Application docu

bull

- (BOULDER COUNT Y PUBLIC HEALTH

Opportunit y fo r a n ea l t h y 18

Request for Retail Food Establishment License

Thank you for notifying Boulder County Public Health (BCPH) about your plans to begin operation or change ownership of a retail food establishment catering operation or mobile unit The following pages include a list of common items to be addressed before a retail food license can be issued

If you plan to extensively remodel the facility change menu items or change equipment a plan review may be required Extensively remodeled is defined in Section 1-202 (18) of the Colorado Retail Food Establishment Rules and Regulations and includes

bull Increase in seating capacity by 20 bull Change or alteration made in the nonpublic areas that result in an increasereduction of total space by

2sor more

bull Alteration that requires a building permit by local authorities

bull Change that affects the facilitys capability to handle food and utensils in a sanitary manner and create potentially hazardous conditions

If your plans meet this definition please go to wwwBoulderCountyFoodorg and download the Retail Food Facility Plan Review packet or call our office at 3034411564 to request a plan review packet

BCPHs team is committed to providing excellence in technical assistance and customer service Information about the requirements of operating a Retail Food Establishment can be found in the Colorado Retail Food Establishment Rules and Regulations available on our website at wwwBoulderCountyFoodorg

Resources included in this packet o Appendix A Sample facility floor plan o Appendix B Minimum requ irements for reta il food establishment license approval o Appendix C Worksheet for Calculating Minimum Hot Water Requirements o Appendix D Commissary Agreement (may need to submit if mobile unit caterer retail food

processor)

Please provide a copy of your menu and as much detail as possible about your operation The information you provide will determine if your food handling techniques are consistent with proper food safety It is important that proper food safety procedures are implemented from the start of operation since the majority offoodborne illness outbreaks are attributed to errors in food handling (eg improper cooling reheating etc)

Onsite wastewater treatment systems and non-community and private water supplies are permitted separately For more information about these requirements contact Boulder County Public Health at

3deg34411564

_ _

bull

r------=-===----=----------==----=------j 20100 Tavern License (City) $50000 1-2~~---~~~E----____~~~~~~=E~ 2011 0 Tavern License (County) $50000

20120 Manager Registration - Tavern $ 7500

Application Fee for New License Application Fee for New Licensemiddot wConcurrent Review

2310 0 Application Fee for Transfer

19850 Resort Complex License (City) 19860 Resort Complex License (County) $50000 19880 Add Related Facility to Resort Complex $ 7500 X__ Total _19900 Club License (City) $30875 19910 Club License (County) $30875

1905 0 Retail Gaming Tavern License (City) $50000 20200 Arts License (City) $30875 1906 0 Retail Gaming Tavern License (County) $50000 20210 Arts License (County) $30875 1940 0 Retail Liquor Store License (City) $22750 20300 Racetrack License (City) $50000 1941 0 Retail Liquor Store License (County) $31250 20310 Racetrack License (County) $50000 1950 0 Liquor Licensed Drugstore (City) $22750 2040 0 Optional Premises License (City) $50000 1951 0 Liquor Licensed Drugstore (County) $31250 2041 0 Optional Premises License (County) $50000 1960 0 Beer and Wine License (City) $351 25 20450 Vintners Restaurant License (City) $75000 1961 0 Beer and Wine License (County) $43625 20460 Vintners Restaurant License (County) $750001970 0 Hotel and Restaurant License (City) $50000 22200 Add Optional Premises to H amp R $10000 X __Total 1971 0 Hotel and Restaurant License (County) $50000 23700 Master File Location Fee $ 2500 X Total1975 0 Brew Pub License (City) $75000 23750 Master File Background $25000 X- - Total shy

1976 0 Brew Pub License (County) $75000 1980 0 Hotel and Restaurant License wopt premises (City) $50000 1981 0 Hotel and Restaurant License wopt premises (County) $50000 1983 0 Manager Registration - H amp R $ 7500

DR 8404 (0507109) Page 1 COLORADO DEPARTMENT OF REVENUE 21 DEPARTMENT USE ON L Y

LIQUOR ENFORCEMENT DIVISION DENVER CO 80261 COLORADO LIQUOR

RETAIL LICENSE APPLICATION

D NEW LICENSE D TRANSFER OF OWNERSHIP D LICENSE RENEWAL

ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPEWRITIEN APPLICANT MUST CHECK THE APPROPRIATE BOX(ES)

bull LOCAL LICENSE FEE $ _________ APPUCANT SHOULD OBTAIN A COpy OF THE COLORADO UQUOR AND BEER CODE Call n n -

1 Applicant is applying as a D Individual D Corporation D Limited Liability Company

D Partnership (includes Limited Liability and Husband and Wife Partnerships) D Association or Other

