT OF REVENUE •· LIOU ENFORCEMENT DIVISION 1375 SHEAMAN STREET DENVER CO 80261 (303) 205-2300 (2355)~ LLC (2350)f j CORPORATION 7. Mailing Address if dlllerenl than above 21 LIMITED LIABILITY COMPANY AND CORPORATE REPORT OF CHANGES Liquor and 3.2 Beer Licenses Submit to. Local Authority {Local Authority will submit to State) $100 PER MEMBER FOR BACKGROUND INV. $100 PER PRINCIPLE FOR BACKGROUND INV. 2. State Tax Accounl Number City / DO NOT WRITE IN THIS SPACE 5. TelephOne Number ,d30$-7L?/~~ State ZIP Code {!_~ ~~/)tJ State ZIP Code 8. LIST ALL officers, directors (corporation) or Managing Members (L.L.C.). Attach a certificate of designation (good standing) and each officer, director or manager MUST FILL OUT a DR 8404-1 (Individual History Record). -posilion Names of ALL Officers, Held Directors or Managing Members DOB Home Address Replaces 'cf};'~.~ f( ~e)t,;r,A'J (" (1 LJ-~/v. ... / :JIJ<..">r 1,,1 i!/:J•.1r1A~,,/ Av.o //-~/A' LA-~d'7 <:\,. . .-L rz;f( c..,~A JPl-r9..f (I;.') xnJ<J/1 9. LIST ALL 10% (or more) Stockholders or 10% (or more) Members. All 10% (or more) stockholders and members MUST also fill out DR 8404-1 (Individual History Record). Stockholders/Members •;. Home Address DOB Replaces owning 10•1. (or more) of business Owned l--~--''--~"--~~~~~~--t-~~-t-~~~~~~~~~~~~~~~~1---~~-r-~--~~~~--i 1 0. Registered Agen.~ I Address For Service / OATH OF APPLICANT I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to th.e best of my knowledge. ·· · 1Tit1eT~_o~~,,f/..P~ REPORT OF LOCAL LICENSING AUTHORITY / I The foregoing changes have been received and examined by the Local Licensing Authority. 1 2. Lo~I Licensinr .... ~~"~.' For 0 County 0 Town/City '-=---Signature I Tille Date Anesi Date DO NOT WRITE IN THIS SPACE -FOR DEPARTMENT OF REVENUE USE ONLY LIABILITY INFORMATION License Account Number Period Cash Fund TOTAL -100 (999) AFFIDAVIT CONCERNING CRIMINAL HISTORY I, My date of birth is __ 4....,._..j?tl.__2_3_/_Cf_C(_r;-____ _ ~ (initial) (initial) Offense I certify that I have not been convicted of any criminal offense excluding minor traffic offenses ofless than eight (8) points but including any traffic offense in which drugs or alcohol were involved. OR I cenify·that I have been convicted of the following criminal offenses . List offense, date of conviction, court and case number, and state and county of the court. (Minor traffic offenses ofless than eight (8) points need not be listed if no alcohol or drugs were involved.) Date of Conviction Court & Case Number State & County of the Court ------------------- State of Colorado · ) ) SS County of Arapahoe ) lb£!_~--- . sigrultUfC8Dd Date Subscribed and sworn to before me on this 7,7 -rJI day of ¥t . ..1-9 ;)0()':{ expires: &/ffa~------ affcrim 4 • DR 8404-1 (02/94) COLORADO DEPARTMENT OF REVENUE UOUQA ENFORCEMENT DIVISION 1375 SHEAMAN STREET DENVER CO 80261 INDIVIDUAL HISTORY RECORD To be completed by each individual applicant, all general partners of a partnership, all limited partners owning 10% (or more) of a partnership; all officers and directors of a corporation, all stockholders of a corporation owning 10% (or more) of the stock of such corporation ; all limited liability company MANAGING members, or other limited liability company members with a 10% (or mora) ownership interest in such company and all managers of a Hotel and Restaurant license. NOTICE: This individual history record provides basic information which is necessary for the licensing authorities investigation . ALL questions must be answered in their entirety . EVERY answer you give will be checked for its truthfulness. A deliberate falsehood will jeopardize the application as such falsehood within Itself constitutes evidence regarding the character of the applicant. Date I 3. Also Known. As (maiden name/n ickname, e1c .) 