MMD2015-00037 MMD2O15 - 00037
Growler ' s Public
House
NOTICE OF TYPE I DECISION
MINOR MODIFICATION (MMD) 2015-00037 111 -0
GROWLER'S PUBLIC HOUSE
TIGARD
120 DAYS = March 24, 2016
SECTION I. APPLICATION SUMMARY
FILE NAME: Growler's Public House
CASE NO.: Minor Modification(MMD) MMD2015-00037
PROPOSAL: The applicant is proposing a change of use to a newly-created tenant space (Suite
3A) at 14350 SW Barrows Road. The space, approximately 1,025 square feet in
size, is changing from a repair-oriented retail use to an eating and drinking
establishment,Growler's Public House.
APPLICANT: KLY,Inc. dba Growler's Public House
Atm: Krysta York
14350 SW Barrows Road,Suite 3A
Tigard,OR 97223
OWNER: Aluli Real Estate Holdings,LLC
c/o Elliot Associates, Inc.
Attn: Scott Anderson
901 NE Glisan Street
Portland,OR 97232
LOCATION: 14350 SW Barrows Road,Suite 3A
WCTM 2S104BB,Tax Lot 7800
ZONING
DESIGNATION: C-C: Community Commercial District.The C-C zoning district is designed to
provide convenience shopping facilities which meet the regular needs of nearby
residential neighborhoods.With a service area of about 1.5 miles, such
commercial centers typically range in size from 30,000-100,000 gross square
feet on sites ranging from 2-8 acres. Separated from other commercially-zoned
areas by at least one-half mile,community commercial centers are intended to
serve several residential neighborhoods,ideally at the intersection of two or
more collector streets or at the intersection of an arterial and collector street.
Housing is permitted on or above the second floor of commercial structures at a
density not to exceed 12 units/net acre, e.g., the maximum density permitted in
the R- 12 zone.A limited number of other uses,including but not limited to car
washes,gas stations,religious institutions,and transit-related park-and-ride lots,
are permitted conditionally. In addition to mandatory site development review,
design and development standards in the C-C zone have been adopted to insure
that developments will be well-integrated,attractively landscaped,and
pedestrian-friendly.
MMD2015-00037 Growler's Public House 1
APPLICABLE
REVIEW
CRITERIA: Community Development Code Chapters 18.360.060.0
SECTION II. DECISION
Notice is hereby given that the City of Tigard Community Development Director's designee has
APPROVED the above request. The findings and conclusions on which the decision is based are noted
in Section IV.
THIS APPROVAL SHALL BE VALID FOR 18 MONTHS
FROM THE EFFECTIVE DATE OF THIS DECISION.
SECTION III. BACKGROUND INFORMATION
Site Information:
The project is located at 14350 SW Barrows Road; south of SW Walnut Street and east of SW Barrows
Road. The subject property is an approximately 1,025-square-foot tenant space (Suite 3A) within an
existing shopping center. The 8.46-acre development site is made up of four tax lots (WCTM 2S104BB,
Tax Lots 7800, 7900, 8000, and 8100), which are operated by two different property owners: Tax Lots
7800, 8000, and 8100 are owned by Aluli Real Estate Holdings, LLC, and Tax Lot 7900 is owned by
Haggen Opco South, LLC. The entire shopping center contains 281 on-site parking spaces, which are
shared by all existing tenants. The site is zoned Community Commercial (C-C).
Proposal Description:
The applicant is proposing a change of use to a newly-created tenant space (Suite 3A) at 14350 SW
Barrows Road. The space, approximately 1,025 square feet in size, is changing from a repair-oriented
retail use to an eating and drinking establishment,Growler's Public House.