County City Industry Type License Account Number

Slate __-750 (999)

City 2180-100 (999)

2300-100 (999)

County

2190-100 (999) Managers Reg

__-750 (999)

$ bull

DR 8404 (0507109) Page 2 APPLICATION DOCUMENTS CHECKLIST AND WORKSHEET

Instructions This check list should be utilized to assist applicants with filing all required documents for licensure All documents must be properly signed and correspond with the name of the applicant exactly All documents must be typed or legibly printed Upon final State approval the license will be mailed to the local licensing authority Application fees are nonrefundable

ITEMS SUBMITTED PLEASE CHECK ALL APPROPRIATE BOXES COMPLETED OR DOCUMENTS SUBMITTED

I APPLICANT INFORMATION

D A ApplicantLicensee identified

D B State sales tax license number listed or applied for at time of application

D C License type or other transaction identified

D D Return originals to local authority

D E Additional information may be required by the local licensing authority

II DIAGRAM OF THE PREMISES

D A No larger than 8 12 X 11

D B Dimensions included (doesnt have to be to scale) Extenor areas should show control (fences walls etc)

D C Separate diagram for each floor (if multiple levels)

D D Kitchen - identified if Hotel and Restaurant

III PROOF OF PROPERTY POSSESSION

D A Deed in name of the Applicant ONLY (or)

D B Lease in the name of the Applicant ONLY

D C Lease Assignment in the name of the Applicant (ONL Y) with proper consent from the Landlord and acceptance by the Applicant

D D Other Agreement if not deed or lease

IV BACKGROUND INFORMATION AND FINANCIAL DOCUMENTS

D A Individual History Record(s) (Form DR 8404-1)

D B Fingerprints taken and submitted to local authority (State authority for master file applicants)

D C Purchase agreement stock transfer agreement and or authorization to transfer license

D D List of all notes and loans

V CORPORATE APPLICANT INFORMATION (If Applicable)

D A Certificate of Incorporation (andor)

D B Certificate of Good Standing if incorporated more than 2 years ago

D C Certificate of Authorization if foreign corporation

D D List of officers directors and stockholders of parent corporation (designate 1 person as principal officer)

VI PARTNERSHIP APPLICANT INFORMATION (If Applicable)

D A Partnership Agreement (general or limited) Not needed if husband and wife

VII LIMITED LIABILITY COMPANY APPLICANT INFORMATION (If Applicable)

D A Copy of articles of organization (date stamped by Colorado Secretary of States Office)

D B Copy of operating agreement

D c Certificate of Authority (if foreign company)

VIII MANAGER REGISTRATION FOR HOTEL AND RESTAURANT TAVERN LICENSES WHEN INCLUDED WITH THIS APPLICATION

D A $7500 fee

D B Individual History Record (DR 8404-1)

DR 8404 (050709) Page 3

6 Is the applicant (including any of the partners if a partnership members or manager if a limited liability company or officers stock- Yes No holders or directors if a corporation) or manager under the age of twenty-one years D D

7 Has the applicant (including any of the partners if a partnership members or manager if a limited liability company or officers stockholders or directors if a corporation) or manager ever (in Colorado or any other state) (a) been denied an alcohol beverage license D D (b) had an alcohol beverage license suspended or revoked D 0 (c) had interest in another entity that had an alcohol beverage license suspended or revoked D 0If you answered yes to 7a b or c explain in detail on a separate sheet

8 Has a liquor license application (same license class) that was located within 500 feet of the proposed premises been denied within the

preceding two years If yes explain in detail D 0

9 Are the premises to be licensed within 500 feet of any public or private school that meets compulsory education requirements of Colorado law or the principal campus of any college university or seminary D 0

10 Has a liquor or beer license ever been issued to the applicant (including any of the partners if a partnership members or manager if a limited liability company or officers stockholders or directors if a corporation) If yes identify the name of the business and list any current or former financial interest in said business including any loans to or from a licensee 0 0

11 Does the Applicant as listed on line 2 of this application have legal possession of the premises by virtue of ownership lease or other arrangement