4. Mailing AOOress (ii OiH erent lrom resiOence) Home Telephone '303. 798'·3cJ;2:> 0 No When Name ot U.S. Dismct Coun Naturaliz auon Cenrticate Numoer Date ol Cemficate II an Alien . Give Allen 's Registr.u1on Cara Numoer P!rmanent AeSldence C.;rd Numcer 13. Present Posmon C-r:; Ow 1.i "1a111a1 Status 16 1 i . a oress. 11 different tnan yours (street ano numoer . cu y. state . ZIP) List the name(s) of II relatives working in or having a financial interest in the liquor industry. NAME OF RELATIVE RE LATIONSHIP T O YOU POSITION HELD NAME OF EMPLOYER LOCATION OF EMPLOYER I I I ~--~----+---+----+---! ----1 I I I ~~~~~~~~~~~~...:..-~~~~~~~~~'--~~~-'-~~~~~~-'-~~~~~~~~~~~~~ ~] 21 . Do y ou now . or nave you eve r helo a State ct Ca1oraca Liquor or Beer Li cense . or loaned money , furniture. fix tu res . equipment or inventory . to any Coloraoo Liquor or 9ee r I I ~·:::'"'" ;·::'m'f,.,J~1v/ f/}5 17%(/217 I CO NTIN UED ON REVERSE SIDE DA 8404-1 (2/94) Page 2 -22. Have you ever been convicted of a cnme. or received a suspended sentence . delerred sentence , or lorle11ed batl tor any ottense in cnm1nat or mililary court" (Do no11nclude traff ic .I violations. unless they resulted in suspension or revocation al your driver's license . or you were convic1ed ol drivmg under tile influence ol drugs or aJcollolic beverages .) II yes . explam 1n detatl . ~ D Yes / No I I 23. Have you ever received a v1olat1on nouce. suspension or revocauon tor a liquor Jaw v1olat1on . or been den1ea a liquor or beer license anywhere 1n 1ne U.S.? II yes. explain 111 aeta.1. i I D Yes ~o I I 24 . Mi~ j8'2_1pr(/;K ~ /F6ji3 IT3jgjsena?Zt?fs2 <f5{ Typ,L.Jischarge I 25 . , , List all addresses where you have lived for the past five years. (Attach separate sheet if necessary) STREET AND NUMBER I CITY . STATE. ZIP FROM I TO /\1.A I I I I I I 26 . List all former employers or businesses engaged in within the last five years. (Attach separate sheet if necessary.) . NAME OF EMPLOYER I ADDRESS (STRE::T. NUMBER. CITY. STATC:. ZIP) POSITION HELD I FROM I TO i.Jd--I : I I I I I I ! I I I I I I I i i I I ! I I I I I I I I i 27 . What •S your .Mt!A bWicant' (sole owner . partner . corporate office r. direc:or . stockholder , member or m;.nager) I I I 28. II Stockholaer . numoer ot shares ownea ::ene1tc1ally er ct record . fl/4-I Percen1 of outit/7-stock ownea I 29 . If ;ianner . s1a1e whetr.er Li General L! Limited 'Percent al P3l:i"'Fwned I" L1m1tea LlaJJ 4--pany (percent ownec ; ' N~ JO . To1a1 amounl you will :nves1 in 1111 s ous1ness .. nc1ua1n9 notes . :cans. casn . services or equipment. anc op era11n9 cao11a1. (Reg . 46-106.1 and Reg . 47-107 .1) I Amount S d),!J I Jl . Identify the sources of all funds you will invest in this business as listed in 30 above. List all bank names, I I account numbers and the amount derived from such source. Also identify all persons authorized to sign on, I or who are part owners of said account. (Attach copies of all your notes or loans used in or for this business.) -I Amounts Sources -Account Numbers I Names on accounts or person who can I ' sign on this account i ! I s A/ /J-I .! I I I s i I I $ I I I i $ I I I I I Oath of Applicant I I declare under penalty of perj ury in the sec:Jnd degree that this application and all attachments are true , correct. and complete :c :he :es : i of my knowledge. ! ' '"/ZW~ I Tille Date . ' 7'/sfar; I ///~k~ I I i ! LIQUOR LICENSING AUTHORITY AGENDA ITEM NO. 3 a) DATE: September 15 , 2004 REASON FOR COMING BEFORE THE AUTHORITY : Renewals NAME OF BUSINESS & ADDRESS a) Full House Hotel/Restaurant 4272 S. Broadway Expires November 4, 2004 b) EITepehuan Beer/Wine 3457 S. Broadway Expires November 26, 2004 