SECTION IV. APPLICABLE REVIEW CRITERIA AND FINDINGS
MINOR MODIFICATION OF SITE DEVELOPMENT REVIEW:
Section 18.360.060.0 states that a Minor Modification shall be approved, approved with
conditions or denied following the Director's review and as follows:
1. The proposed development is in compliance with all applicable requirements of this
title; and
Because the applicant has only proposed a change of use, which primarily affects off-street parking
regulations, that is the main focus of this review. The change of use is from a repair-oriented retail use
to an eating and drinking establishment. The 8.46-acre shopping center is a mixed-use,multi-tenant site,
and is therefore subject to the required minimum vehicle parking formula outlined in TDC
18.765.030.D. The table below calculates the minimum off-street vehicle requirements based on this
formula:
Use Category Square Parking Spaces Percentage Total Parking
Footage Required Required Spaces Required
Sales-Oriented Retail 40,000 120 100% 120
Personal Services 5,987 15 85% 13
MMD2015-00037 Growler's Public House 2
Repair-Oriented Retail 5,358 18 70%
Fast Food Eating& 4,000 28 60% 17
Drinking Establishment
Medical/Dental Office 1,759 7 60% 4
Eating& Drinking 1,025 9 60% 5
Establishment
TOTAL 172
Staff finds that 172 parking spaces are required for the entire shopping center, taking into consideration
the change of use discussed above. Based on the applicant's submitted site plan, staff finds there is
adequate parking in the shopping center,with 281 parking spaces provided.
Upon review of the applicant's plans and narrative, staff finds that all other applicable requirements are
met.This criterion is met.
2. The modification is not a major modification.
FINDING: Staff finds that the changes listed in TDC 18.360.050.B.1-11 are either satisfied or do
not apply. Therefore, the proposed development is not a major modification.This criterion is met.
CONCLUSION: The proposal is a Minor Modification of existing site development and is in
compliance with the applicable requirements of this Title.
SECTION V. PROCEDURE AND APPEAL INFORMATION
Notice:
Notice was posted at City Hall and mailed to:
X The applicant and owners
X Affected government agencies
Final Decision:
A Minor Modification is a Type I procedure. As such, the Director's decision is final on the date it is
mailed or otherwise provided to the applicant,whichever occurs first. The Director's decision may not
be appealed locally and is the final decision of the City.
„ .. ---
\_
THIS DECISION IS FINAL ON NOVEMBER 30, 2015
AND BECOMES EFFECTIVE ON DECEMBER 1, 2015
Questions:
If you have any questions,please contact Lina Smith at (503) 718-2438 or LinaCS@tigard-or.gov.
November 30,2015
APPROVED BY: Lina Smith
Assistant Planner
MMD2015-00037 Growler's Public House 3
APPLICANT
MATERIALS
• RECEIVED
11114
. City of Tigard NOV 16 2015
COMMUNITY DEVELOPMENT DEPARTMENT CITY OF
TIGARD
TIGARD
Minor Modification Type I Application 'NEE° .;VG
PROPOSAL SUMMARY (Brief description)
REQUIRED SUBMITTAL
X [ - ) ELEMENTS
C3/� p'� / authorization
izr Title Transfer Instrument or Deed
Site Plan(2 large plans drawn to scale
and one reduced to 8.5"x111/2")
•Property address/location(s): I,. / I. S / �Applicant's Statement/Narrative
(2 copies)Address criteria in:
' I /, /- .1- 1 DC 18.360.050.B.1-11
Tax map and tax lot #(s): t(FilingFee
4
Site size:
mil; s i kt I I �L l)vI.)
Applicant': i"-i. i. _ .'.1, 4/.,i 't. /MI 4;•• rase No.: MI t DaO1 C- boo 37
Address:/1% ,SLA) ,- 7r'75Lt)S 61. 5tti i-e_ 3A
Related Case No.(s):
City/state: T 4fl -d, / (Y),, Zip: C ) 22-g
Phan . _ (1 Application Fee: -7I$:b
F�mail: _. ri /. N , _A.1 ./i
tO� AQ, A,v-P ,irony. 1 Application accepted:
PRO11 IOWNLK`/IDE �th ���'�(�/ Y CAC-- Date: ((-1 Co —lS
7` �Sune as ppliernt
Name: Application determined complete
Address: 9',/ /Ug 67-, 5iL. q By I// S
LS Date: ���
City/state:,P6#/11414 / ) Zip: 172-32- IACURPINVAsStersUand Use:Applications Rev.11/24/2014
Contact name: 5E r I V5 /
Phone number: 5D3- „.2-24- t' /'
.When the owner and the applicant are different people,the applicant must be the purchaser of record or a lessee in
possession with written authorization from the owner or an agent of the owner.The owner(s)must sign this application
in the space provided on the back of this form or submit a written authorization with this application.
