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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 „....--..,,,, SITE PLAN \-.....40 -— - • _ _ — - s-y.4. - BARR OWS ROAD _ (-•- _-- •, )••-•."\\.r 4FrP., *--4---- , / 1."-kigit• i 1 , i 1 I i .1 ,---A 1----- '-1 1 ---.; -- (Lt.,' ...." /' ' 4.• ' ...._// 1, , GODFA T HE RS PIZZA \I\s.\....1 - ' 14 ).••• . \ • ‘ . /• 1 \ •• i ' 1\ , ' ‘ , 44e- • ',.....,:\ ' ---, --.• .' C •\ \ ' '4'.;. ' A. .!1' ' p , , i • , 4. .... I . 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(1.-Y.r ' - • :".it" W.,4,` VI..10 it ' , Is 1 l ir: r _.-- -• - ttl'i 1 1 ' r 1 ' ' I ' el 2 ; k \ t • '. . • 1 ,--I •-•,..„........:----*Li Mil - FAMILY-- . • • -1 A, -P ' i \. / •• .. . . - . ALBERTSONS , • ,••• ' •••• . ”I , i :- t,.•:- -- 40,000 SF '' •ti•-•• .. , :-F • t . i ' ' \ . ' .., 61 i c) ii I/ - - \ '. . , ,00ct s . - .-...:•;.e-_: . • . \ ‘6,4 ; 'Rs; -a .h i 1 `c;----- - , • -!-,1 ...,, -. ...--... ,lr,- . 1i !I ;I . . ;. \ \...,.. ;, 140011:titAt ãr - g .. e. i g ,.--v . . , . .. . ........"--:00mM,, gill.t.Ina.r.r, ,,,,,. lii .an• -- 11 . -. • --,. WI IV-,redesuen Atcr„es..i i! • -----•77..'"-- ,„„ - ;f NA••-••;::016 -- *dam Rev$1.1.8 I i -^: ell n..'7.' .,........... .....--". .. . . .---.—.--------....--.•-: 1 . . -. l'••'' -' . , iiiir,',**---0,'v . - . ...-- - . . . 0.1-,,,...,....,., ., . , N.J.Evereen itreert .., . '' rt ANT PALETTE - i 1,-, c 1 - „.....„ ..... ,.. Weer treeicUll.. - AP '-- - - .. , /7-0921 f3 Street Tree . ... Conifer”Screenog Tree I k u..1•,,ctr..• .,r-/- /--: - i * Parking Tree ,.......,,,.. . . . . ...- \ i \\Nizt,,,,,..... a Specimen Tree ........... r. ' , . ,.--- ` 0 Accent Tree 0.,.-...,....K.. I ."°77"----1.,: i .. ' ._ 'CL•CI'S..a"..r., • r .•-. . • - • - - - MOB Shrubs&Groundcovers jr111, ..--1 - - ..• ...i.:. .. . • ESE I.awn --..- — 7LANDSCAPE PLAN "`""' •-•: A-34 . .. .,.....•••.•-.• , __I -.' --• . - . . - . 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} SITE PLAN I ,,,,:.•... 01 ill() if n10441‘at+cq.. _ _ . . _ .... ... _ ..,„,. 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