TYPE OF ACTION REQUIRED: _X_APPROVE OR DENY __ RESOLUTION __ SET HEARING DATE __ INFORMATION ONLY COMMENTS: All forms and tees have been received. .................. "'. ,,......, DR 8400 (01/021 COLORADO DEPT OF REVENUE t.IQUOR ENFORCEMENT OIVISION 1881 PIERCE ST #108 LAKEWOOD CO 80214 LIQUOR OR 3.2 BEER LICENSE RENEWAL APPLICATION 22-08973-0000 1970 Liability Information • 10 006722110 c 110579 KONA COAST INC FULL HOUSE 4272 S BROWY ENGLEWOOD CO 80110-4635 ~ This renewal reflects no changes from the last application. Complete page 2 and file now! 0 Yes there •e changes from the last application. If applicant is a Corporation or Limited Liability company, use DR 8177 and send in with this renewal. Any other changes of ownership require a transfer of ownership. See your Local Licensing Authority immediately. 0 Delivery Permit requested? Retail Liquor Store. Drug Store or 3 .2% Beer -Combination On/Off Premises Licenses ONLY . Check the box if you w..-it the permit to be issued Business Location 4272 S BROWY ENGLEWOOD CO Current License Expires NOV O 4 1 2 O O 4 Wholesaler, manufacturer, importer. and public transportation system license renewals do not need Local Licensing Authority approval and must be returned directly to the Colorado Department of Revenue at least 30 days prior to the current license expiration date. ~s apphcabon for renewal must b6 returned to your c:...._ COlA'ITY Licensing Authority at least 45 days prior to the epcpiration date of yt:>l.W" cLXrent license. FaillJr'e to do so may r suit in your license not being renewed. Include both pages o this renewal and payment ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::OATtt:OF:APPLJCANT::::::::::::::::::;:::::::::::::::::::;:::::::::::::::::::::;:::::::::::::::::::::::::::::::::::::::::::::::::::::::::: I declare under penalty of per jury in the second degree that this appl ication and all attachments are true, correct.. and complete to the best of my knowledge. Authorized Signature 2JJJ;tf81{)6j{_ Business Phone 3'B-78f-"ScJ'7 '7 lY ::::::::::::::::::::::::::::::::::::::::::::::::::::::: . . . . The foregoing application has been examined and the prem ises, business conduct ed and character of the applicant are satisfactory, and we do hereby report that such license, if granted, will comply with the provisions of Title 1 2. Articles 46 and 4 7, C.R.S . THEREFORE THIS APPLICATION IS APPROVED. Local Licensing Authority for Signature _DO NOT DETACH DR 8400 (O 1/02) COLORADO DEPT OF REVENUE 1881 PIERCE ST #108 LAKEWOOD CO 80214 Business Name FULL HOUSE TYPE OF LICENSE ISSUED HOTEL AND RESTAURANT LIQUOR LICENSE -MALT, VINOUS, AND SPIRITUOUS Date D Town/City D County Title Attest DO NOT DETACH DO NOT DETACH • I LIQUOR OR 3.2 BEER LICENSE 21 RENEWAL APPLICATION LICENSE NUMBER <Use for all reference) RENEWED LICENSE EXP IRES AFTER 22-08973-0000 11-04-05 CASH FUND 2320-100(999) $ 50.00 STATE FEE 1970-750(999) $ 25.00 CITY 85% OAP 2180-100(999) $ 425.00 SUB-TOTAL ADD $100.00 TO RENEW RETAIL WAREHOUSE STORAGE PERMIT2210-100(999) TOTAL AMOUNT DUE $ 500.00 $ . $ $00 .O D Make check payable to: Colorado Department of Revenue DR 8401 (0797) . COLOR.Ao.:i DEPARTMENT OF REVENUE U\lUOR ENFORCEMENT DIVISION 1881 PIERCE LAKEWOOD, CO 80261 (303) 205-2300 ATTACHMENT TO LIQUOR OR 3.2 BEER LICENSE RENEWAL APPLICATION This page must be completed and attached to your signed renewal application form. Failure to include this page with the application may result in your license not being renewed. Trade ~e of Esj/_;ff. /-lAll . I State License Number ~-0&-9'73 1. Ope~anager .