APPLICANT'S STATEMENT
The applicant's statement must include a summary of the proposed changes. Criteria in either 18.360.050(B)or
18.330.020(B)(2)must be addressed with a detailed response to each criterion.Failure to provide the information needed to
process the application would he reason to consider an application incomplete and delay review of the proposal.
In addition,the I)irector must find that the proposed change is in compliance with all applicable requirements of Title 18 of
the Tigard Development Code.To complete this review,the Applicant's proposal must include a discussion indicating how the
site expansion/change will continue to comply with the maximum setback,building height,parking; and landscaping standards.
Other requirements of this title such as clear vision,solid waste storage,non-conforming situations,signs,and tree removal
may also he applicable depending on the type and location of the proposed modifications.
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page.1 of 2
APPLICANTS
To consider an application complete,you will need to submit ALL of the REQUIRED SUBMITTALELEMENTS as
described on the front of this application in the"Required Submittal Elements" box.
THE APPLICANT(S) SHALL CERTIFY THAT:
• The above request does not violate any deed restrictions that may he attached to or imposed upon the subject property
• If the application is granted,the applicant will exercise die rights granted in accordance with the terms and subject to all the
conditions and limitations of the approval.
• All of the above statements and the statements in the plot plan,attachments,and exhibits transmitted herewith,are true;and
the applicants so acknowledge that any permit issued,based on this application,may be revoked if it is found that any such
statements are false.
• The applicant has read the entire contents of the application,induding the policies and criteria,and understands the
requirements for approving or denying the application.
SIGNATURES of each owner of the subject property required.
N
App . ant's sign. Print e 1t� /iS
�"` Dat
Al A i kk_,11.0 Tht (i Ii- s
0wigr's signature Piiint name
Date
Owner's signature Print name
Date
ADDITIONAL OWNER/DEED HOLDER INFORMATION
Name:
Name:
Address: Address:
City/state: Zip: City/state:
Zip:
Signature: Signature:
�;��,-—.�,.LWs:�..,v.:�:.14wiaMi:�'0•2121 ::ACCaa �,:�a..,:-,.m4.3*.14.+ gip,
MINOR MODIFICATION APPLICATION
City of Tigard • 13125 SW Hall Blvd. • Tigard,Oregon 97223 • www.tigard-or.gov • 503-718-2421 • Page 2 of
7/1/13 TO 6/30/14 REAL PROPERTY TAX STATEMENT
WASHINGTON COUNTY OREGON * 155 N FIRST AVE., RM 130* HILLSBORO,OREGON 97124
PROPERTY DESCRIPTION MAP: 2S14I3B-07800 ACCOUNT NO: R2075535
SITUS: 14350 SW BARROWS RD,
RECEIVED
OCT 2 5 2013 2013-2014 CURRENT TAX BY DISTRICT:
ALULI REAL ESTATE HOLDINGS LL
415-C ULUNIU ST �Sr -PORTLAND 497.78
KAILUA ESD-NW REGIONAL 270.73
OAHU, HI 96734 SCHOOL-BEAVERTON 8,298.73
SCHOOL-BEAVERTON LOL 2,210.40
LEGAL DESCRIPTION CODE AREA: 051.85 EDUCATION TAXES: $11,277.64
RUSSELL'S SCHOLLS FERRY, LOT 1, ACRES 1.33 WASHINGTON COUNTY 3,956.26