0 Ownership 0 Lease o Other (Explain in Detail) 0 D a If leased list name of landlord and tenant and date of expiration EXACTLY as they appear on the lease

ILandlord I Tenant IExpires

I Attach a diagram and outline or designate the area to be licensed (including dimensions) which shows the bars brewery walls partitions entrances exits and what each room shall be utilized for in this business This diagram should be no larger than 8 12 X 11 (Doesnt have to be to scale)

12 Who besides the owners listed in this application (including persons firms partnerships corporations limited liability companies) will loan or give money inventory furniture or equipment to or for use in this business or who will receive money from this business Attach a separate sheet if necessary

DATE OF BIRTH INTERESTNAME FEIN OR SSN

Attach copies of all notes and security instruments and any written agreement or details of any oral agreement by which any person (including partnerships corporations limited liability companies etc) will share in the profit or gross proceeds of this establishment and any agreement relating to the business which is contingent or conditional in any way by volume profit sales giving of advice or consultation

13 Optional Premises or Hotel and Restaurant Licenses with Optional Premises Yes No

Has a local ordinance or resolution authorizing optional premises been adopted 0 0

Number of separate Optional Premises areas requested (See License Fee Chart)

14 Liquor Licensed Drug Store applicants answer the following Yes No

Pharmacy COpy MUST BE ATTACHED 0 0 (a) Does the applicant for a Liquor Licensed Drug Store have a license issued by the COlorado Board of

15 Club liquor License applicants answer the following and attach Yes No(a) Is the applicant organization operated solely for a national social fraternal patriotiC political or athletiC purpose and

not for pecuniary gain 0 0 (b) Is the applicant organization a regularly chartered branch lodge or chapter of a national organization which is

operated solely for the object of a patriotiC or fraternal organization or society but not for pecuniary gain 0 0 (c) How long has the club been incorporated (d) Has applicant occupied an establishment for three years

(Three years required) that was operated solely for the reasons stated above D D 16 Brew-Pub license or Vintner Restaurant Applicants answer the following Yes No

(a) Has the applicant received or applied for a Federal Permit 0 0 (Copy of permit or application must be attached)

17a Name of Manager (for all on-premises applicants) ___ _ (If this is an IDate of Birth

application for a Hotel Restaurant or Tavern License the manager must also submit an Individual History Record (DR 8404-1)

17b Does this manager act as the manager of or have a financial interest in any other liquor Yes No licensed establishment in the State of Colorado If yes provide name type of license and account number DO

18 Tax Distraint Information Does the applicant or any other person listed on this application and including its partners officers directors stockholders members (LLC) or managing members (LLC) and any other persons with a 10 or greater financial interest Yes No

in the applicant currently have an outstanding tax distraint issued to them by the Colorado Department of Revenue 0 0 If yes provide an explanation and include copies of any payment agreements

DR 8404 (0507109 ) Page 4

19 If applicant is a corporation partnership association or limited liability company applicant must list ALL OFFICERS DIRECTORS GENERAL PARTNERS AND MANAGING MEMBERS In addition applicant must list any stockholders partners or members with OWNERshySHIP OF 10 OR MORE IN THE APPLICANT ALL PERSONS LISTED BELOW must also attach form DR 8404-1 (Individual History record) and submit finger print cards to their local licensing authority

NAME HOME ADDRESS CITY amp STATE DOB POSITION OWNED

If total ownership percentage disclosed here does not total 100 applicant must check this box

D Applicant aHirms that no individual other than these disclosed herein owns 10 or more of the applicant

Additional Documents to be submitted by type of entity

D CORPORATION D Cert of Incorp D Cert of Good Standing (if more than 2 yrs old) D Cert of Auth (if a foreign corp)

D PARTNERSHIP D Partnership Agreement (General or Limited) D Husband and Wife partnership (no written agreement)

D LIMITED LIABILITY COMPANY D Articles of Organization D Cert of AuthOrity (if foreign company) D Operating Agrmt

D ASSOCIATION OR OTHER Attach copy of agreements creating association or relationship between the parties

Registered Agent (if applicable) IAddress 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 the best of my knowledge I also acknowledge that it is my responsibility and the responsibility of my agents and employees to comply with the provisions of the Colorado Liquor or Beer Code which affect my license

Authorized Signature ITitle IDate

REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITYCOUNTY)