£v l0077re~ f5ur~ 1:>r ~' C!.o rso1a-o Date of Birth < ~ /).J. I< Oo-2-Cr,.. !918' 2. Do you have legal possession of the ~which this application for license is made? Yes No Are the premises owned or rented : ____ If rented, expiration date of lease: 1)/-01-~0 'foo[-Of-;)...O/b ~ D 3. Has there been any change In financial interest (new notes, loans, owners, etc.) since the last annual application? If yes, explain in Yes No detail and attach a listing of all liquor businesses in which these new lenders or owners, (other than licensed financial institutions) are D Ck] materially interested . 4. Since the date of filing of the last annual application, has the applicant, or any of its agents, owners, managers, principals, or lenders Yes No (other than licensed financial institutions), been convicted of a crime? If yes, attach a detailed explanation . D 0 5 . Since the date of filing of the last annual application, has the applicant, or any of its agents, owners, managers, principals, or lenders {other than licensed financial institutions), been denied an alcoholic beverage license, had an alcoholic beverage license suspended or Yes No revoked, or had Interest In any entity that had an alcoholic beverage license denied, suspended or revoked? If yes, attach a detailed D 0 explanation. 6. Does the applicant, or any of its agents, owners, managers, principals, or l~nders (other than licensed financial Institutions), have a Yes No direct or indirect interest in any other Colorado liquor license (include loans to or from any licensee, or interest in a loan to any D ~ licensee)? If yes, attach a detailed explanation. 7 . Sole owners or hu1ban·c1-wlfe partnership• answer this queation. Since the date of filing of the last annual license application: Has ownership changed in whole or in part, from a sole owner to any other person, partnership, corporation, or limited liability Yes No company other than the licensee listed on your state liquor license? If yes, this license must be transferred to the new owner and D D may not be renewed. Contact your Local Authority immediately . .. 8. Partnership applicant& must answer this question. Since the date of filing of the last annual license · application: Yes No (a) Are there, or have there been any general partners added to, or deleted from the partnership? If yes, this license must be D D transferred to the new partnership and may not be renewed. Contact your Local Authority immediately. (b) Are there, or have there been any limited partners with a 10% or niore interest, added or deleted from the partnership? If yes, this D D license must be transferred to the riew partnership and may not be renewed. Contact your Local Authority Immediately. 9 . Corporate applicant& must answer this question. Since the date of filing of the last annual license application: Yes No (a) Are there, or have there been any officers or directors added to, or deleted from the corporation? If yes, complete and attach D [kl DR 81n and submit to your Local Authority immediately. (b) Are there, or have there been any stockho!ders with 10% or more of tne issued stock, added to , or deleted from the corporation? If yes, complete and attach DR 81n and submit to your Local Author1tY immediately. l~U>Oc/. D 10 (c) Date of filing last annual corporate report with the Colorado Secretary of State: j./Y-.)U.Af''=j. 10. Umlted Uability Company applicants must answer this question. Since the date of fiUng of the last annual license application: Yes No (a) Are there, or have there been any managing members added to, or deleted from the company? If yes, complete and attach D D DR 81IT and submit to your Local Authority immediately. (b) Are there, or have there been any members with 10% or more membership Interest, added to, or deleted from the company? If ye~. complete and attach DR 81 n and submit to your Local Authority immediately. ,. D D (c) Date of filing last