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Home My WebLink AboutAgenda - City Council - 04/02/2012 . r, dts southburlington VERMONT AGENDA SOUTH BURLINGTON CITY COUNCIL City Hall 575 Dorset Street SOUTH BURLINGTON, VERMONT Executive Session 5:00 p.m. Monday, April 2, 2012 Consider entering executive session to discuss personnel, contract negotiations and litigation. Regular Meeting 6:00 p.m. Monday, April 2, 2012 1. Agenda Review: Additions, deletions or changes in order of agenda items. 2. Comments and questions from the public (not related to the agenda). 3. Announcements and City Manager's Report. 4. Consent Agenda: • ***Approve Minutes from March 14 & 19th • #HfttSign Disbursements • *** Consider approval of Entertainment permits o Higher Ground-Annual Permit o Sheraton Burlington Hotel-Annual Permit o Community Bible Church-June 16th, 2012 o National MS Society-August 11-12, 2012 • *** Consider authorizing the Fire Department to submit a grant application to VLCT's Equipment Grant program. (Doug Brent, Fire Chief). VLCT annually offers municipalities up to $5,000 to purchase safety related equipment. This year, our Fire Department is requesting funds from VLCT to assist with the purchase of a "power safety cot"which is designed to be safer for patients and reduce injuries to our EMTs. The total cost of this item is $13,330.26 and the matching funds will come from budgeted funds of$8,330.26 from the FY 2012 Fire Department budget. 5. *** Recommendation from the Social Service Committee for approval of funding to local agencies for FY 12. (Bob Rusten, Deputy City Manager 6. ***Waive First reading of Street Lighting Standard Ordinance; schedule Public Hearing for May 7th, 2012 (Justin Rabidoux, Public Works Director). 7. ***Consider Authorizing Re-financing of a Stormwater Mitigation Grant Anticipation Note for $200,000 (Bob Rusten, Deputy City Manager). 8. Consider Councilor to serve as UVM liaison (Sandy Dooley, Councilor and Sandy Miller, City Manager). 9. *** Reconvene as Liquor Control Board to consider 2012-2013 annual liquor licenses: • Aviation Deli & Fine Foods • Champlain Farms-Exxon • Eagles Fraternal Order#793 • Champlain Farms • Higher Ground • Chick Charlie's • Holiday Inn • Gonzo's Indoor Golf • Leisure World, Inc. • Green Mountain Suites Hotel • M.T. Bellies Deli • Short Stop#105 • Maplefields • Moe's Southwest Grill • Olive Garden • Price Chopper#228 • One Flight Up • Silver Palace • The Pour House • Sugarsnap, LLC • Rotisserie • Windjammer Restaurant • Sheraton VT Corp • Zachary's Pizza • Applebee's 10. ### Discuss Possible Rules of Procedure and Other Regular Expectations for City Council (Councilors, Sandy Miller, City Manager and Bob Rusten, Deputy City Manager). 11. Other Business. • Any items held from the Consent Agenda. • Other? 12. Consider entering executive session for discussion of personnel matters, litigation and real property matters. 13. Adjournment. Respectfully Submitted: Sanford I. Miller, City Manager *** Attachments Included ### Attachments Sent Separately or Previously South Burlington City Council Meeting Participation Guidelines The City Council Chair is presenting these guidelines for public participation and attendance at City Council meetings in an effort to insure that everyone has a chance to be heard and meetings function as smoothly as possible. 1. Please raise your hand to be recognized to speak. The Chair will make every effort to recognize the public in the order in which hands are raised. 2. Once recognized by the Chair, please identify yourself to Council. 3. If the Council has suggested time limits, please respect them. Time limits will be used when they can aid in making sure everyone is heard and sufficient time is available for Council to conduct business items. 4. In order for City Councilors and other members of the audience to hear speakers' remarks,side conversations between audience members should be kept to an absolute minimum. The hallway outside the Community Room is available should people wish to chat more fully. 5. Please address the Chair. Please do not address other audience members or staff or presenters and please do not interrupt others when they are speaking. 6. Make every effort not to repeat the points made by others. 7. The Chair will make reasonable efforts to allow everyone who is interested in participating to speak once before speakers address the Council for a second time. 8. Council desires to be as open and informal as possible within the construct that the Council meeting is an opportunity for Councilors to discuss, debate and decide upon policy matters. Council meetings are not"town meetings". To this end, after the public has had the opportunity to make comments,the Chair may ask that discussion be among Councilors. April 2, 2012 City Council Meeting Please Print Name Name Name 1f 3Q/(c e Pa`9 c-e-l'f 18 35 2r*(,L_ 19 36 3 `e- 3LA 20 37 4 I A v 21 38 5 /JhJ �� 22 39 6 p1\0101 Nu_ 23 40 7 24 41 8 25 42 9 26 43 10 27 44 11 28 45 12 29 46 13 30 47 14 31 48 15 32 49 16 3 33 50 17 34 51 _J A B C D E F i 1 2 SOCIAL SERVICES FUNDING RECOMMENDED APPROPRIATION FY 12 3 4 FY 12 $ Change $ Change 5 AGENCY FY 11 Approved Funding FY 12 Request Recommended FY11 - FY12 FY11 - FY12 6 American Red Cross 0 4000 0 7 C.V.A.on Aging 3100 3600 3000 -$100 -3.23% 8 Chittenden Community Action(no request FY 12) 650 0 0 -$650 -100.00% 9 Chittenden Emerg. Food Shelf 1900 3000 1900 $0 0.00% 10 Common Roots(new for FY 12) 0 no amount given 0 11 COTS 3900 3900 3800 -$100 -2.56% 12 HomeShare VT 2600 2600 2500 -$100 -3.85% 13 Howard Center(no request FY 12) 5400 0 5000 -$400 -7.41% 14 Northern Vermont Resource Conservation&bey.Council(new for FY 12) 0 100 0 15 PACT 1500 1500 1200 -$300 -20.00% 16 RSVP(United Way) 1750 2000 1700 -$50 -2.86% 17 South Burlington Family Center 5200 5265 5000 -$200 -3.85% 18 Special Needs Fund(City's fund) 0 0 19 Vermont Center for Independent Living 0 1400 0 zo VNA (request amount 3%over last years) 9000 9270 8200 -$800 -8.89% 21 Winooski Natural Res.Conservation District 0 500 0 22 Women Helping... 3600 4500 3500 -$100 -2.78% 23 Woman's Rape Crisis Center(no request FY 12) 300 0 0 -$300 -100.00% 24 VT Assoc for the Blind(no request FY 12) 200 0 200 $0 0.00% 25 26 Total 39100 41635 36000 -3100 27 28 Budget$36,000 29 30 31 _ 32 3/30/2012 4:41 PM Recommended Social Service Organization Funding Internal Policy Regarding Social Service Organizations Requesting Money through City of South Burlington's Budgetary Preparation Process — Starting for FY 2014 1. A Social Service Allocation Committee (Committee) will be created by the City Manager with no more than 5 members. Three members of the Committee should be: Deputy City Manager (Deputy), one Councilor (chosen by the Council); and public member not directly connected to any organization seeking an allocation. 2. If a Social Service Organization (SSO) has in the previous fiscal year received an appropriation from the City, and they submit a level-funded request with some documentation detailing the services provided to the City of South Burlington and its citizens, they do not have to meet with Committee before Committee considers SSO request. 3. If a previously funded Social Service Organization (SSO) requests more money than they received the previous year they may be asked to meet with Committee. 4. If this is the first year of a request a SSO may be asked to meet with Committee before Committee will consider putting in the request. • If previously-funded SSO requests money but doesn't submit documentation detailing the services provided to the City of South Burlington and its citizens, they need to do so before Committee will consider voting in their request. Even if SSO does the above there is no guarantee that Committee will vote to recommend allocation to the South Burlington City Council. 5. No later than November 1st of each year the city administration will send a communication, including this policy, to all SSOs that had requested funding the previous year reminding SSO of process to request allocation. 6. If SSO doesn't request money in writing by November 15th, they will not be considered in the Committee's recommendation to the City Council's proposed general fund budget. 7. Shortly after the November 15thst submittal deadline the Committee shall meet to determine which SSOs they will meet based on the criteria of this policy. 8. By December 1st the Committee will submit in writing to the Deputy their recommendations for how much money is to be allocated to which organizations. Committee is to use its discretion in recommending the total amount of money to be allocated, but in doing so keep in mind previous year's total allocation amount as well as impact on overall budget. 9. Upon receipt of recommended allocation Deputy will include total amount in proposed FY budget. If in finalizing draft budget Deputy feels that recommended allocation creates a problem for the total budget, Deputy may either request meeting with Committee or highlight to Council issues related to the allocation request. 10.Council will make final determination as to total allocation amount, as well as allocation amounts to specific SSOs as part of proposed budget to voters. Council may request to meet with Committee as part of its allocation decision. 11.Upon final approval by the voters of the proposed fiscal year budget city administration will inform SSOs that had requested an allocation the final decision of that request. 