Date application flied with local authority Date of local authority hearing (for new license applicants cannot be less than 30 days from date of application 12-47-311 (1raquo CRS

THE LOCAL LICENSING AUTHORITY HEREBY AFFIRMS

That each person required to file DR 8404-1 (Individual History Record) has Yes No

o Been fingerprinted bull 0 0 o Been subject to background investigation including NCICCCIC check for outstanding warrants 0 0 That the local authority has conducted or intends to conduct an inspection of the proposed premises to ensure that the applicant is in

compliance with and aware of liquor code provisions aHecting their class of license 0 0 (Check One)

0 Date of Inspection or Anticipated Date

0 Upon approval of state licensing authority

The foregoing application has been examined and the premises business to be conducted and character of the applicant are satisfactory

We do report that such license if granted will meet the reasonable requiremems of the neighborhood and the desires of the adult inhabitants

and will comply with the provisions of Title 12 Article 46 or 47 CR8 THEREFORE THIS APPLICATION IS APPROVED_

Local Licensing Authority for I Telephone Number 0 TOWN CITY

0 COUNTY Signature Title Date

Signature (attest) Title Date

OMB Approval No 3245-0016 Expiriltion Dilte II 13UI2U 12

U S Small Business Administration

APPLICATION FOR BUSINESS LOAN

IndivIdual I Full Address

Name of Applicant Business Tax LD No or SSN

Full Street Address ofBusiness Tel No (inc Area Code)

Llty I County I State LIp Number of Employees (including

subsidiaries and artiliates)

At Time of Application --shy

J f Loan )S Approved ---

SubsidIaries or AffIliates --shy(Separate for above)

Type of Business Date Business Established

Bank of Business Account and Address

Use of Proceeds (Enter Gross Dollar Amounts Rounded to the Nearest Hundreds)

Loan Requested Loan Request

Land Acquisition Pay otrSBA Loan

New Construction Expansion Repair

Pay otrBank Loan (Non SBA Associated)

Acquisition andor Repair of Machinery and Equipment

Other Debt Payment (Non SBA Associated)

Inventory Purchase All Other Working Capital (including Accounts Payable) Total Loan Requested Acquisition of Existing Business Term of Loan - (Requested Maturity) Yrs

CURRENT AND PREVIOUS SBA AND OTHER GOVERNMENT DEBT Complete the chart below if you your business any principal of your business any atliliate of your business any other business currently owned by a principal or any business previously owned by you or a principal of your business has received or applied for any direct or guaranteed financial assistance from the Federal Government including student loans and disaster loans All current previQus and pending Government debt must be listed including loans that have been paid in full or those that

resulted in a loss to the Government (Note Loans that resulted in a loss to the Government include loans that were charged off compromised or discharged as a result of bankruptcy The amount of the loss is the outstanding principal balance of the loan that the Government had to write off after all collection activities (including compromise) were finalized)

Name ofAgency Borrowers Name Original

Amount of Loan

Date of Application

Loan Status Outstanding Balance $ Amount of Loss to the

Government Agency Loan

1 $ $ $

2 $ $ $

3 $ $ $

4 $ $ $

ASSISTANCE Did you commit to pay -- or have you paid -- anyone (including the lender) to assist you in either obtaining this loan (such as a

broker consultant or relerral agent) or in preparing the application or application materials lor this loan (such as a loan packager) Yes 0 No 0 If yes complete SBA Form 159 (7a) - (Fee Disclosure Form and Compensation Agreement) for each [lrty that was [laid or will bt laid)

Note The estimated burden completing this form is 120 hours per response You will not be required to respond to collection of information unless it displays a currently valid OMB approval number Comments on the burden should be sent to the US Small Business Administration Chief AlB 409 3d St SW Washington DC 20416 and Desk Office for Small Business Administration Office of Management and Budget New Executive Building room 10202 Washington DC 20503 OMB Approval (3245-0016) PLEASE DO NOT SEND FORMS TO OMB SUBMIT COMPLETED APPLICATION TO LENDER OF CHOICE

bull

SBA Form 4 (9-09) Previous Edition Obsolct~ Page l

ALL EXHIBITS MUST BE SIGNED AND DATED BY PERSON SIGNING THIS FORM

BUSINESS INDEBTEDNESS Furnish the followmg infonnation on all outstanding installment debts contracts notes and mortgages payable Ind icate by an asterisk (0) items to be paid by loan proceeds and reasons lor paying them (Present balance should agree with the latest balance sheet submitted)