annual LLCO report with the Colorado Secretary of State: 11. Bed and Breakfast applicants must answer this question and certify compliance with 12-47-118.5 C.R .S., to the state licensing authority by initialing the following listed questions: That it has no more than 20 sleeping rooms, and That It provides at least 1 meal per day at no charge other than for ovemight lodging, and That it doe• not sell alcoholic beverages by the drink or in sealed containers, and That It shall not serve alcoholic beverages for more than 4 hours In any one day, as follows: MONDAY HOURS TUESDAY HOURS WEDNESDAY HOURS THURSDAY HOURS FRIDAY HOURS SATURDAY HOURS SUNDAY HOURS From : 7 ll m. From : ;Am. From : 7A m. From: 711 m . From: 7ft m. From: 7A m. From: BA m. To: /It m. To : ,.ft m . To: .;;.,If m . To : ;)fr m . To: &/:'.I m. To: ;)./I m. To: J;}-/1-m . AFFIDAVIT OF HOTEURESTAURANT LICENSEES State Statute 12-47-411 (a) requires that at least 25 % of gross income from sales of food and drink of a liquor licensed outlet with a Hotel/Restaurant License be derived from the sale of food. T he establishment listed below cert ifies that d-5 ,4 I % of the gross in c ome from sales of food and drink of this business is from the sale of food . Name of Establish m ent ¢-if ~ (>/~'*-µ t706~tlcJ 7>,. C' () g-0 11 0 Address of Es tabl is hm e nt ~//l/~L_ Li ce nsee Signature ~bee Date Stat e of C o lo rado SS County of Arapah o e Su bscrib e d a nd swo rn to befo re m e t his q day of ,lle.p7i.ovl.y;_g_o olf ~'·· '~(, 1----------------------· ~C/IA-/ ~L_ ! SUSAN CLARK ' !Notary Public : : : NOTARY PUBLIC : I STATE OF COLORADO ' My co mm is sio n expi re s : ________________ 1 1 ''''''''''··-··-·-·----! My Commissio n Expir es Feb. 4, 20 06 Ret u rn t h is co m pleted for m to the City Clerk, City of E nglewood, 1000 E nglewood Pa rkway, E ngl ewood, CO 80110 , with t he renew a l application papers . Info r matio n p rov ided by t he Lice nsee is su bject to audit by the C it y of E ng le wood . aifhoiel OFFICE OF THE SECRETARY OF STATE OF THE STA TE OF COLORADO CERTIFICATE I , Donetta Davidson , as the Secretary of State of the State of Colorado, hereby certify that, according to the records of this office, KONA COAST, INC. is a Corporation formed or registered on 12112/1978 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 1987136091 O This certificate reflects facts established or disclosed by documents delivered to this office on paper through 07 /23/2004 that have been posted , and by documents delivered to this office electronically through 09/11/2004 @ 11 :25:43 . I have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, authenticated , issued , delivered and communicated this official certificate at Denver , Colorado on 09/11/2004@ 11:25:43 pursuant to and in accordance with applicable law . This certificate is assigned Confirmation Number 6047524. Secretary of State of the State of Colorado ****************************************End of Certificate**************************************** Notice: A certifica te issued elec tronically (rom th e Co lorado Sec retary o(State 's Web site is fully and immediately valid and ef[ective. How ever, as an option , th e issuance and validity of a certifi cate obtained elec tronically may be established by visiting th e Ce rtifica te Co nfirmation Page of th e Secretary of State 's Web site, hup:!!www .sos.state.co.usl hiz!Cerri fica teSe archCriteria.do entering th e ce rt ifica te's confirmation number displayed on th e certificate , and following th e instructions displayed. Co nfirming th e issuance o( a ce rtifica te is merely op tional and is not necessary to th e valid and effective issuance o(a certificate. For more information, visit our Web site , h11p :/lwww.sos.state.co.us/ cli ck Business Ce nter and se lect "Frequently Asked Questions. " Colorado Secretary of State -Information On File Page 1of1 For this Record ... Cert of Good Standing File Document Email Notification History & Documents Business Home Business Information Business Search I FAQs Glossary Information On File ID Number: Name: Registered Agent: Registered Agent Street Address: Registered Agent Mailing Address: Principal Office Street Address: Principal Office Mailing Address: Status: Form: Jurisdiction: Formation Date: Term of Duration: Annual Report Month: You may: • View History and Documents 19871360910 KONA COAST, INC. LEW Y OOK LIM 4272 SO . BROADWAY, ENGLEWOOD, C O : 4272 SO . BROADWAY, ENGLEWOOD , CO Good Standing Corporation Colorado 12/12/1978 Perpetual December • Obtain Certificate of Good Standing • File a Document • Set Up Email Notification Previous 'Page Business Center: 303 894 2200 •Fax: 303 869 4864 •Forms fax back : 303 860 6975 •e-mail: sos.busi ness@ sos .state .co .us Search I Contact us I Pri vacy statement I Term s of use http ://www .sos.state.co.us/biz/BusinessEntityDetail.do;jsessionid=OOOOE9ITfBdqxjufMA 7 ... 9/11/2004 -2004 Periodic Report DONETTA DAVIDSON Colorado Secretary of State Person responsible for accuracy of report data: JAMES W . BOK 6677 SO BUFFALO DR LITILETON CO 80120 Name of Entity's Registered Agent: LEW YOOK LIM Street Address of Registered Office: 4272 SO . BROADWAY ENGLEWOOD CO 80110 *PO Box Addr of Registered Office: Address of Entity's Principal Office : 4272 SO. BROADWAY ENGLEWOOD CO 80110 , United States *Entity's Additional Mailing Address: *Denotes optional information that is not required by law. ff no information is displayed for this item, none was reported by the reporting entity. All information available to the Secretary of State is displayed above. NOTICE: This "image" is merely a display of information that was filed electronically. It is not an image that was created by optically scanning a paper document. No such paper document was filed. Consequently, no copy of a paper document is available regarding this filing. Questions? Contact the Business Division . For contact information, please visit the Secretary of State's web site. u ;,: I<) '--~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~--'~ License Number DR 8400 (01 /02) <:lLORADO DEPT OF REVEMJE LIQUOR ENFORCEMENT DIVISION 1881 PIERCE ST #108 LAKEWOOD CO 80214 LIQUOR OR 3.2 BEER LICENSE RENEWAL APPLICATION 22-92264-0000 Liability Information 10 006 722110 I License Type 1960 I 112791 11 •• 1.11 •••••• 11 ••• 1111 •••• 11 ••• 1.1.11 ••• 1 •• 1 ••• 11.1 ••• 1 ••• 111 CORRAL GRACIELA M EL TEPEHUAN 4737 S CHEROKEE ENGLEWOOD CO 80110-6508 D This renewal reflects no changes from the last application. Complete page 2 and file now! D Yes there are changes from the last application If applicant is a Corporation or Limited Liability company, use DR 81 77 and send in with this renewal. Any other changes of ownership require a transfer of ownership. See your Local Licensing Authority immediately. 0 Delivery Permit requested? Reta il Liquor Store. Drug Store or 3 .2% Beer -Combination On/Off Premises Licenses ONLY. Check the box if you want the permit to be issued Business Location 3457 s BROADWAY ENGLEWOOD CO Current License Expires NOV 26, 2004 Wholesaler. manufacturer. importer. and public transportation system license renewals do not need Local Licensing Authority approval and must be returned directly to the Colorado Department of Revenue at least 30 days prior to the current license expiration date. is application for renewal must be returne to your _ R COUNTY Licensing Authority at least 45 days prior to the xpiration date of your current license. Failure to do