3/30/12 merchants BANK Note No. 1 of 1 $200,000.00 City of South Burlington GRANT ANTICIPATION NOTE 1160089346 South Burlington,Vermont March 21,2012 For value received,the City of South Burlington promises to pay to MERCHANTS BANK,or order, the principal sum of: TWO HUNDRED THOUSAND AND 00/100 DOLLARS ($200,000.00) with interest at the rate of 1.86%per annum,calculated on the basis of an actual 365 day year from the date of original delivery of this note,with principal and interest payable in lawful money of the United States at the Main Office of Merchants Bank, in the City of Burlington,Vermont. One principal installment of$100,000.00,together with accrued interest on the unpaid balance, will be due on January 21,2013. All unpaid principal and accrued interest shall then be payable in full on January 21,2014. This note issued in anticipation of grants-in aid for the purpose of financing certain capital improvements authorized by vote of the City Council for the City of South Burlington at a meeting thereof duly noticed,called and held on January 22,2008,and pursuant to a resolution adopted by the City Council of said City of South Burlington at a meeting thereof duly noticed,called and held on April 2,2012. Said note(s) shall be paid from such grants-in-aid, upon receipt thereof. It is hereby certified and recited that all acts,conditions and things required to be done precedent to and in the issuance of this note have been done,have happened and have been performed in regular and due form as required by law and that the full faith and credit of the said City of South Burlington are hereby irrevocably pledged for the payment of this note. City of South Burlington By: Treasurer City Council RESOLUTION GRANT ANTICIPATION BORROWING WHEREAS,the City Council is authorized and empowered to borrow money on the credit of the City of South Burlington in anticipation of certain grants-in-aid for the construction of certain capital improvements authorized voted at the meeting held on January 22,2008; and WHEREAS,the said City Council finds it expedient and in the best interests of the City of South Burlington to borrow the sum of$200,000.00 in anticipation of the said grants-in-aid; and WHEREAS,grants-in-aid in anticipation of which this borrowing is undertaken have been awarded and authorized by appropriate federal and/or state agencies; and WHEREAS,the City Council has been and is now proceeding to construct the improvements authorized at said meeting and funds are needed to defray the cost thereof; and WHEREAS,in order to have funds available to defray the cost of making said improvements as aforesaid,the City Council has arranged to borrow$200,000.00 from MERCHANTS BANK,with such borrowing evidenced by promissory note(s)as hereinafter set forth,which note(s)does/does not refund and replace any previously issued note(s). THEREFORE,BE IT RESOLVED,that the City Council and the Treasurer proceed forthwith to complete said transaction and issue said evidence of indebtedness to cover the same; and BE IT FURTHER RESOLVED,that said evidence of debt when issued and delivered pursuant to this Resolution shall be a valid and binding general obligation of the City of South Burlington,payable according to the terms and tenor thereof from unlimited ad valorem taxes duly assessed on the grand list of taxable property in said City of South Burlington,as established by law; and BE IT FURTHER RESOLVED,that all acts and things heretofore done by the lawfully constituted officers of the City of South Burlington and its City Council in, about,or concerning the expenditure of proceeds of the note evidencing the borrowing and the issuance thereof are hereby ratified and confirmed; and We, the undersigned City Council and Treasurer,hereby certify that we as such officers have signed a Grant Anticipation Note(s)numbered 1,dated March 21,2012 and due January 21,2014 with an interest rate of 1.86%,payable as therein set forth and further certify that the note(s)are issued under and pursuant to this Resolution adopted at a duly noticed and warned meeting of the City Council of the City of South Burlington held on April 2, 2012. We the said City Council and Treasurer of the City of South Burlington,hereby certify that we are the duly chosen,qualified and acting officers as undersigned,that the note(s)is issued pursuant to authority,that no proceeding relating thereto has been taken other than as shown in the foregoing recital, that no such authority or action has been amended or repealed,and that there is no litigation threatened or pending in any state or federal court of competent jurisdiction seeking to enjoin either the issuance of the above-described note(s)or the expenditures being financed by the proceeds of the same. We also certify that there has been full and timely compliance with all public procurement, solicitation and bidding laws,ordinances and regulations with respect to each of the transactions embodied in this Resolution. We certify also that no litigation is pending or threatened affecting the validity of the note(s)or the apportionment and assessment of taxes,if necessary,to pay the same when due,that neither the corporate existence nor the boundaries of the City of South Burlington,nor the title of any of us to our respective offices,is being questioned or contested. Further,we hereby certify to and covenant with MERCHANTS BANK,its successors and assigns,including specifically the transferees,assigns,holders and owners of the above-described note(s) that: 1. No proceeds of the note(s) (including investment proceeds thereof)will be used(directly or indirectly)in any trade or business carried on by any person other than the City of South Burlington nor used to make or finance loans to any person. 2. During the current calendar year,the City of South Burlington will not issue debt of any sort aggregating$10,000,000.00 or more. 3. The City of South Burlington will file when and as required with the Treasury Department or Internal Revenue Service information returns relating to the issuance of this note(s)and all other obligations of the City of South Burlington. 4. The City of South Burlington will comply with,perform,maintain and keep each and every covenant,representation,certification and undertaking in the accompanying Tax Certificate, execution and delivery of which is hereby authorized. City of South Burlington By: Treasurer City Council TAX CERTIFICATE GRANT ANTICIPATION BORROWING We,the Treasurer and at least a majority of the City Council of the City of South Burlington, Vermont(the "Issuer"),hereby certify and represent as follows with respect to the aggregate$200,000.00 Grant Anticipation Note(s)numbered 1 through 1,of the Issuer(the "Note(s)"),which Note(s)is dated March 21, 2012 and is payable as therein set forth: 1. The Issuer is issuing and delivering the Note(s)simultaneously with the delivery of the Certificate. 2. We are the officers of the Issuer charged by law with the responsibility for issuing the Note(s). 3. The Note(s)is being issued for the purpose of financing capital improvements approved by the Issuer at a duly held meeting thereof on January 22,2008. 4. The entire amount borrowed by the issuance of the Note(s),together with all of such,if any, amounts previously raised or borrowed for the same purpose, does not exceed the total costs of the improvement(s) less all other funds available for the purpose, and all of the proceeds of the Note(s)have been or are expected to be needed and expended for the improvement(s)within three(3)years from the date of the first borrowing for these expenses. 5. Substantial binding obligations to commence the improvement(s)being financed by the Note(s)have been made, consisting of at least a binding obligation by the Issuer to expend more than five percent of the total cost of said improvement(s). Work on the improvement(s)being financed by the Note(s)is expected to proceed hereafter with due diligence. 6. The Note(s)is/is not being issued to refund Note(s)previously issued for the same purpose described in paragraph(3). 7. Any real and personal property,acquisition of which has been financed by the Note(s) has not been and is not expected during the life of the Note(s)to be sold or otherwise disposed of for consideration. 8. It is expected that any earnings or net profit derived from investment or deposit of the proceeds of the Note(s), including transferred proceeds,any accrued interest received upon sale of the Note(s)and any premium received on the delivery thereof,will be expended for the improvement(s)within the period stated in paragraph(4)above to the extent such funds are not commingled for accounting purposes in the general funds of the Issuer with tax and other substantial operating revenues. 9. The Issuer has not created and does not expect to create or establish any debt service fund,bond payment reserve,sinking fund,or other similar fund pledged to the payment of the Note(s)or from which it is expected that payment of the Note(s)would be made. 10. To the best of our knowledge, information and belief,the above expectations are reasonable. 