REG-METRO SERVICE 170.11
PORT-PORTLAND 123.43
FIRE-TV FIRE & RESCUE 2,683.78
CITY-TIGARD 4,422.04
VALUES: LAST YEAR THIS YEAR CLEAN WATER SERVICES 0.00
UR-TIGARD-DOT 62.78
MARKET VALUES: FIRE-TV FIRE & RESCUE LOL 442.08
LAND 1,166,250 1,166,250 WASHINGTON COUNTY LOL AFTER 1,043.31
STRUCTURE: 2,049,340 2,049,340 REG-METRO SERVICE-AFTER 169.76
TOTAL RMV VALUE: 3,215,590 3,215,590 GENERAL GOVERNMENT TAXES: $13,073.55
TAXABLE VALUES:
ASSESSED VALUE 1,716,820 1,768,320 BOND-WASHINGTON COUNTY 227.23
BOND-METRO SERVICE DIST 164.45
BOND-PCC 308.75
BOND-SD #48-BEAVERTON 2,598.90
BOND-TV FIRE & RESCUE AFTER 231.47
PROPERTY TAXES: $27,309.80 $30,586.63 BOND-CITY OF TIGARD AFTER 762.85
BOND-METRO SERVICE AFTER 320.24
APPEAL DEADLINE December 31,2013 BOND-PCC-AFTER 488.06
Value Questions 503-846-8826 BOND-SD #48-BEAVERTON-AFTER 1,133.49
Tax Questions 503-846-8801
Business Personal Property Questions 503-946-8838 BOND AND MISC TAX: $6,235.44
Other Questions 503-846-8741
2013-14 TAX (Before Discount) $30,586.63
PROPERTY TAX PAYMENT OPTIONS
(See back of Statement for payment instructions.)
Due Discount Net Amount Due
Pay DELINQUENT TAXES: NO DELINQUENT TAXES DUE
In Full 11/15/13 917.60 $29,669.03
2/3 11/15/13 407.82 $19,983.27 (See back for explanation of taxes marked with an asterisk(').
1/3 11/15/13 NONE $10,195.55 Delinquent Tax Total is included in payment options to the left.)
MAKE PAYABLE TO:Washington County TOTAL (After Discount)
Online- https://ecomm.co.washington.or.us/propertytax $29,669.03
Pay By Phone:1(888)510-9274
MY MARKET VALUE WENT DOWN, BUT MY TAXES WENT UP?
Your property taxes are based on your ASSESSED value not your MARKET value. A decline in the market value does not
automatically reduce your property taxes.
For more information,review the enclosed Washington County Property Tax Statement Guide or visit our website:
http:l/www.co.washington.or.us/AssessmentTaxation
All Payments Processed Upon Receipt
V Tear Here
V Tear Here
RETURN THIS PORTION WITH PAYMENT - SEE BACK OF STATEMENT FOR INSTRUCTIONS
2013-2014 Property Tax Payment Stub WASHINGTON COUNTY,OREGON ACCOUNT NO: R2075535
nMailing address change on back of stub.
SITUS: 14350 SW BARROWS RD,
UNPAID DELINQUENT TAX IS INCLUDED IN PAYMENT OPTIONS
FULL PAYMENT(Includes 3%Discount) DUE: 11-15-13 $29,669.03
2/3 PAYMENT(Includes 2%Discount) DUE: 11-15-13 $19,983.27
1/3 PAYMENT(No Discount Offered) DUE: 11-15-13 $10,195.55
DISCOUNT IS LOST&INTEREST APPLIES AFTER DUE DATE
ALULI REAL ESTATE HOLDINGS LLC
415-C ULUNIU ST Make Payable to:
KAILUA WASHINGTON COUNTY ENTER AMOUNT PAID
OAHU, HI 96734 Property Tax Payment Center
P.0.Box 3587 Due Date:11/15/2013
Portland,OR 97208-3587
34000120755350002966903000199832700010195552
REC =D
NOV 1 6 2015
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RECEIVED
November 10, 2015 NOV 16 Z015
Minor Modification Summary CITY OF TIGARD
PLANNING/ENGINEERING
Address: 14350 SW Barrows Road Suite 3A,Tigard, OR 97223
KLY INC is the lessee for 14350 SW Barrows Rd. Suite 3. We have received approval
for an additional suite #of 3A for a portion of the space.