so may r ult in your license not being renewed Include both pages f this renewal and payment ·••••••••••••••OAJtt :OF)~t=>~.:.JCANT••:•:•:•:•:•:•:•••••••••••••••••••••••••:•:•:•:•:•:•:•:•:•••••••••••••••:•:•:•:•:•:•:•:•:•:•:::•:•:•:•:•:•••••:•:•:•:: I declare under penalty of per jury 1n the sec o nd degree that this application and all attachments are true. correct. and complete to the best of my knowledge. Authorized Signature Date Business Phone 9 -~-ol/ 7~/ -0-;.... Title of Signer (if corporation) {CJ J-J ~ Sales Ta x Number .......................................................... Bef>Oi:trAND APP.~OVA~·OF •C.IJ:Y::OR:·COUNTY:•U~!NG :A!JJ:l100!'f'C •:::•:•:::• :···:·:·:·:··.·.·.·.·.·.·.· .. · .. The foregoing applicat ion has been e x amined and the prem ises. business conducted and character of the applicant are satisfactory, and we do hereby report that such license, if granted. wil l comply w ith the pr ovisions of Title 12, Arti cles 46 and 4 7, C.R.S . THEREFORE THIS APPLICATION IS APPROVED. Local Licensing Authority for Signature -DO NOT DETACH DR 8400 (01/02) COLORADO DEPT OF REVENUE 1881 PIERCE ST #108 LAKEWOOD CO 80214 Business Name EL TEPEHUAN TYPE OF LICENSE ISSUED BEER AND WINE LICENSE - MALT AND VINOUS LIQUORS Date O Town/Ci t y O County Title Attest DO NOT DETACH DO N OT DEi:ACl=I LIQUOR OR 3.2 BEER LICENSE 21 RENEWAL APPLICATION LICENSE NUMBER (U se for all r e f e rence) RENEWED LICENSE EX PIRES AFTER 22-92264-0000 11-26-05 CASH FUND 2320-100(999) $ 50.00 STATE FEE 1960-750(999) $ 25.00 CITY 85% OAP 2180-100(999) $ 276.25 SUB-TOTAL ADD $100.00 TO RENEW RETAIL WAREHOUSE STORAGE PERMIT2210-100(999) TOTAL AMOUNT DUE $ 351.25 $ . $==·= Make check payable to: Colorado Department of Revenue DR 8401 (0797) . COLORAD6 DEPARTMENT OF REVENUE U~UOR ENFORCEMENT DIVISION 1881 PIERCE ATTACHMENT TO LIQUOR OR LAKEWOOD, CO 80261 (303) 205-2300 3.2 BEER LICENSE RENEWAL APPLICATION This page must be completed and attached to your signed renewal application form. Failure to include this page with the application may result in your license not being renewed. Trade Name of Establishment State License Number 2. 3. 4. 5. 6. 7. 8. 9. :2-l. - Do you have legal possession of the premises tor which this application for license is made? _ -2 ),,{; Are the premises owned 0 r rented : ~ If rented, expiration date of lease : / ?--r 00 Has there been any change in financial interest (new notes, loans, owners, etc.) since the last annual application? If yes, explain in detail and attach a listing of all liquor businesses in which these new lenders or owners, (other than licensed financial ins.titutions) are materially interested. . Since the date of filing of the last annual application, has the applicant, or any of its agents, owners, managers, principals, or lenders (other than licensed financial instiMions), been convicted of a crime? If yes, attach a detailed explanation. Since the date of filing of the last annual application, has the applicant, or any of its agents, owners, managers, principals, or lenders (other than licensed financial institutions), been denied an alcoholic beverage license, had an alcoholic beverage license suspended or revoked, or had interest in any entity that had an alcoholic beverage license denied, suspended or revoked? If yes, attach a detailed explanation. Does the applicant, or any of its agents, owners, managers, principals, or l~nders (other than licensed financial institutions), have a direct or indirect interest in any other Colorado liquor license (include loans to or from any licensee, or interest in a loan to any licensee)? If yes, attach a detailed explanation . Sol~ owners or husband-wife partnerships answer this question. Since the date of filing of the last