To Whom Payable Original Amount

Origmal Date

Present Balance Rate of Interest

Maturity Date

Monthly Payment

Secunty Current or Past Due

Acc $ $ $

Ace $ $ $

Aecl $ $ $

Acc $ $ $

Acct $ $ $

bull MANAGEMENT (PropnelOr partners officers directors all holders of outstanding stock -100 of ownershi[l must be shown ) Use separate sheet if necessary

Name and Social Security Number Pos itionrritle

Complete Address Owned

Gender

Veteran Status Veteran Yes[]NoO If yes service-disabledYesDNoL

Race bull Amer Indian or Alaska Nalive 0 ASlanO Black or African-Amet 0 Native Haw or Pacific lslanderO White 0 EthniciryHispanic or LatinoO Not Hisp or Lantino[]

L-Race Amer Indian or Alaska Native[] AsianOBlack or African-AmeLO Native Haw or Pacilic Islander 0 WhiteD

Veteran SUltus 1 Veteran YesON0B fyes servlce-d l sabledYespN_~O___ -

EtbnicityHlspanic or LatinoO Not Hisp or LantinoO

Veteran Status Veteran Yes[]No f yes serVice-disabled YeUNo

Race Amer Indian or Alaska NativeO As ianOBlack or African-A meLONative Haw or PaCific IslanderO WhiteD EthniciryHispanic or Latino 0 Not Hisp or Lantino 0 Veteran Status

lVeteran Yes[]NoO fyes service-disabledYes[]No

Race Amer Indian or Alaska Native 0 ASlanOBlack or African-AmerO Native Haw or Pacific Islander 0 WhiteD EthnicityHlspanic or Latino 0 Not Hisp or Lantino 0 This data is collected for statistical purposes only It has no bearing on the credit deCision Disclosure is voluntary One or more boxes for race may be se I ected

Also include the tax id number [EIN or Social Security Number -or Guaranty Loans please provide an original and one copy (Photocopy (SSN)l Label it [xhibit B

s Acceptable) of the Application Form and all Exhibits to the participating Lender For Direct Loans submit one original copy 4 Inc lude the financial statements listed below a b c lor the last plthe application and Exh ibits to SBA three years also a b c and d as olthe same date - current within

I Submit SBA Form 912 (Statement of Personal History) lor each 90 days of tiling the application and statement e if applicable All

information must be signed and daled (a) Balance Sheet (b) Profit proprietor (ifsole proprietorship) partner (if a partnership) and by each and Loss Statement (if not avai lable explain why and substitute pflicer director and owner 0120 or more of the companys stock (if a federal income tax forms) (c) Reconciliation of Net Worth (d) orporation limited liability company or development company) Aging of Accounts Receivable and and Payable (summary) (e)

7 If your collateral consists oC(A) Land and Building (B) Machinery Projection of earnings for at least onc year where linancial

and Equipment (C) furniture and fixtures (D) Accounts Receivable statcments for the last three years are unavailable or when SBA

E) Inventory (F) Other please provide an itemized list that contains reques ts them Label it Exhibit C (Contact SBA for a referral if erial and identification numbers for all articles that had an original value assistance with preparation is wanted)

of greater than $5000 Include a legal description of Real Estate oIHred as collateral l abel it Exhibit A 5 Provide a brief history of your company and a paragraph

describing the expected benefits it will receive from the loan Label

3 Furnish a signed current personal balance sheet (SBA Form 413 it Fxhibit D

may be used tor this purpose) lor (I) each proprietor or (2) each limited 6 Provide a brief description similar to a resume of the education partner who owns 20 or more interest and each gcneral partner or (3) technical and business background tor all the people listed under each stockholder owning 20 or more of voting stock Include the Management Label it Exhibit L assets and liabilities of the s pouse and any minor children

SBA corm 4 (9-09) Previous Edition Obsolete ra~e 2

7 Submit the name addresses tax ID number (EIN or SSN) and current persunal linancial statement of any co-signers whu are not utherwise affiliated with the business and any guarantors for the loan nut covered hy 3 abuve Exhibit F

8 Include a list or any machinery or equipment or other non-real estate assets to be purchased with luan proceeds and the cost of each item as quoted by the seller Include the sellers name and address Exhibit G