Two entrances were already designated for the entire 5540 sq. ft. of space before we
signed the lease. One entrance is currently being used for the doggy daycare. The
other entrance is Suite 3A and is 1025 sq. ft.
As you can tell from the plans, a devising wall, door, plumbing and bathroom have
all been approved previously and are currently in the Suite 3A space.
We are applying for a minor modification to open Growler's Public House in the
1025 sq. ft. It will be a tap house for pints, glasses and growlerie refill station.
We have included a site map that has ample parking for both businesses.
The only item we will be adding is a walk-in cooler and bar top and table and chairs.
Everything else is already in the space.
Sincerely,
Krysta York- 0 ner
KLY INC.
Evaluation Criteria RECE!\IED
Growler's Public House NOV 16 2015
14350 SW Barrows Rd.Suite 3A CITY
Tigard, OR 97223
Square footage: 1025
1. Not applicable
2. Not applicable
3. Parking is sufficient: see site plan
4. Not applicable
5. Not applicable
6. Not applicable
7. See site plan for all parking spaces. Parking is more than sufficient for the
type of business and will not impede the parking for any other business in
the surrounding area.
8. Not applicable
9. Not applicable
10.Not applicable
11.Not applicable
Lina Smith
From: Scott D. Anderson <ScottAnderson@elliottassociatesinc.com>
Sent: Tuesday, November 24, 2015 4:53 PM
To: Lina Smith
Subject: RE: Minor Modification for Growler's Public House
14200 Building:
- Godfather's Pizza—4,000 sq. ft.
RECEIVED
14250 Building: NOV 2 5 2015
- Ultimate Tan & Beauty—1,823 sq. ft.
- Catrick Cleaners—843 sq.ft. CITY OF Ti'3ARD
- Great Clips—1,333 sq. ft. PLANNING/ENGINEERING
14350 Building
- Avalon Salon—1,505 sq. ft.
- Mathnasium—1,326 sq.ft.
- Growlers—5,540 sq. ft.
- Barrows Dental—1,759 sq. ft.
I do not have the information regarding Haggen's—as it is not owned or managed by us.
ELLIOTT
ASSOCIATES
Scott Anderson, REAL ESTATE MANAGER, BROKER
901 NE Glisan Street: Portland, Oregon 97232
503.972.7186 D I R 503.224.6791 TEL 503.983.4100 CELL 503.228.3169 F A X
ScottAnderson@elliottassociatesinc.com : elliottassociatesinc.com
FACEBOOK TWITTER LINKED-IN
From: Lina Smith [mailto:LinaCSC�tigard-or.gov]
Sent: Tuesday, November 24, 2015 4:47 PM
To: Scott D. Anderson
Subject: Minor Modification for Growler's Public House
Dear Scott,
I'm reviewing a Minor Modification for Growler's Public House at 14350 SW Barrows Road, Suite 3A.
Can you please send me a list of all tenants and the square footage of every tenant space in this
shopping center? I need this to calculate the total required parking for all the uses in the shopping center.
Feel free to e-mail me if you have additional questions.