11. The Issuer has not been notified of any action by the Commissioner of Internal Revenue to disqualify it as an issuer whose arbitrage certificates may be relied upon. 12. No part of the proceeds derived from the issuance and sale of the Note(s)nor the expenditures financed by the proceeds of the Note(s)shall be: a. Used,loaned or otherwise made available to any person or other entity,other than the Issuer or a governmental body,so as to cause the Note(s)to be classified as private activity bonds or arbitrage bonds,as those terms are defined under the Internal Revenue Code of 1986. b. Used directly or indirectly in a trade or business by any person other than the Issuer or another municipal entity; c. Loaned to any person directly or indirectly other than the Issuer; d. The subject of any contract, lease or agreement of any sort having a term of one year or more and calling for the payment by the Issuer of consideration other than a flat fee; e. Expended to finance the construction, alteration or renovation of any improvement the use,occupancy, availability or beneficial enjoyment of which shall be restricted among public users thereof or for which preferential,different or unique fees,rates,assessments or charges shall be levied; f. Invested in such a manner or for such a period or at a yield to result in the rebate of interest earnings thereon to the United States under any public law now or hereafter in effect; 13. The Issuer shall furnish to the United States,or any agency,department or instrumentality thereof,in a timely fashion,such information as may be required by law with respect to all evidences of debt now or hereafter issued by the Issuer. 14. Neither the proceeds of the Note(s),nor any earnings derived from the investment thereof,shall be expended for the purpose of paying any costs associated with the issuance of the Note(s). 15. The proceeds of the Note will not be used in a manner that will cause the Note to be a "private activity bond"or an"arbitrage bond"within the meaning of Sections 103(c), 141 and 148 of the Internal Revenue Code of 1986, and the Regulations thereunder. 16. The Note(s)will not be refunded or otherwise paid,defeased or secured by the proceeds of any form of debt issued by the Issuer,unless the manner of such payment,refunding or security preserves the characterization of the Note(s)as essential function bonds under federal legislation denominated by the Internal Revenue Code of 1986. 17. The Note is declared to be a"qualified obligation"under Section 265(b)of the Internal Revenue Code. This Certificate is executed and is being delivered pursuant to Sections 1.103-13, 1.103-14,and 1.103-15 of the Treasury Regulations under Section 103(3),141 and 148 of the Internal Revenue Code of 1986, as amended. City of South Burlington Treasurer City Council • City of South Burlington Ordinance for Historic Style Street Lighting Department of Public Works DRAFT 02-10-12 Lighting district: This ordinance shall apply to the segment of Williston Road (U.S. Route 2) beginning at the boundary with the City of Burlington and extending westerly to the Dorset Street intersection. It shall apply to all lighting located within, or intended to illuminate, the public right of way. The installation of new historic style light fixtures will be required as part of any future street reconstruction project or significant street expansion project. Purpose: The purpose of this ordinance is to continue the pedestrian scale street lighting with historic style fixtures matching those existing along Main Street (U.S. Route 2)in the City of Burlington. The continuation of the lighting present along Main Street in Burlington to Williston Road in South Burlington is one component of extending the pedestrian scale streetscape to the Dorset Street intersection. Lighting standards: Historic style light fixtures, mounting arms, poles, and base covers shall be of the model and type specified below, as manufactured by Philips Lumec [640 Cure-Boivin, Boisbriand, Quebec, CN J7G 2A7 (450 430- 7040)] In recognition of the need to provide adequate illumination of the full street, including travel lanes, shared use shoulders, and pedestrian crossings, and that pedestrian scale lighting is less efficient in accomplishing this goal, the use of high mount traditional style street lights is allowed in combination with pedestrian scale lighting. At a minimum, high mount street lights shall alternate with the historic style light fixtures. Additional high mount lights maybe used at intersections and on traffic signal poles. High mount street lights and poles shall be of the model and type specified below, as manufactured by Philips Lumec [640 Cure-Boivin, Boisbriand, Quebec, CN J7G 2A7 (450 430-7040)] All light fixtures shall have LED lamps, with a color temperature of 4000 Kelvin (+/- 10%), with a 70 color rendering index. All light fixtures shall be full cutoff in accordance with IESNA standards. All electrical work shall conform with the National Electrical Code. Historic style lighting specifications See attached drawing for detailed specifications. Light fixtures: Octagonal style lantern, with finial, cage, and hood to be cast aluminum with clear tempered glass. Lamp/Optics: LED, full cutoff. Optical distribution to be determined based upon site specific design Mounting arm: Decorative, cast aluminum arm and tenon, to be mechanically fastened to City of South Burlington Ordinance for Historic Style Street Lighting Department of Public Works DRAFT 02-10-12 the pole retaining adapter with stainless steel bolts and nuts. Mounting height: 22 feet nominal height (maximum) Pole: Tapered aluminum shaft, welded to the bottom anchor plate. Base cover: Two piece cast aluminum components, mechanically secured with stainless steel bolts and nuts. Access door covering an opening of 4" x 9" with copper ground lug. Finish: Electrostatically applied, thermosetting polyester powder coat paint. All components shall be BLACK. Bases: Poles shall be mounted on circular cast in place or precast concrete bases. The dimensions of the concrete base shall be determined based upon the site conditions. The diameter of the concrete base shall be compatible with the dimensions and mounting requirements of the pole base cover. High mount lighting specifications See attached drawing for detailed specifications. Light fixtures: Lumec Roadstar cobra head style, cast aluminum. Lamp/Optics: LED, full cutoff. Optical distribution to be determined based upon site specific design Mounting arm: Aluminum support arm Mounting height: 35 feet nominal height (maximum) Pole: Tapered aluminum shaft, welded to the bottom anchor plate. Base cover: Two piece cast aluminum components, mechanically secured with four decorative medallions. Access door covering an opening of 4" x 9" with copper ground lug. Finish: Electrostatically applied, thermosetting polyester powder coat paint. All components shall be BLACK. Bases: Poles shall be mounted on circular cast in place or precast concrete bases. The dimensions of the concrete base shall be determined based upon the site conditions. The diameter of the concrete base shall be compatible with the dimensions and mounting requirements of the pole base cover. • SOUTH BURLINGTON EXIT 14 mom guiTt £ co CO AIME i 15 5/8" 397mm `Nt ERiEk Eon: Type A Qty 1 Luminaire L70-90W49LED4K-GL-FC-LE3-120-SF70-HS-BKTX-LMS12027N Description of Components: Finial: Decorative cast 356 aluminum, mechanically assembled. Hood: In an octogonal tapered shape, this hood is made of a one-piece cast 356 aluminum mechanically assembled to the luminaire. Guard: In a octogonal tapered shape, this guard is a one-piece cast 356 aluminum mechanically assembled to the fitter. Access-Mechanism: Two-integrated hinges on hood with stopper and a captive screw shall offer access to the inside of the luminaire and to the lamp. An embedded memory-retentive gasket shall ensure weatherproofing. Lens: (GL-FC), Made of frosted clear tempered glass assembled on the guard with brackets. Lamp: (Included), Composed of 49 high-performance white LEDs, 90w lamp wattage. Color temperature of 4000 Kelvin nominal, 70 CRI. Operating lifespan after which the system emits 70% of its original lumen output, all of those parameters are tested for 100% of light engines. Use of a metal core board insures greater heat transfer and longer lifespan of the light engine. Optical System: (LE3), I.E.S type III (asymmetrical). Shall have an individual pre-oriented acrylic lens to achieve desired distribution. Each LED shall have a protection against shut off maintaining operation of light engine. System is rated IP66. An independent photometric laboratory test certifies it's performance. Heat Sink: Made of cast aluminum optimising the LEDs efficiency and life. Product does not use any cooling device with moving parts(only passive cooling device) Driver: High power factor of 90%. Electronic driver, operating range 50-60 Hz. Auto-adjusting to a voltage between 120 and 277 volt AC rated for both application line to line or line to neutral, Class II, THD of 20% max. Maximum ambient LMS12027N0-16513(SA)IT PH, i Il IPS 01-30-2012 Page 1 /6 � 640,care-aotvin IL LI m e c BcanadiandaJ7G(Quebec2A7 ) anad , SOUTH BURLINGTON EXIT 14 operating temperature from -40F(-40C) to 130F(55C) degrees. Certified in compliance to cULus requirement. Weather tightness rating IP66. Assembled on a unitized removable tray with Tyco quick disconnect plug resisting to 221F(105C) degrees. The current supplying the LEDs will be reduced by the driver if the internal temperature exceeds 185F(85C), as a protection to the LEDs and the electrical components. Output is protected from short circuits, voltage overload and current overload. Automatic recovery after correction. Surge Protector: LED Driver 3 poles 10KV surge Protectors that protect Line-Ground, Line-Neutral, and Neutral-Ground in accordance with IEEE/ANSI C62.41.2 guidelines. LMS12027N0-16513(SA)ITP HIUP S 01-30-2012 Page 2/6 hJ^/1/ J E Bois viandCure-(Quebec) Boisbriand(QuQbec) Canada,J7G 2A7 SOUTH BURLINGTON EXIT 14 29" 737 m m Configuration N co N ORIFICE 90' v, 1 1/2"95 UQFOR WIREWAY � � d r � ,oT EN rEA 270° CiMi■ Type A ® ■ Qty 1 Bracket LMS-IA-BKTX-LMS12027N w/ '8O soo,2� Description of Components: Tenon: Shall be made from aluminum tubing,2 3/8"(60mm)outside diameter,welded to the arm. Arm: Shall be made from cast 356 aluminum,mechanically assembled