9 Have you or any oJJicer oryour company ever been invulved in bankruptcy or insolvency proceedings) [ ]Yes [ JNo If yes please provide the details as Exhibit H

10 Are you ur yuur business involved in any pending lawsuits [ ]Yes

[ JNo If yes provide the details as Exhibit I

1100 you or yuur spuuse or any member ufyour househuld ur anyone whu owns manages or directs yuur business or their spouses ur members uf their huuseholds work for the Small Business Administration Small Business Advisory Council SCORE or ACE any Federal Agency ur the participating lender [ ]Yes I INo Iryes please provide the name and address uf the person and the otTIce where employed Iabel this Exhibit J

12 Does your business its owners or majority stockholders own or have a controlling interest in other businesses I ]Yes [ ]No If yes please provide their names and the relationship with your company along with financial data requested in question 4 Label this Exhibit K

13 Do you buy from sell to or use the services of any concern in which someone in yuur cumpany has a significant financial interest) I ]Yes [ ]No I f yes provide details on a separate sheet uf paper Exhibit k

14 Is your business is a Iranchise [ ]Yes [ ]No Iryes include a copy of the tranchise agreement and a eupy of the FTC disclosure statement supplied to you by the Franchisor Label this Exhibit M

CONSTRUCTION LOANS ONLY

AGREEMENTS AND CERTIFICATIONS

AGREEMENTS

By signing below you agree to the following

(a) A reements of non-em 10 menl of SBA Personnel I agrec that if SBA approves this application I will not for at least two years hire as an employee or consultant anyone that was employed by the SBA during the one year period prior to the loan disbursement

(b) Waiver of Claims As consideration for any Management Technical andor Business Developmenl Assistance that may be provided I waive all claims against SBA and ils consultants

(c) Criminal Background I authorize the SBAs Oftice uflnspector General to requesl criminal record informatiun about me from crim inal justice agencies for the purpuse uf determining my eligibility tor assistance under the Small Business Act

(d) Reimbursement uf EXQli~ I agree 10 pay for ur reimburse SBA lor the cust uf any surveys title or mortgage examinations appraisals credil reports etc performed by non-SBA personnel provided I have given my cunsent

(e) Reporting I agree to repurt tu the SBA Office oflhe Inspeclor General Washington DC 20416 any federal guvernment employee whu uffers in relurn for any type of compensalion 10 help get this loan appruvtd

READ THE FOLLOWING CAREFULLY

If you knowingly make a false statement you can be fined up to $250000 andor imprisoned for not more than five years under J8 USC 1001 if submitted to a Federally insured institutiun under 18 USC 1014 by Imprisunment ufnut mUre than twenty years andor a fine of not more than $1000000

15 Include as a separate exhibit the estimated cost of the pruject and a statement of the suurce of any additional funds l o I hi xhi t

16 Pruvide copies of preliminary construction plans and specificatiuns Labellhis as Exhibit O Final plans will be required prior to disbursement

EXPORT LOANS

17 Does your business currently expurt ur will it start exporting pursuant to this loan (if approved) ) Check here I JYes I )No

18 If you answered yes to item 17 what is your estimate of the total export sales this loan would support $

19 Wuuld you like informatiun on Expurting Check here [ JYes I ]No

COUNSELINGTRArNING

20 Have you received counseling or training from SBA (eg SCORE ACE SBDC WBC etc) J

Check here [ ]Yes [ ]No

SUBMIT COMPLETED APPLICATION TO L~ND~R OF CHOICE

CERTIFICATIONS By signing beluw yuu certify as 10 tht following

(a) All informatiun in this Application and the Exhibits is true and cumplete tu the best ufyuur knowledge You undersland Ihat Ihis inlormatiun is being submiued tu a lender and SBA so Ihey can decide 10 make a loan or give a luan guaranty and Ihalthe lender and SBA are relying un Ihis infurmation

(b) You have nol paid anyone employed by the Federal Government for help in gttting this luan Yuu understand that yuu do not need to

pay any olher third-party for assistance in locating a knder or preparing this Application or Exhibits and you certify that you will disclose all parties that were paid fur such assistance to the Lender and will complete the SBA Form 159 for all such persons

(c) I have read a copy of the Slatements Required By Law And Executive Order which is auached to this application and agree to cumply with the reljuiremcnts in this Notice