Thank you,
Lina Smith
Assistant Planner
City of Tigard Community Development
13125 Hall Blvd. Tigard,OR 97223
E mail: LinaCS(&,tigard-or.gov
1
too `oA
(MCC, OREGON LIQUOR CONTROL COMMISSION
Mr./L LIQUOR LICENSE APPLICATION
Application is being made for: CITY AND COUNTY USE ONLY
LICNSE TYPES ACTIONS Date application received:
Full On-Premises Sales ($402.60/yr) 0 Change Ownership
G' 0 Commercial Establishment ., 'New Outlet The City Council or County Commission:
❑Caterer 0 Greater Privilege
0 Passenger Carrier 0 Additional Privilege (name of city or county)
0 Other Public Location ❑Other
recommends that this license be:
Private Club
Limited On-Premises Sales ($202.60/yr) GI Granted ❑ Denied
aOff-Premises Sales ($100/yr) By:
D with Fuel Pumps (signature) (date)
(Brewery Public House ($252.60) Name:
1U'Winery ($250/yr)
0 Other: Title:
90-DAY AUTHORITY
❑Check here if you are applying for a change of ownership at a business OLCC USE.ONLY
that has a current liquor license, or if you are applying for an Off-Premises Application Recd by: k A
Sales license and are requesting a 90-Day Temporary Authority '
APPLYING AS:, Date: NOV 2 0 0� I `
['Limited Corporation 0 Limited Liability 0 Individuals
I
Partnership Company 90-day authority: ❑ Yes ❑ o
1. Entity or Individuals applying for the license: [See SECTION 1 of the Guide]
2. Trade Name (dba): GI Z L()I€r S At,bir i✓ delL.L24--1
3. Business Location:/1LS t.) /�4,J S 1 j fe 3.4 7Jz,- f q?-2-23
5
number,street,rural route) (city) (county) ate)
(ZIP code)
244/
4. Business Mailing Address: ,Sit,fil W/97/11 0y`"1
(PO box, number,street,rural route) (city) (state) (ZIP' de)
5. Business Numbers: 50,33 - Srly b s
(Phone) � (fax)
6. Is the business at this location currently licensed by OLCC? ❑Yes o
7. If yes to whom: Type of License:
8. Former Business Name:
9. Will you have a manager? :fres o Name:/70 /i�` . .e_7 'I,YjzL_ j‘;)-7
J (ma ger must fill out an Individual form)
10.What is the local governing body where your business is located? // . a__„0---,,i..._
/ _ (name of city or county)
11.Contact person for this application: JX j 41 Gl �L il,t1,- I ,'L.. 6.e3 ._gey'-G,7 5
name) (phone number(s))
�� L�lt yd Gil_ 1 r[l/i? . I'� rt •� DGL� SOS 1.i�� r
i/ I� t r I �c b , vim.
(address) a �<`ia ( ,(yj q) LZ 5 (fax number) s7-mail address
I understand that if my answers are not true and complete, the OLCC may deny my license application.
Applicant ) Signature s and D. ,•
% •i 01.11P- 1 . , •Date��jp//. ® Date
® / Date 0 Date
,ohl Lig
014 IIIII ('°13
!MCC,} OREGON LIQUOR CONTROL COMMISSION
\o5' CORPORATION QUESTIONNAIRE
Please Print or Type
Corporation Name: Ay—Are. Year Incor orated:
� l p „;ZC) 1 `
Trade Name (dba): , /r �, NI"
Business Location Address:)3 TO 5w ,-z� 3
,J 5 +�Gt � c )lvt.r �Z
City: p6-1,--Ha4 4_ la... ZIP Code: g7z2s
List.CorporateOfficers::
xi5,7,
(name) j P/5:d,-
List Board of Directors:
,5 , - 41 C-1-4Z1 ��,_
(name)
List Stockholders: (Note: If any stockholder is another legal entity, that entity may also need to complete another
Corporation Questionnaire. See Liquor License Application Guide for more information.)
Number of
S ockholders: Shares Held: Number of Stock Shares:
� L
/ j/L1$J7 - 1/22 ,Gl.zi_ itt.c� icZ"lb Issued:
Unissued:
Total Shares Authorized
to Issue:
1i , 4_ 1,(;m
Server Education Designe , _,/ " 44"/ DOB: ,.�// /3-9
3
(See Liquor License Application G ide for�'ore in � � _0, 44"/orma •n) /
I understand that if my answe s 1JZ)
no true and complete th- •LCC maydenymy license application.