to the adaptor. Adaptor: Clamps made of two-piece cast 356 aluminum, mechanically fastened to the pole by stainless steel bolts and nuts, c/w a wire retainer. LMS12027N0-16513(SA)IT k PHLS 01-30-2012 Page 3/6 640,cure-Bonn Irn E C BCanadaoisbrianJ7G d(Quebec2A7 ) , SOUTH BURLINGTON EXIT 14 Base&Bolts Information Anchor Plate Free opening 6 1/4"0 -B.C.: 159mm0 12 1/2" 3312"(89mm) (318mm) /r Projection (/ -Material: /!0 a Cast Aluminum 6 Comes with 4 steel anchor bolts,1"X — ,� 33"+3",8 nuts and 8 washers. j �1�,Important:Do not obstruct space 15" �- _ �r � ��;g� e, between anchor plate and concrete i base. 381mm r ERTpk [(e Type A 1111111111161) Qty 1 Pole VSPA-23.75-PH8/120-BKTX-LMS12027N Description of Components: Pole Shaft: Shall be made from spun aluminum 6063-T4, tempered to T6 after g—-—-— welding, having a base diameter of 7" (178mm) and top diameter of 5" (127mm) wall Cy g thickness 0.188" (4.7mm) welded to the base. The pole shaft is c/w a decorative clamp made of two-piece cast 356 aluminum, mechanically fastened with stainless steel bolts and nuts. Maintenance Opening: The pole shall have a 4" x 9" (102mm x 229mm) maintenance opening centered 15" (381mm) from the bottom of the anchor plate, b E complete with a factory assembled copper ground lug. ,,Pi n Pole Options: (PH8/120)twist lock type photocell, 120 volts, on pole top. Note: A tenon will be provided when the luminaire or bracket does not fit directly on pole shaft. Tenon not shown on the drawing. E n m rE ,1 -.IF-ACCESS IMPORTANT: Philips Lumec strongly recommends the installation of the complete go...E DOOR SIDE lighting assembly with all of its accessories upon the anchoring of the pole. This will 4.3127m.mJ ensure that the structural integrity of the product is maintained throughout its lifetime. LMS12027N0-16513(SA)IT / PHILIPS 01-30-2012 Page 4/6 IM/I/ 640,Cure-Boivin L IJ C Boisbriand(QuAbec) Canada,J7G 2A7 • SOUTH BURLINGTON EXIT 14 Miscellaneous Description of Components: Wiring: Gauge (#14) TEW wires included from luminaire to the bracket and from bracket to the base of pole with Gauge (#10)TEW. Note: All wire connections will be supplied with quick disconnect plugs. Hardware: All exposed screws shall be stainless steel with Ceramic primer-seal basecoat to reduce seizing of the parts. All seals and sealing devices are made and/or lined with EPDM and/or silicone. Finish: Color to be black textured (BKTX). Application of a polyester powder coat paint. (4 mils/100 microns). The chemical composition provides a highly durable UV and salt spray resistant finish in accordance to the ASTM-B117-73 standard and humidity proof in accordance to the ASTM-D2247-68 standard. Quality Control: The manufacturer must provide a written confirmation of its ISO 9001-2008 and ISO 14001-2004 International Quality Standards Certification. Mechanical resistance: In order to ensure the mechanical resistance of the poles, the projected area should be calculated according to AASHTO 2001. Web site information details: Click on any specific information details you need: Paint finish / Warranties / ISO 9001-2008 Certification / ISO 14001-2004 Certification LMS12027N0-16513(SA)IT , / PHILIPS 01-30-2012 Page 5/6 /%/'/ sao,curt Boivin IL LI firli C CanadaBoisbriandJ7G(Quebec2A7 ) , S Burlington EXIT 14 4 * "-,... Li, , , • WAntcuaca Catalogue 45 1/8" 1146mm Co E .- t=:f 35 L'" yam EPA:1.1 sq ft/weight:31 lb(14.09 kg) Note:3D image may not represent color or option selected. i®` Logos above include link,click to access. Imum Qty 1 Luminaire GPLM-180W98LED4K-LE3-120-COLTX ,S1`II/ odb Description of Components: Housing: the upper and lower part of the housing are made of die cast A360 Aluminum alloy 0.100 (2.5mm) minimum thickness. The mounting means includes two brackets made of stamped galvanized-steel (12ga.). Fits on a 1.9"(48mm)to 2 1/2" (63mm) OD by 7" (178mm) minimum long tenon,fixed by 1/2-13 UNC steel zinc plated bolts.An integral part of the housing permits an adjustment of+/-5°. The housing is complete with a secured access door avoiding accidental dropping, a ground lug and a terminal block that accepts(#8 max.)wires from the primary circuit. Access-Mechanism: The mechanism shall offer toolfree access to the inside of the luminaire. Light Engine: LifeLEDTM composed of 4 main components: LED lamp/Optical System/Heat Sink/Two Drivers Electrical components are RoHS compliant. Lamp: (Included), Composed of 98 high-performance white LEDs, 180w lamp wattage. Color temperature of 4000 Kelvin nominal, 70 CRI. Operating lifespan after which the system emits 70% of its original lumen output, all of those parameters are tested for 100% of light engines. Use of a metal core board insures greater heat transfer and longer lifespan of the light engine. Optical System: (LE3), I.E.S type III (asymmetrical)full cutoff. Composed of high-performance acrylic collimators, optimized with varying beam angles to achieve desired distribution. System is rated IP66. Performance shall be tested per LM63 and LM79 (IESNA) certifying its photometric performance. Dark Sky compliant. Heat Sink: Built-in the upper housing, optimising the LEDs efficiency and life. Product does not use any cooling device with moving parts (passive cooling device) SPEC20120113_143235_10361_0 PHILIPS 01-30-2012 Page 1 /5 640,Cure-Boivin LU mi C Boisbriand(Quebec) Canada,J7G 2A7 S Burlington EXIT 14 Driver: High power factor of 90%. Electronic driver, operating range 50-60 Hz. Auto-adjusting to a voltage between 120 and 277 volt AC rated for both application line to line or line to neutral, Class II, THD of 20%max. Maximum ambient operating temperature from -40F(-40C) to 130F(55C) degrees. Lamp starting capacity -40F(-40C) degrees. Certified in compliance to cULus requirement. Weather tightness rating IP66. Assembled on a unitized removable tray with Tyco quick disconnect plug resisting to 221 F(105C) degrees, located in a separate enclosure in order to protect from heat generated by the LEDs. The current supplying the LEDs will be reduced by the driver if the internal temperature exceeds 185F(85C), as a protection to the LEDs and the electrical components. Output is protected from short circuits, voltage overload and current overload. Automatic recovery after correction. Surge Protector: LED Driver 3 poles 10KV surge Protectors that protect Line-Ground, Line-Neutral, and Neutral-Ground in accordance with IEEE/ANSI C62.41.2 guidelines. Bird Guard: Prevents birds from entering the luminaire. Made of high-density polyethylene 0.030" (0.8mm)thick and captive to the housing. SPEC20120113_143235_10361_0 PHIL IPS 01-30-2012 Page 2/5 640,curd-Bonn L E C Boisbriand(Quebec) Canada,J7G 2A7 S Burlington EXIT 14 Miscellaneous Description of Components: Wiring: Gauge (#14) TEW/AWM 1015 or 1230 wires, 6" (152mm) minimum exceeding the bracket. Hardware: All exposed screws shall be stainless steel with Ceramic primer-seal basecoat to reduce seizing of the parts. All seals and sealing devices are made and/or lined with EPDM and/or silicone. Finish: Textured color to be advised (Standard Lumec color): (COLTX). Application of a polyester powder coat paint. (4 mils/100 microns). The chemical composition provides a highly durable UV and salt spray resistant finish in accordance to the ASTM-B117-73 standard and humidity proof in accordance to the ASTM-D2247-68 standard. Note: IMPORTANT:All missing details must be clearly specified on the return of these approval drawings. Thank you for your cooperation. COLOR: Pole Information: This bracket is available for a 4"(102mm), 5"(127mm) or 5 9/16" (141mm) Outside Diameter pole or tenon. Please specify diameter required: Quality Control: The manufacturer must provide a written confirmation of its ISO 9001-2008 and ISO 14001-2004 International Quality Standards Certification. Certification: The manufacturer will have to supply a copy of approval products certificate, CSA, UL or CE. Vibration Resistance: The GPLM meets the ANSI C136.31-2001 table 2, American National Standard for Roadway Luminaire Vibration specifications for Bridge/overpass applications. (Tested for 3G over 100 000 cycles by an independent lab) Web site information details: Click on any specific information details you need: Paint finish / Warranties / Installation pictures / Driver Specification / ISO 9001-2008 Certification / ISO 14001-2004 Certification / Certification CE / cULus Certification SPEC20120113_143235_10361_0 PHILIP S 01-30-2012 Page 4/5 640,curd.Boivin IL LI NI C CanadaBoisbriand(QuebecJ7G2A7 ) , 4 I 3 W 2 I 1 a NO. POLE SHAFT SPECIFICATIONS 96.00 1 SHAFTS ARE ONE SECTION DESIGN FABRICATED FROM 6063 T6 ALUMINUM (g') EXTRUSION-SPUN TAPERED. 2 BASE CASTING IS 356 T6 ALUMINUM.THE SHAFT TELESCOPES INTO THE BASE CASTING AND IS CIRCUMFERENTIALLY WELDED TOP AND BOTTOM. REMOVABLE CAP ANCHOR BOLTS ARE"L"FORMED RODS HAVING A MINIMUM YIELD STRENGTH OF 3 55,000 P.S.I.FABRICATED FROM ASTM F1554 GR.55 THEN PARTIALLY GALVANIZED PER ASTM A153 SPECIFICATIONS AND FURNISHED COMPLETE WITH 2 HEX NUTS AND 2 FLAT D l WASHERS. 0 4. POLES SHALL BE POLYESTER POWDER COAT CUSTOM COLOR FINISH. 32.00 POLE DIMENSIONS RISE POLE HGT(FT.) TOP DIA.(IN.) BOTTOM DIA.(IN.) GAGE MTG.HGT.(FT.) --_ — 33' 5.00 8.00 .250 35' BASE PLATE DIMENSIONS 00 BOLT CIRCLE(IN.) RASP PLATE DIM.(IN.) BOLT HOLE(IN.) PLATE THK.(IN.) 11.00-14.00 13.00 SQ 1.31 1.00 ANCHOR BOLT DIMENSIONS WIRE INLET ANCHOR BOLT DIA.