If Applicant is a proprietor or general partner sign helow

By

If Applicant is a Corporation sign below

Corporate Name and Seal Dale

By Signature u r Presidenl

AUested by Signature uf Corporate Secrttary

SBA porm 4 (9-09) Provious Edilion Obsolele Page 3

Other than the person that signed on page 3 each Pa11ner each Stockholder owning 20 or more and each Guarantor must sign below In addition if a husband and wife collectively own 20 or more of a company each spouse must also sign No one should sign more than once

Business Name _____________________ _______________

APPLICANTS CERTIFICATION READ THE FOLLOWING CAREFULLY -- FALSE STATEMENTS ARE SUBJECT TO CRIMINAL PROSECUTION If you knowingly make a false statement you can be fined up to $250000 andor imprisoned for not more than five years under 18 USC 1001 if submitted to a Federally insured institution under 18 lISC 1014 by Imprisonment of not more than twenty years andor a fine of not more than $1000000

By signing below you certify as to the following

(a) You have reviewed (I) the responses to the question about debt on page I of the application (2) the responses to questions II 12 and 13 (application-page 3) and (3) any financial statement that)Ql were required to complete as Exhibit B or r to the application and certii) that as to you personally all information in this Application and Financial Statement is true and complete to the best of your knowledge You acknowledge that this information is being submitted to a lender and SBA so they can decide to make a loan or give a loan guaranty and that the lender and SBA are relying on this in1ormation

(b) You have read a copy orthe Statements Required By Law And Executive Order which is attached to this application and agree to comply with the requirements in this Notice

Signature Date

Check all that apply [ ] guarantor r ] owner-indicate percentage owned r ] [ ] partner-indicate whether [ ] general or [ ] limited

Signature Date

Check all that apply [ 1guarantor l I owner-indicate percentage owned l J l J partner-indicate whether r ] general or [ ] limited

Signature Date

Check all that apply [ ] guarantor [ 1owner-indicate percentage owned [ 1 [ 1 partner-indicate whether [ 1general or l J limited

Signature Date

Check all that apply l 1 guarantor [ ] owner-indicate percentage owned [ J [ 1partner-indicate whether [ ] general or [ ] limited

Signature Date

Check all that apply [ ] guarantor l J owner-indicate percentage owned [ J [ ] partner-indicate whether [ Jgeneral or l J limited

Signature Date

Check all that apply [ ] guarantor [ ] owner-indicate percentage owned [ 1 [ 1 partner-indicate whether l ] general or [ ] limited

Signature Date

Check all that apply l ] guarantor [ ] owner-indicate percentage owned l J [ ] partner-indicatc whether [ 1general or [ llimited

SBA Form 4 (9-09) Previous Edition Obsolete Page 4

_ _

bull

r------=-===----=----------==----=------j 20100 Tavern License (City) $50000 1-2~~---~~~E----____~~~~~~=E~ 2011 0 Tavern License (County) $50000

20120 Manager Registration - Tavern $ 7500

Application Fee for New License Application Fee for New Licensemiddot wConcurrent Review

2310 0 Application Fee for Transfer

19850 Resort Complex License (City) 19860 Resort Complex License (County) $50000 19880 Add Related Facility to Resort Complex $ 7500 X__ Total _19900 Club License (City) $30875 19910 Club License (County) $30875

1905 0 Retail Gaming Tavern License (City) $50000 20200 Arts License (City) $30875 1906 0 Retail Gaming Tavern License (County) $50000 20210 Arts License (County) $30875 1940 0 Retail Liquor Store License (City) $22750 20300 Racetrack License (City) $50000 1941 0 Retail Liquor Store License (County) $31250 20310 Racetrack License (County) $50000 1950 0 Liquor Licensed Drugstore (City) $22750 2040 0 Optional Premises License (City) $50000 1951 0 Liquor Licensed Drugstore (County) $31250 2041 0 Optional Premises License (County) $50000 1960 0 Beer and Wine License (City) $351 25 20450 Vintners Restaurant License (City) $75000 1961 0 Beer and Wine License (County) $43625 20460 Vintners Restaurant License (County) $750001970 0 Hotel and Restaurant License (City) $50000 22200 Add Optional Premises to H amp R $10000 X __Total 1971 0 Hotel and Restaurant License (County) $50000 23700 Master File Location Fee $ 2500 X Total1975 0 Brew Pub License (City) $75000 23750 Master File Background $25000 X- - Total shy