Officer's Signature /R . tLk
_ /2(ArdP.."1 i Date: ///)--//5-
name (title)
1-800-4 -OLCC (6522)
www.oregon.gov/olcc (rev. 08/11)
Aiiiizo
° OREGON LIQUOR CONTROL COMMISSION
IOLCC& INDIVIDUAL HISTORY
1. Trade Name 7l- /e t' .5 Pi{./of Heng - 2. City / /4,-- - rte(.,
3. Name �G� � irti 75717L..., `v(Last) ( (Mid*4. Other names used (maiden, other) /)--l�// /
5. *SSN .5--YY- OZ- -75516. Place of Birth (� O�-`, 7. DOB 0.L / /3 /19Y' 8. Sex M O /'
(St to or Country) (mm) (cid) (yyyy) �T
*SOCIAL SECURITY NUMBER DISCLOSURE:As part of your application for an initial or renewal license, Federal and State
laws require you to provide your Social Security Number(SSN)to the Oregon Liquor Control Commission (OLCC) for child
support enforcement purposes(42 USC§666(a)(13)&ORS 25.785). If you are an applicant or licensee and fail to provide your
SSN, the OLCC may refuse to process your application.Your SSN will be used only for child support enforcement purposes
unless you sign below.
Based on our authority under ORS 471.311 and OAR 845-005-0312(6), we are requesting your voluntary consent to use your
SSN for the following administrative purposes only: to match your license application to your Alcohol Server Education records
(where applicable), and to ensure your identity for criminal records checks. OLCC will not deny you any rights, benefits or
privileges otherwise provided law if you do not consent to use of your SSN for these administrative purposes(5 USC§552(a).
If you consent to these us: ple:se sign her-: ,-,/
Applicant Signatu / ,' , I,( ;\.../
9. Driver License or St- - ID# 55t9/ 10. State C e.
11. Residence Address,,29(6() Stc) �(-2,-der U,t ) Ava eN---fria-,41._ 6 97,-02-5
(number and street) (city (state) (zip code)
12. Mailing Address (if different)
(number and street) (city) (state) (zip code)
13. Contact Phone 56 3---go4/—(/9/ 5 14. E-Mail address (optional)
15. Do you have a spouse or domestic partner? Yes ❑ No "
If yes, list his/her full name: iee V) - )–ee, yet r IL)
16. If yes to#15, will this person work at or be involved in the operation or management of the business?
°Yes c4 No
17. List all states, other than Oregon, where you have lived during the past ten years:
18. In the past 12 years, have you been convicted ("convicted" includes paying a fine) in Oregon or any
other state of driving a car with a suspended driver's license or driving a car with no insurance?
❑ YesNo 0 Unsure If yes, list the date(s), or approximate dates, and type(s) of convictions.
If unsur , explain. You may include the information on a separate sheet.
19. In the past 12 years, have you been convicted "convicted" includes paying a fine) in Oregon or any other
state of a misdemeanor or a felony ? 0 Yes No 0 Unsure
If yes, list the date(s), or approximate dates, d type(s) of convictions. If unsure, explain. You may
include the information on a separate sheet.
1H Form-Page 1 of 2 1-800-452-OLCC (6522) (rev.02/12)
www.oregon.gov/OLCC
20. Trade Name .• - ?, / , _ _ 21. City I i , o v((___)
22. Do you have any arrests or citations that have not been resolved? 0 YesNo 0 Unsure
If yes or unsure, explain here or include the information on a separate shee .
23. Have you ever been in a drug or alcohol diversion program in Oregon or any other state? (A diversion
program is where you are required, usually by the court or another government agencyt complete certain
requirements in place of being convicted of a drug or alcohol-related offense.) 0 Yes No 0 Unsure
If yes, list the date(s), or approximate dates. If unsure, explain. You may include the in ormation on a
separate sheet.
24. Do you, or any legal entity that you are a part of, currently hold or have previous) held a liquor license
in Oregon or another US state? (Note: a service permit is not a liquor license.) 0 Yes No 0Unsure
If yes, list the name(s) of the business, the city (or cities) and state (or states) where located, and the
date(s) of the license(s). If unsure, explain. You may include the information on a separate sheet.
25. Have you, or any legal entity that you are a part of, ever had an application for a license, permit, or
certifica a denied or cancelled by the OLCC or any other governmental agency in the US?