(IN.) ANCHOR BOLT LENGTH(IN.) s. 1.00 40.00 - i k ALLOWABLE WIND LOADING(SQ.FT.)PER ARM _ WIND' 100 MPH " EPA 2.0 _ *WITH 1.3 GUST FACTOR 8 FT.ARM 1 h_¢1.00 ill a ' c elk r33 i 1/2-13 UNC HEX BOLTS I., < POLE SHAFT Or 1/2 FLAT WASHERS `. f + P� MOUNTING DETAIL VIEW 396.00 13.00 5Q. - 3 36.00 (33') k" € aG `B } ~' M , 4 - Ba � at � 3lk 'ta 6 i'.Y .qia 'F�3aZA 5:€a,5 4'4‘„,, Y; _, i $ g >k 3-CS-MOD ?: 2 PCBB SE CASTING N x`'k ti OBOLT CIRCLE 1 a a " x �� Y s I s�. ) L-4.00 \ ° ,.r4. A° 01.00 X 40.00 ANCHOR BOLT 4 z DRAWN LYTE POLES,INC. j M.HARVALA 1/18/2012 R ,. as 1 OfECKED M/�' P.O.BOX 390 f II f Ll EASTPOINTE,MI 98021 A !1j' 1f9{1� ��', ,:, .;-> a ,. REVISION: DATE: TITLE A 36.00 lI`�o3. ' '... i IN. . °A t a, NFG SOUTH BURLING1ON f c'�+�. '> \til�S. `'" �. z. ,.4`. APPROVED EXIT 14 '*. .. a^a3w ,Aaw n i.... ' ,1 * SIZE CATALOG NO. ---I 024.00 -- _/ C 405-801S-23.75-MOD-MODBASEOB343-MODCC POLE DETAIL 13.00 X 13.00 X 4.00 THK. BASE CASTING SCALE NONE ID9GNO. SD-150 1SHEET1 OF 1 I 3 41, 2 I 1 • ��zH ern iHcrcy 1 4 f , City of South Burlington �lt�l akill`r ��d it 575 DORSET STREET ./1lti� -�'� SOUTH BURLINGTON, VERMONT 05403-6260 he sNtO 4 TOWN 10j'C FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION 0 .7kC)3(1-66 ) DOING BUSINESS AS/TRADENAME %---Ay_i yL__-fir l 6 Imo_:- (0, � I C� ADDRESS )4 LS r4p1)144 rlo FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE Dar?. c �� J�i South Burlington Police Department Chief Trevor S. Whipple Date So Burlingto ire Department .3/15`1 7 Chief Douglas S. Brent Date South Burlington Tax Department 1 -—-NCI i / I Martha Lyons, Deputy Tax Collector Date Date Sent to Montpelier: i • 2012 LIQUOR LICENSE RENEWAL APPLICATION 7413-001-SECN-01 SECOND CLASS LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $100.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $50.00 is paid to town/city $50.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Aviation Deli & Fine Foods LLC Doing Business As: Aviation Deli & Fine Foods TIC Mailing Address: 1223 Airport Drive 1223 Airport Drive South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 399-2206 PLEASE INCLUDE EMAIL ADDRESS: e'filA.A0ney �o c—sf. /► L� Description of Premises: Lessor: Store in a single story structure located on the west side of Airport City of Burlington Parkway desingated as #1223 directly across the road from the Burlington VT Burlington Airport in the city of South Burlington, VT Last Enforcement Seminar: 08/03/2011 Filed Articles of Organization: Yes Date Filed: 09/22/2010 Federal ID Number: 27-3535813 Majority of Members are US Citizens: Y e s ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Limited Liability Company Name Address Town/City State Zip Code Member 1. Mahoney, Robert P 45 Arrowhead Avenue Milton VT 05468 Has any person been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes )(No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes )(No If yes, please attach the following information: Individual's name, office and jurisdiction Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. 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M 0 --I Z -.I • -cn-I • • 0 M-.I, Z 3 I.7) • • I 71 0-...° C) • '.1 0 Z<m • • 33 m Z 1 . -, CC?37 W e I I - M r" m -I 0 Ci 1 S =Z-I 1 • r- m_,0 • • 3_ <0)r, # # ...• • Z CO -(in • • m ,..,CO S • in 1.,-I> S • Z m--I -i m S co • . • • 411.4kosolobrb4keikm.ftokkokotkiloblagorgolk 41.•••40 • 2012 LIQUOR LICENSE RENEWAL APPLICATION 7413-001-SECN-01 SECOND CLASS LICENSE TO SRT,T, MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify thatthat the information in this application is true and complete. Dated at ju0 �h /CS[3 f/r5/0 y) , in the county of(A, fM yj , and State of itz-yrv-20 this /777t j, day of U/n 0 4 y V , RD/2-- Signature of authorized agent Signature of individual or partners of corporation, c , c or association C (Title) Are you making this application for the benefit of any other party? Yes Y No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the cauoissionem will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual catmmissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of a . of<f�A Total Membership 45 , members present a �-- ) C ld.!'Omn Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 1 1 2012 TOBACCO LICENSE RENEWAL APPLICATION 7413-001-TOBC-01 TOBACCO LICENSE TO SETA', TOBACCO Page 1 License Year Beginning May1, 2012 endingOptional Fee: $1 0.0 0 of which g g April 30, 2013 $10.0 0 is paid to town/city $0.0 0 is paid to DLC Fee due only if licensee does not have a liquor license Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Aviation Deli & Fine Food' LLC Doing Business As: Aviation Deli & Fine Foods LLC Mailing Address: 1223 Airport Drive 1223 Airport Drive South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 399-2206 PLEASE INCLUDE EMAIL ADDRESS: g/9 /7U J4Q fl/✓)/7,7��s � �2 Description of Premises: `'� Lessor: Store in a single story structure located on the west side of Airport City of Burlington Parkway desingated as ((1223 directly across the road from the Burlington VT Burlington Airport in the city of South Burlington, VT Last Enforcement Seminar: 08/03/2011 Filed Articles of Organization: Yes Date Filed: 09/22/2010 Federal ID Number: 27-3535813 Majority of Members are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Limited Liability Company Name Address Town/City State Zip Code Member 1. Mahoney, Robert P 45 Arrowhead Avenue Milton VT 05468 Has any person been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes )'No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following inform tion: Individual's name, office and jurisdiction ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. I/We hereby certify that the information in this application is true and complete. Dated at(<j0 y�`j //(3 fV/1, in the county of IX//ice') / , and State of 1- 7,,,12-) this 4a.//\ day of A Gtti Y,)/ , Signature of authorized agent Signature of individual or partners ofxporation, company, club r association J0 A/vwr (Title) Are you making this application for the benefit of any other party? Yes .0;41\lo Continued on next page D`0 1eu.,.Orok YtA4� O4 4 1 City of South Burlington /r+.�� ,�`p•�,��I;� 575 DORSET STREET EIt�,/1��i�`' ,� SOUTH BURLINGTON, VERMONT 05403-6260 t,�'B`''hFO,i M ."' I`'eIRST, SECOND CLASS AND CABARET LICENSE APPLICATION OWN FULL NAME OF PERSON, PARTNERSHIP, CORPORATION DOING BUSINESS AS/TRADENAME fna�l�� v E MI o�� 6F ,ri6., 743 ADDRESS /1133 0 / r rrj - . IRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE d r ' ao/ - • South Burlington Police Department Chief Trevor S. Whipple Date South B gton Fire Dep rtment 3/i9//2- Chief Douglas S. Brent Date South Burlington Tax Department 1Mart a /ii/11 Lyons, Deputy Tax Collector Date Date Sent to Montpelier: I 2012 LIQUOR LICENSE RENEWAL APPLICATION 517-002-1CLB-01 FIRST CLASS LICENSE FOR CLUB TO SF'T., MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0 0.0 0 is paid to town/city $100.00 is paid to DIE Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Eagles, Champlain Aerie #793, F.O.E., Inc. Doing Business As: Eagles, Fraternal Order of Aerie #793 Mailing Address: 1233 - B Shelburne Road 1233 - B Shelburne Road South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 651-9004 PLEASE INCLUDE EMAIL ADDRESS: 4--`/7c(,jry ® L Je Re. s ('U 4 C0 Description of Premises: Premises: XX Owned Leased Restaurant located within a one story wood framed building on the west side of Shelburne Road designated as 1233 Shelburne Road, located in the city of South Burlington, Vermont Last Enforcement Seminar: 02/23/2010 Fed. ID Number: 03-0123326 Incorporation Date: 11/19/1949 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Ye s ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Chagnon, Bruce P.O. Box 8553 Burlington VT Director 2. Brown, Lynn 36 Howard Street Burlington VT 05401 Has any director or stockholder been convicted or pleaded guilty to aryl criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? (/Yes No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective der appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes t/No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: Expiration Date: Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 440030123326F-01 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: XX Yes No Are there any changes to this Outside Consumption area?: Yes V No (If yes, attach necessary information) Deck on back of north side of building 16x16 11:00am to 12:00am year round use Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands that he/she must maintain a list of the names and residences of paid up members, a list of club officers, and a list of employees of the club and their annual salaries. These lists must remain on the licensed premises and be available for inspection upon request. The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page i i .f 2012 LIQUOR LICENSE RENEWAL APPLICATION 517-002-1CLB-01 FIRST CLASS LICENSE FOR CLUB TO cF.TT MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this applica ion is true and complete. �� 7�Dated at �, ,,>(/Y(/1/,r. -ti .., , in the county of 1�11/ 4�/JG�,, , and State of -af'Y'"""J this day of Signature of authorized agent Signature of individual or partners corporation, company, club or association 6 ) Wv"-i5 --470-41 2,2 a41/ 64,7,3„, / if (Title) Are you making this application for the benefit of any other party? Yes 1./ No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as emended, have been fully met by the applicant, the commissioners will endorse their recaumendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of th ity or Town of Total Membership , members present hest % 4 tp/}&'own Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city 1-nard of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 j i City of South Burlington to e City Clerk's Office VOTE f° v Donna Kinville, City Clerk • FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION DOING BUSINESS AS/ TRADENAME rot)ncl ADDRESS //)/ ). l4- 4-6D1 //,: o i (J FIRST CLASS SECOND CLASS /` `' CABARET Th DATE RECEIVED BY CLERK'S OFFICE ;;;',E; � ��(�J SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO URLINGTON E DEPT j//7//2-- Chief Douglas 'S. Brent Date SO. BURLINGTON TAX DEPT /EP' Mart a Lyons, Deputy ax Collector' Date sent to Montpelier: ' I 2012 LIQUOR LICENSE RENEWAL APPLICATION 5589-001-1CAB—01 FIRST CLASS CABARET LICENSE TO SRra, MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $100.00 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: 0-B-2, TJC Doing Business As: Higher Ground Mailing Address: 1214 Williston Road 1214 Williston Road . South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 652-0777 j,� ex �v YU4k PLEASE INCLUDE EMAIL ADDRESS: l� D /`' lVl � � �C.