1976 0 Brew Pub License (County) $75000 1980 0 Hotel and Restaurant License wopt premises (City) $50000 1981 0 Hotel and Restaurant License wopt premises (County) $50000 1983 0 Manager Registration - H amp R $ 7500

DR 8404 (0507109) Page 1 COLORADO DEPARTMENT OF REVENUE 21 DEPARTMENT USE ON L Y

LIQUOR ENFORCEMENT DIVISION DENVER CO 80261 COLORADO LIQUOR

RETAIL LICENSE APPLICATION

D NEW LICENSE D TRANSFER OF OWNERSHIP D LICENSE RENEWAL

ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPEWRITIEN APPLICANT MUST CHECK THE APPROPRIATE BOX(ES)

bull LOCAL LICENSE FEE $ _________ APPUCANT SHOULD OBTAIN A COpy OF THE COLORADO UQUOR AND BEER CODE Call n n -

1 Applicant is applying as a D Individual D Corporation D Limited Liability Company

D Partnership (includes Limited Liability and Husband and Wife Partnerships) D Association or Other

County City Industry Type License Account Number

Slate __-750 (999)

City 2180-100 (999)

2300-100 (999)

County

2190-100 (999) Managers Reg

__-750 (999)

$ bull





































D A $7500 fee


DR 8404 (050709) Page 3





























DR 8404 (0507109 ) Page 4











OATH OF APPLICANT









































Amount of Loan

Date of Application



1 $ $ $

2 $ $ $

3 $ $ $

4 $ $ $




bull





Origmal Date


Maturity Date

Monthly Payment


Acc $ $ $

Ace $ $ $

Aecl $ $ $

Acc $ $ $

Acct $ $ $




Gender

































AGREEMENTS











EXPORT LOANS




COUNSELINGTRArNING










By







Business Name _____________________ _______________





Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date







































D A $7500 fee


DR 8404 (050709) Page 3





























DR 8404 (0507109 ) Page 4











OATH OF APPLICANT









































Amount of Loan

Date of Application



1 $ $ $

2 $ $ $

3 $ $ $

4 $ $ $




bull





Origmal Date


Maturity Date

Monthly Payment


Acc $ $ $

Ace $ $ $

Aecl $ $ $

Acc $ $ $

Acct $ $ $




Gender

































AGREEMENTS











EXPORT LOANS




COUNSELINGTRArNING










By







Business Name _____________________ _______________





Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date



DR 8404 (050709) Page 3





























DR 8404 (0507109 ) Page 4











OATH OF APPLICANT









































Amount of Loan

Date of Application



1 $ $ $

2 $ $ $

3 $ $ $

4 $ $ $




bull





Origmal Date


Maturity Date

Monthly Payment


Acc $ $ $

Ace $ $ $

Aecl $ $ $

Acc $ $ $

Acct $ $ $




Gender

































AGREEMENTS











EXPORT LOANS




COUNSELINGTRArNING










By







Business Name _____________________ _______________





Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date



DR 8404 (0507109 ) Page 4











OATH OF APPLICANT









































Amount of Loan

Date of Application



1 $ $ $

2 $ $ $

3 $ $ $

4 $ $ $




bull





Origmal Date


Maturity Date

Monthly Payment


Acc $ $ $

Ace $ $ $

Aecl $ $ $

Acc $ $ $

Acct $ $ $




Gender

































AGREEMENTS











EXPORT LOANS




COUNSELINGTRArNING










By







Business Name _____________________ _______________





Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date



























Amount of Loan

Date of Application



1 $ $ $

2 $ $ $

3 $ $ $

4 $ $ $




bull





Origmal Date


Maturity Date

Monthly Payment


Acc $ $ $

Ace $ $ $

Aecl $ $ $

Acc $ $ $

Acct $ $ $




Gender

































AGREEMENTS











EXPORT LOANS




COUNSELINGTRArNING










By







Business Name _____________________ _______________





Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date






Origmal Date


Maturity Date

Monthly Payment


Acc $ $ $

Ace $ $ $

Aecl $ $ $

Acc $ $ $

Acct $ $ $




Gender

































AGREEMENTS











EXPORT LOANS




COUNSELINGTRArNING










By







Business Name _____________________ _______________





Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date














AGREEMENTS











EXPORT LOANS




COUNSELINGTRArNING










By







Business Name _____________________ _______________





Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date




Business Name _____________________ _______________





Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date


Signature Date



Technology

Application docu