OYes No 0 Unsure If yes, list the date(s), or approximate dates. If unsure, explain. You may include
the information on a separate sheet.
Questions 26 and 27 apply if you, or any legal entity that you are part of, are applying for a Full On-
Premises, Limited On-Premises, Off-Premises, or Brewery-Public House license. If you are not applying
for one of those licenses, mark"N/A" on Questions 26 & 27.
26. Do you have any ownership i terest in any other business that makes, wholesales, or distributes
alcohol? 0 N/A 0 Yes No 0 Unsure If yes, list the date(s), or approximate dates. If unsure,
explain. You may include the information on a separate sheet.
27. Does, or will, a mar, wholesaler, or distributor of alcohol have any ownership interest in your business?
0 N/A OYes No 0 Unsure If yes or unsure, explain:
Question 28 applies if you, or any legal entity that you are part of, are applying for a Brewery, Brewery-
Public House, Distillery, Grower Sales Privilege, Warehouse, Wholesale Malt Beverage & Wine, or
Winery license. If you are not applying for one of those licenses, mark "N/A" on Question 28.
28. Do you, or any legal entity that you are part of, hany ownership interest in any other business that
a
sells alcohol at retail in Oregon? 0 N/A 0 Yes No0 Unsure If yes or unsure, explain:
You must sign your own form (you can't have your attorney or a person with power of attorney sign your form).
I affirm that my answers are true and complete. I understand the OLCC will use the above information to
check my records, including but not limited to, criminal history. I understand that if my answers are not true
and complete, the OLCC ay deny my license pplication.
G
Applicant Signatur . a . SM �2 �� - ^ ' Date: //// //..3
IH Form-Page 2 of 2 1-800 2-OLCC(6522) (rev.02/12)
www.oregon.gov/OLCC
04..GO�G�9
'pr,, 4 OREGON LIQUOR CONTROL COMMISSION
o
.��g BUSINESS INFORMATION
Please Print or Type
Applicant Name: /--L/ L/V('. Phone: u3 -��Q/- (1'
Trade Name (dba):61-7-6Li/e- ?tL.h//L, .
Business Location Address: /1/350 SE-0 at K-(1,)S ,ed, <S'u,,f+° g4
City: -77:94,,---,L ZIP Code: c)22 3
DAYS AND HOURS OF OPERATION 'iEl"'
Business Hours: Outdoor Area Hours: The outdoor area is used for:
Sunday /Up1—to /o p,—, Sunday to ❑ Food service Hours: to
Monday 4,,in to142if Monday to ❑ Alcohol service Hours: to
Tuesday 7 to JO p,,,/ Tuesday to
ID Enclosed, how
Wednesday -,,0,7„ to /D itii,.. Wednesday to
Thursday 3 v,g., to /S7,4,.. Thursday to The exterior area is adequately viewed and/or
Friday //2 , to /I77,1.,i Friday to supervised by Service Permittees.
Saturday /1 Cti1,- to II pm- Saturday to (Investigator's Initials)
—P74—
Seasonal Variations: 0 Yes 0 No If yes, explain: As- _ ,,t,,c _,L, cyp-r iJJ.-v)
ENTERTAINMENT Check all that apply: DAYS & HOURS OF LIVE OR DJ MUSIC
❑ Live Music 0 Karaoke
Sunday to
153t Recorded Music ❑ Coin-operated Games Monday to
❑ DJ Music 0 Video Lottery Machines Tuesday to
Wednesday to
❑ Dancing ❑ Social Gaming Thursday to
Friday to
❑ Nude Entertainers 0 Pool Tables Saturday to
0 Other:
NA
SEATING COUNT
Restaurant: r Outdoor:
OLCC USE ONLY
Investigator Verified Seating: (Y) (N)
Lounge: Other (explain): Investigator Initials: _
Banquet: Total Seating: '2.-Lt Date:
I understand if my answers are not true and complete, the OLCC may deny my license application.
Applicant Signatua>///
,,( jc (c) OArY/1,11 c LLA/ Date: j� 11,5
1-800-453? OLCC (6522}
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