� ` OM\ Description of Premises: Lessor: Cabaret consisting of two rooms and lobby area with an upstairs LBJ Enterprises, LLC mezzanine area, with a total approximate size of 13,700 square feet 105 Appletree Point Road being a primary steel and block constructed building, located as 1214 Burlington VT 05401 Williston Road, in the City of South Burlington, Vermont. Last Enforcement Seminar: 05/18/2011 Filed Articles of Organization: Yes Date Filed: 09/14/2004 Federal ID Number: 20-1656098 Majority of Members are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Limited Liability Company Name Address Town/City State Zip Code Member 1. Statesir, Kevin 502 Acorn Drive Waterbury VT 05676 Member 2. Crothers, Alex 98 Park Street Burlington VT 05401 Has any person been convicted or pleaded guilty to any criminal or mo or vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's name, c /traffic bureau, offense and date In the past year has any person held any el tive or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following information: Individual's name, office and jurrisjurisdictionVt. Dept. of Health Food License No.: 2579 Expiration Date: ///�/ '9'2,-- Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 440-201656098F-01 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN If these premises are licensed as a Caharet, I/We hereby certify that the receipts from entertainment, dancing and sale of alcohol beverages are greater than the receipts from the sale of food. The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from Stae and Federal record repositories. I e hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full carp ance with a plan approved by the Carmissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of s application. (VSA, Title 32, Section 3113) I, e hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with re t to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b),OWe certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of con ntr�p' utions due to the Department of Employment and Training. e have registered the trade name of these premises with the Secretary of State. Continued on next page 2012 LIQUOR LICENSE RENEWAL APPLICATION 5589-001-1CAB-01 FIRST CLASS CABARET LICENSE TO SFT,T, MALT AND VINOUS BEVERAGES Paae 2 ' I Te reby ce ify that the ' formation in this application is true and complete. 0Dated a &)C 1J , in the county of ) OEjV , and State of Vel-AMOWT , this / day of , '261) 2---- Signature of authorized agent Signature of individual or partners of co ration, club r oci ion C ' ,KeiiiJ '-il-yrK,/117--- Ouv/1)01-/A1/97-141617L. . (Title) Are you making this application for the benefit of any other party? Yes 4 No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall rsrry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of e City of v // ' J Total Membership 5 , members present ,\lU" C.__ i=-;.:.nn. ,3=-SL C.t l town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 1 I 1 1 ,�' '<0 City of South Burlington 4 City Clerk's Office VOTE �`° Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION a___ /i �4 i i Do/ ad9-i- , DOING BUSINESS AS/ TRADENAME a ADDRESS 1060 09 ;111.4DYL , FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE —2',:: o/ — SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. 3 tic/�ry RLINGTON F -RE DEPT Ch ouglas S. Brent Date SO. BURLINGTON TAX DEPT /6-e Marth Lyons, Deputy T x Collector Date sent to Montpelier: ' 2012 LIQUOR LICENSE RENEWAL APPLICATION 5037-002-1HTL—01 FIRST CLASS HOTEL LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0 0.0 0 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this , indicating any changes in the spaces provided. Applicant: Larkin,John & Marilyn /40//:diner t n r ) Doing Business As: Champlain School Apartments Partnership (H) Mailing Address: 1068 Williston Road 1068 Williston Road South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 864-7444 PLEASE INCLUDE EMAIL ADDRESS: Description of Premises: Premises: XX Owned Leased Hotel in a 4 Story building on the Northerly side of Williston Road, adjacent to the entrance ramp of I-89, designated as 1068 Williston Road, in the City of South Burlington, Vermont. Last Enforcement Seminar: 01/20/2010 2, lq I I a ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Partnership Name Address Town/City State Zip Code Partner 1. Larkin, John 170 Spruce Street Burlington VT 05401 Partner 2. Larkin, Marilyn 170 Spruce Street Burlington VT 05401 Has any person been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's , court/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes )( No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 4844 Expiration Date: ?? 010 Vt. Dept. of Health Lodging No.: 4844 Expiration Date: ?? 0 3 0 it;,3. Vt. Tax Dept. Meals & Rooms Cert./Acct. No.: 030347091F-01 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: XX Yes No Are there any changes to this Outside Consumption area?: Yes X'No (If yes, attach necessary information) outdoor pool area being 54'x80' in size with small 13'x7' long alcove with fence around entire area. Lower patio area 14'x48' in size to be used after fence installed Year round use 8am to llpm Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN If these premises are licensed as a Cshsret, I/We hereby certify that the receipts from entertainment, dancing and sale of alcohol beverages are greater than the receipts from the sale of food. The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page .. ... •:: ': ',... ... _ -+3.K:"sip.`....."�--i•gee-+-w^*k.'.,w.•...,"qry.:..;-`�s.w..r. - .. Vermont Department of Liquor Control Certificate of First Class Seminar Attendance Name (print): t3 i1A-1 f .. .-/t vA ' i Signature: rllyl +- � )�1 rr Date: r; -- (expires two years from above date) Investigator's Signature: "7--".Y".7 Certificate of First Class Seminar Attendance Category (circle one): Owner Director Partner (Manager ) Employee Licensee Name: V IN lr'tr !1) SC.)1 Q (it N-1)A (31-1 Q.A 51- d/b/a: Address: 10 (JJ i\\.` ‘?... 6 n . (s s \\JP7 At (-)Education Regulation 3-B V.S.A.T.7 §239 DLC:10M:0I/07:SC • Vermont Department of Liquor Control Certificate of First Class Seminar Attendance Name (print): z ./ Signature: t ' ' Date: (./ / ' f (expires M•o years from above date) Investigator's Signature: / / "..... Certificate of First Class Seminar Attendance Category (circle one): Owner Director Partner c Manager Employee Licensee Name: ()j1 ire(r."rile;tts cx-z4_00( • d/b/a: Address: 7/9 �" lII, lit .hWit, t? r�) %)t.�� ( V ��>� �' _ Education Regulation 3-B V.S.A.T.7§239 DLC:10M:01/07:SC Vermont Department of Liquor Control Certificate of First Class Seminar Attendance k ' Name (print): n i - • • Signature: LIV,Arv`"xk. Date: ! 531 w'2 (expires two years from above date) • Investigator's Signature: Certificate of First Class Seminar Attendance Category (circle one): Owner Director Partner ( Manager) Employee (.• „ Licensee Name: .$)L a (IV P.,'0 Ciri./Viyi, d/b/a: Address: .1 / f / 0 6 0 , I 11'17 "A "1/ / 11.,/1 1///- Education Regulation 3-B V.S.A.T.7§239 DLC:10M:01/07:SC . . • • • • . • • • •.• . •• •• • • . . . •• . •• • • 2012 LIQUOR LICENSE RENEWAL APPLICATION 5037-002-1HTL-01 FIRST CLASS HOTEL LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated at rA _ , in the county of , and State of ' -(.4r/91-1.)).-/fr this ado- day of 1-ebrkLu'..1 , Signature of authorized agent Signature of individual or partners of corporation, company, club or association (Title) Are you making this application for the benefit of any other party? Yes KNo Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED , / 1f � , Approved by Board of Control Commissioners of e City or l---- if Approved �[/, / Split n___- . Total Membership , members present Attes , "�"' 3 spa`t''lbwn Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control cammissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 0` 'd® City of South Burlington ate® d City Clerk's Office "°'E r Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION ./Z) UYCei b0br i , )ry) __L_______________ DOING BUSINESS AS/ TRADENAME ) 2.i6 A li dd D j'-'ea*LDa CIADDRESS FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE ,: :::)9, c SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. BURLIN T1 FIRE DEPTEP I 3fi°i/ice Chief Doug . Brent Date • SO. BURLINGTON TAX DEPT ---W61-/Wiet_., 2-24 3/0//- - Martha Lyons, Deputy Tax Collector Date sent to Montpelier: o 2012 LIQUOR LICENSE RENEWAL APPLICATION 7284-002—SECN-01 SECOND CLASS LICENSE TO SFTJ MALT AND VINOUS BEVERAGES Page 1 Fee: $100.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $50.00 is paid to town/city $50.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Leisure World Inc. '�r n� L � Doing Business As: I W Leisure World Inc. Mailing Address: . 