annual license application: Has ownership changed in whole or in part, from a sole owner to any other person, partnership, corporation, or limited liability company other than the licensee listed on your state liquor license? If yes, this license must be transferred to the new owner and may not be renewed. Contact your Local Authority immediately. Partnership applicants must answer this question. Since the date of filing of the last annual license application: (a) Are there, or have there been any general partners added to, or deleted from the partnership? If yes, this license must be transferred to the new partnership and may not be renewed. Contact your Local Authority immediately. (b) Are there, or have there been any limited partners with a 10% or niore interest, added or deleted from the partnership? If yes, this license must be transferred to the new partnership and may not be renewed. Contact your Local Authority immediately. Corpor•te applicants must answer this question. Since the date of filing of the last annual license application: (a) Are there; or have there been any officers or directors added to, or deleted from the corporation? If yes, complete and attach DR 8177 and submit to your Local Authority immediately. (b) Are there, or have there been any stockho!ders with 10% or more of the issued stock, added to, or deleted from the ·corporation? If yes, complete and attach DR 8177 and submit to your Local Authority immediately. (c) Date of filing last annual corporate report with the Colorado Secretary of State:------------- 10. Limited Uablllty Company applicants must answer this question. Since the date of fiiing of the last annual license application: (a) Are there, or have there been any managing members added to, or deleted from the company? If yes, complete and attach DR 8177 and submit to your Local Authority immediately. (b) Are there, or have there been any members with 10% or more membership interest, added to, or deleted from the company? If ye~. complete and attach DR 8177 and submit to your Local Authority immediately. ,. (c) Date of filing last annual LLCO report with the Colorado Secretary of State:------------- 11. Bed and Breakfast applicants must answer this question and certify compliance with 12-47-118.5 C.R.S., to the state licensing authority by initialing the following listed questions: That it has no more than 20 sleeping rooms, and That it provides at least 1 meal per day at no c:harge other than for ovemight lodging, and That it does not sell alcoholic beverages by the drink or in sealed containers, and That it shall not serve alcoholic beverages for more than 4 hours in any one day, as follows: Yes No ~ D Yes No D ~ Yes No D ~ Yes No D ~ Yes No D jg! Yes No D ~ Yes No D ~ D [XJ Yes No D ~ D ~ Yes No D ~ D 18 MONDAY HOURS TUESDAY HOURS WEDNESDAY HOURS THURSDAY HOURS FRIDAY HOURS SATURDAY HOURS SUNDAY HOURS From: m. From: To: m. To: m. From: m. To: m. m. From : To: m . From : m. To : m . From: m. To: m. m. From: To: m. m. Page 1of1 Mary White From: Mary White Sent: Saturday , September 11 , 2004 10:35 AM To: Leigh Ann Hoffhines Subject: LLA Agenda Oooops! Sorry for being so late! 9/11/2004 Page 1of1 Mary White From: Mary White Sent: Saturday , September 11 , 2004 10:41 AM To: Susan Werntz Subject: LLA Meeting No meeting on Wednesday, September 15. Susan , I'm so sorry for this late notice. I have taken the posting off of the calendar and I will be posting the Telephone Poll on the four designated boards downstairs. My head has been full of that darn UDC I guess! 9/1112004 Mary White From: Sent: To: Mary White Saturday, September 11, 2004 10:42 AM Linda Wilks Subject: LLA Meeting There will be no meet ing on Wednesday , September 15. 9/11/2004 Page 1of1