0~-4 • L-f(S'^`` rca 1245 Airport Parkway 1245 Airport Parkway South Burlington VT 05403 South Burlington VT 05403 -.K( Telephone: (802) 862-1552 �^ p / PLEASE INCLUDEY EMAIL ADDRESS: J O 0 L.e('5"4-4, 'C' e. `I ' 1.ao.z.o Description of Premises: Premises: XX Owned Leased Store in a single story building located on the north side of Airport Parkway designated as #1245 consisting of approx 3600 sq ft in the city of South Burlington, VT Last Enforcement Seminar: 11/02/2011 Fed. ID Number: 03-0227944 Incorporation Date: 03/08/1971 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Bessery, Tod R 921 River Road Hyde Park VT 05658 Director 2. Bessery, Elaine M 921 River Ridge Hyde Park VT 05658 Has any director or stockholder been convicted or pleaded guilty to any cr' 1 or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's name, court/ r ffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elect' e or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes jNo If yes, please attach the following information: Individual's name, office and j isdiction Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with ' respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good 1 standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of ' contributions due to the Department of Employment and Training. I I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 02/23/2012 03:57 8028606260 LEISURE WORLD PAGE 01/001 • • � (rd"n,t.. �d i , � � rt �G��9�a�p�� tf + ''�'' �+ lur e�1 ,lp�l,� ri int. t,'i}Cb.,919 i,lai}t Joan .••}+ t74. 14,vftt:;4.''•SI•, i1iO • r .'1 r. 111 tl; ;1 t dp#*.j (ert ' Ct 'Sie1. �' • a 2012 LIQUOR LICENSE RENEWAL APPLICATION 7284-002—SECN-01 SECOND CLASS LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated at D tom -I t^� , in the county of t� I` �-S "t ' 6 +'�^t�"k , and State of �-�''~r",r- , this -2 3 day of t—Ov ci✓lY , Z c/ I----- Signature of authorized agent Signature of individual or partners of corporation, ompany, club or association 69 i_.\( ----.... VI". icig-9---)--"t--"-Tj. ffi e"--e(fe (Title) Are you making this application for the benefit of any other party? Yes No /g Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as anended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual cateni.ssioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED h i Approved by Board of Control Ca[mi.ssioners of A e City o T 5V• 0 Total Membership 15 members present Atte t, -�_�— -,, Q'3 c.�;�,'oh Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 1 r �n City of South Burlington 01 City Clerk's Office YQtit Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION ifil-bei 1'14j- / l'n6 , DOING �BUSINESS AS/ TRADENAME ii• ,6iii .) /111/ ADDRESS L_ „ _____,a4_a_ )C_Ar___ _6._______-4' L _____ 1°.... CI- FIRST CLASS SECOND CLASS CABARET 1 DATE RECEIVED BY CLERK'S OFFI 12-k— A aD/) 1 SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. BU GTON FIR PT J2. Chief D glas S. Brent Date SO. BURLINGTON TAX DEPT 9ObAer - 3/ Mart a Lyons, Deputy De ut ax Collector Y Date sent to Montpelier: • 2012 LIQUOR LICENSE RENEWAL APPLICATION 4909-001-SECN-01 SECOND CLASS LICENSE TO SRT,T, MALT AND VINOUS BEVERAGES Page 1 Fee: $100.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $5 0.0 0 is paid to town/city $50.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Mobrid, Incorporated Doing Business As: M.T. Bellies Deli Mailing Address: 340 Dorset Street 340 Dorset Street South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 863-8058 e 1 PLEASE INCLUDE EMAIL ADDRESS: MA-LIAtu.Satli A Description of Premises: Lessor: Retail store located in a one story cement building being Edgar Welch Trust approximately 4.220 square feet in size and located at 340 Dorset 340 Dorset St. Street in the City of South Burlington, Vermont. So. Burlington Vt Last Enforcement Seminar: 02/14/2010, OZ..(i(v j12- Fed. ID Number: 43-1963111 Incorporation Date: 06/20/2002 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Rowe, Steve R. 44 Sherry Road So. Burlington VT Director 2. Rowe, JoAnn 44 Sherry Road South Burlington VT Stockholder 3. Rowe, Steve R. 44 Sherry Road So. Burlington VT Stockholder 4. Rowe, JoAnn 44 Sherry Road South Burlington VT Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes K No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes k No If yes, please attach the following information: Individual's name, office and jurisdiction Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Comtissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page Vermont Department of Liquor Control Certificate of Second Class Seminar Attendance Name (print): Signature: Date: =. tt,J d . (expires two years from above date) Investigator's Signature: 11-' — . Certificate of Second Class Seminar Attendance Category (circle one): ,,,Owner) Director Partner Manager Employee Corporation Name: $ 7 �' Business Name: "1 • " " ; / , i f, i { Street and Town: __?Alt) ?.?z - `,_j: {L. ia Seminar held in: INA,,��t %,.-� Town/City jf Education Regulation 3-B V.S.A.T.7§239 Page 1 of I • Issued: 01/13/12 Store VT ID Number: 000DWA Expires: 12/31/13 Vermont Agency of Agriculture, Food & Markets Retail License This is to certify that the business named below is licensed by the Vermont Agency of Agriculture, Food & Markets for the following categories: Licensed Devices: 1 Small Scale(s) Milk 1 Meat Processing: Pre Packaged M T Bellies South Burlington VT 05403 Mdig141, PI, A7'4/4/ Kristin Haas Non-transferable Please Post Secretary of Vermont Agency of Agriculture, Food & Markets STATE OF VERMONT-AGENCY OF HUMAN SERVICES STATE BOARD OF HEALTH License to Operate I.D.# 12221 LINK I.D.# CAPACITY: .'6 FEE:$ :3). Q Q LICENSE TYPE: i? .MAT EFFECTIVE DATE: /O 1/2011 EXPIRATION DATE: CI 7/3 1/2 D 1 2 ESTABLISHMENT NAME&LOCATION: MT UELLIES DELI/DOP::T ST -:'1, ..=V-Ri4GETHIS IS TO CERTIFY THAT ABOVE ESTABLISHMENT IS LICENSED TO OPERATE 340 v u P.S E T STRZT.T UNDER THE PROVISIONS OF TITLE 18 SECTIONS 4351-4451 VERMONT STATUTES SOUTH L J R L.:A T O'i ANNOTATED.THIS LICENSE IS VALID PENDING RATIFICATION BY THE VERMONT BOARD OF HEALTH. THIS LICENSE IS NOT TRANSFERABLE AND IS VALID ONLY FOR THE LICENSEE LICENSEE NAME&ADDRESS: LISTED BELOW. ter r sTRELET 33 TH 3U?LIN To w, VT 254 N� THIS LICENSE SHALL BE CONSPICUOUSLY POSTED. �ZZ ZZZZZZZS ZZZZZZZZZZSZSZZZZZZZSZSZZZZZZ ZZZZZZZZZ ZZ=�ZZZZZ ZZ ZSZZZZZ ZZZZZZZZZZZZZ ZZZZZZZZZZZZiZZZ. • • 2012 LIQUOR LICENSE RENEWAL APPLICATION 4909-001-SECN-01 SECOND CLASS LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify thath1 the information in this application is true and complete. \/ j Dated at5bu. \ �v.(lrn w , in the county of C. \i4 t, 1-,.�- , and State of V V"'`^" C ' , f_�1 �i�JJJJJ this day of t'••Q,D(.ke,J76 , oho la- Signature of authorized agent Signature of individual or partners of .7 ..ration, company, club or association (Title) Are you making this application for the benefit of any other party? Yes No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of City o of Total Membership 5 members present A + v -- ) C.C.14.44nClerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control camiissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 S 1 I 2012 TOBACCO LICENSE RENEWAL APPLICATION 4909-001-TOBC-01 TOBACCO LICENSE TO SFiL TOBACCO Page 1 Optional Fee: $10.0 0 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0.0 0 is paid to town/city $0.0 0 is paid to DLC Fee due only if licensee does not have a liquor license Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Mobrid, Incorporated Doing Business As: M.T. Bellies Deli Mailing Address: 340 Dorset Street 340 Dorset Street South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 863-8058 PLEASE INCLUDE EMAIL ADDRESS: i`ri e +eSr i lV1�0 .Cuv'n Description of Premises: cc3 Lessor: Retail store located in a one story cement building being Edgar Welch Trust approximately 4.220 square feet in size and located at 340 Dorset 340 Dorset St. Street in the City of South Burlington, Vermont. So. Burlington Vt Last Enforcement Seminar: oz '�'^^1 02.(i4 I cZ Fed. ID Number: 43-1963111 Incorporation Date: 06/20/2002 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Rowe, Steve R. 44 Sherry Road So. Burlington VT Director 2. Rowe, JoAnn 44 Sherry Road South Burlington VT Stockholder 3. Rowe, Steve R. 44 Sherry Road So. Burlington VT Stockholder 4. Rowe, JoAnn 44 Sherry Road South Burlington VT Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court 1 of law (including traffic tickets by mail) during the last year? Yes p No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes -\ No If yes, please attach the following information: Individual's name, office and jurisdiction ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. I/We hereby,certify that the information in this application is true and complete. i� Dated at c 04).. 8r( , in the county of V1, V"9, and State of ^^',4 this 1 1. day of r L,1j4-r Si ture of authorized agent Signature of individual or partners of corpor ion,o sny: club or association itZ (Title) ,,J Are you making this application for the benefit of any other party? Yes IY No Continued on next page "1 S 2012 TOBACCO LICENSE RENEWAL APPLICATION 4909-001—TOBC-01 TOBACCO LICENSE TO SETT TOBACCO Page 2 Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of .own of40._f ( J1 laAji0a1 Total Membership 5 members present lwiiS5*>e w C k8" Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a tobacco license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 umuna>a��atNr ,4 e r� y *Oy J � City of South Burlington it• IIIP 11 i 575 DORSET STREET 614ti iv_t �, I SOUTH BURLINGTON, VERMONT 05403-6260 iiiiiio`,9NFOA TOWN Moak"'. IRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION . ?s, G . VaJI6 ilrei DOING BUSINESS AS/TRADENAME (robaczi) -->ryev)& ilet ADDRESS �f l 09 ; i li o n . FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE da r) . 4/ aD/ 9 South Burlington Police Department Chief Trevor S. Whipple Date I South B ngton Fire artment _ k 3// 7/2- Chief Douglas S. Brent Date South Burlington T Depart ent i/41 -- Martha'7- yons, Deputy Tax Collector Date Date Sent to Montpelier: 2012 LIQUOR LICENSE RENEWAL APPLICATION 448-024-SECN-01 SECOND CLASS LICENSE TO SRTJ MALT AND VINOUS BEVERAGES Page 1 Fee: $100.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $50.00 is paid to town/city $50.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: R. L. Vallee, Inc. Doing Business As: Maplefields Mailing Address: 811 Williston Road PO Box 192 South Burlington VT 05403 St. Albans VT 05478 Telephone: (802) 863-2896 PLEASE INCLUDE EMAIL ADDRESS: Description of Premises: Premises: XX Owned Leased Store located in a sincle story block constructed building located on the south side of Williston Road designated as #811 Williston Road in the city of South Burlington VT Last Enforcement Seminar: 10/12/2011 Fed. ID Number: 03-0212007 Incorporation Date: 12/27/1961 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Vallee, Rodolphe J. 2302 Polly Hubbard St. St. Albans VT 05478 Director 2. Vallee, Timothy L. 380 Robert Newton Road St Albans VT 05478 Director 3. Vallee, Rodolphe M. 4043 Spear Street Shelburne VT 05482 Stockholder 4. Vallee, Rodolphe M. 4043 Spear Street Shelburne VT 05482 Stockholder 5. Vallee, Timothy L. 380 Robert Newton Road St Albans VT 05478 Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's , court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yeso If yes, please attach the following information: Individual's name, office and jur diction Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page V.lotor Vehicle Violations frector or stockholder been convicted or pleaded guilty to any criminal ,or motor vehicle offense in any court gYes Ho tease complete the fallowfnj information: a asae of Court Offense Date , .flodalphe J. Franklin County Stmp ie Intoxication 11/21/1957 , Rodolphe J. Franklin County Failure Display Solt Red 07/27/1979 ,,Timothy L. Vermont VSL • 12/31/1986 , Timothy L. Vermont ISL 06/04/1987 , Timothy L. Vermont VNI 09/09/1987 , Timothy L. Vermont VSL 12/17/1987 , Timothy L. Vermont FR 05/18/1988 , Timothy L. Vermont ES 05/16/1990 , Timothy L. Vermont VSL 04/22/2001 , Rodolphe R. Vermont 801 08/01/1991 , Rodolphe X. Vermont ER 08/08/1998 , Rodolphe M. Vermont ISL 01/05/1999 '1 !. l: 1,.t G...., t C N( YYif'rt 61!. s tir ` c;2 G�C: (c. • ,,c1 • R. ts�;�'\..C. "\. N `'� t.L0 C9`r 1L, '�'...."\�_w1,t c,..e. CY.,1. e" ►K6,.. a 0 ri f 2012 LIQUOR LICENSE RENEWAL APPLICATION 448-024-SECN-01 SECOND CLASS LICENSE TO SRT,T, MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated at L 6( !/ls , in the county of F�'OLAK Il✓i , and State of Y�-r E"vt®� -1-- this ! o day of se.,-,In , t , Si -ure of authorized agent Signature of individual or partners of cor\porat n, company, club or association <Cc p) 1\_, (Title) Are you making this application for the benefit of any other party? Yes No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of Cit r of v ,hJ Total Membership members present I C l6f K Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meting. VSA T-1,Sec.312 2012 TOBACCO LICENSE RENEWAL APPLICATION 448-024—TOBC-01 TOBACCO LICENSE TO SELL TOBACCO Page 1 Optional Fee: $10.0 0 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0.0 0 is paid to town/city $0.00 is paid to DLC Fee due only if licensee does not have a liquor license Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: R. L. Vallee, Inc. Doing Business As: Maplefields Mailing Address: 811 Williston Road PO Box 192 South Burlington VT 05403 St. Albans VT 05478 Telephone: (802) 863-2896 PLEASE INCLUDE EMAIL ADDRESS: Description of Premises: Premises: X(Owned Leased Store located in a sincle story block constructed building located on the south side of Williston Road designated as #811 Williston Road in the city of South Burlington VT Last Enforcement Seminar: 10/12/2011 -� Fed. ID Number: 03-0212007 Incorporation Date: 12/27/1961 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Vallee, Rodolphe J. 2302 Polly Hubbard St. St. Albans VT 05478 Director 2. Vallee, Timothy L. 380 Robert Newton Road St Albans VT 05478 Director 3. Vallee, Rodolphe M. 4043 Spear Street Shelburne VT 05482 Stockholder 4. Vallee, Rodolphe M. 4043 Spear Street Shelburne VT 05482 Stockholder 5. Vallee, Timothy L. 380 Robert Newton Road St Albans VT 05478 Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? )(Yes No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes j(No If yes, please attach the following information: Individual's name, office and juri{sctiction ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full ccznpliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page VXotor Vehicle Violations 'rector or stockholder been convicted or 'pleaded guilty to Any criminal or motor vehicle offense in any court yes No tease complete the. fotlowin9 information: e Name of Court Offense Date , .Rodotphe J. Franklin County ,simpIe Intoxication 11/21/1957 , Rodotlahe J. Franklin County Failure Display boat'Eteg 07/27/1979 ,.Timothy L. Vermont VSL • 12/31/1986 , Timothy L. Vermont I8L 06/04/1987 , Timothy L. Vermont VN1 09/09/1987 , Timothy L. Vermont VSL 12/17/1987 , Timothy L. Vermont FR 05/18/1988 , Timothy L. Vermont ES 05/16/1990 , Timothy L. Vermont VSL 04/22/2001 , RocSotfhe 1i. Vermont $01 08/01/1991 , RodoLp a H. Vermont OR 08/08/1998 , Rodolphe M. Vermont ISL 01/05/1999 q ; f.�o,44.k,i l..._ •tip i ()At)ri- k 6�....2.-L...8-1--4,,4 57 ac: c. 2012 TOBACCO LICENSE RENEWAL APPLICATION 448-024-TOBC-Ol TOBACCO LICENSE TO SFT,T, TOBACCO Page 2 I/We herebyer certify that the information in this application is true and complete. 5- Dated at • A( ti S , in the county of c ..K.K. r j , and State of \/ yr this it day of 'l c,u:t q-ci , aCA Si tore of authorized agent Signature of individual or partners of torpor 'on, ca pany, club or association (Title) Are you making this application for the benefit of any other party? Yes K No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of City o own of U, Total Membership , members present A C.t j'Pawn Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL ``DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a tobacco license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 411. City of South Burlington .4 �®®&' City Clerk's Office .' " °rE ' Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION DOING BUSINESS AS/ TRADENAME ol;& 6, i r' 'y 4 i a ADDRESS /0 ? .__4K)) 001/'rf -oqJ , IRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE ...4j7.. A 4D l • l SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. INGTON FI DEPT 0 Chief Douglas S. Brent Date SO. BURLINGTON TAX DEPT 2 CZAI L 4 , 1, i Mart a Lyons, Deputy ax Collector Date sent to Montpelier: 575 Dorset Street South Burlinaton.VT 05403 802-846-4105 dkinville@sburl.com 2012 LIQUOR LICENSE RENEWAL APPLICATION 1758-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $100.00 is paid to town/city $100.00 is paid toDLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this fonm, indicating any changes in the spaces provided. Applicant: G4 Restaurants of Vermont, Inc. Doing Business As: Olive Garden Italian Restaurant #1520, The Mailing Address: 1025 Shelburne Road P.O. Box 695016 South Burlington VT 05403 1000 Darden Ctr Drive Telephone: (802) 863-4907 J Orlando FL 32869-5016 PLEASE INCLUDE EMAIL ADDRESS: 380+0 ® darclen. CONY) Description of Premises: Lessor: Restaurant located in a 1 story wood building approx. 6014 sq. ft., Southland Enterprises, Inc. located at 1025 Shelburne Road, City of South Burlington, VT. 69 College St. Burlington VT 05401 Last Enforcement Seminar: 10/19/2011 Fed. ID Number: 03-0330790 Incorporation Date: 07/12/1991 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Kern, Joseph G PO Box 695016 Orlando FL 32869 Stockholder 2. G4RI, Incorporated, 1000 Darden Center Drive Orlando FL 32387 Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's name, court/ raffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes ^✓ No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 3980 Expiration Date: ?? Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 118281 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Catmissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full canpliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Esployment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page ` i 1 "io, j 34,3.,,,, }0 • cv yj .r rif , s...' .+ -a�... ,,v,, f:Mk t *01,rAMP�' ,,, , .. ,,- ., , ,•,, >T I Vermont Department of Liquor Control Certificate of First Class Seminar Attendance l' Name (print): ell/NI& V' Able')of- Signature: „,,, Date: • / /D f 19 )f (expires two years from above date) ! t Investigator's Signature: /"-.- :: Certificate of First Class Seminar Attendance ry.., Category(circle-one), .Owner: ._ . 1� t Part onager::: Employee Corporation Name:. a@ ie{�1 i i 16 ,lf" �erA > 4 - ' Business Name: G, 141 M £'/L / Street and Town: . Q i f/I V , • ®5 Seminar held in: 1 el. vort ilk Town/City Education Regulation 3-B V.S.A.T.7§239 • £ti£ a Vermont Department of Liquor Control Certificate of First Class Seminar Attendance Name (print): (? r L- i G Ai& Signature: j •-' Date: ... /b -/ 9. 2o (r 4* 0 (expires two yeah from above date) *: Investigator's Signature: - Certificate of First Class,Seminar Attendance • ;: :1 :Category (circle one -Owner ( to 'r : :, ;.Partner .- -Manager Employee f I �_ : Corporation Name: ` _ ��"f U t ;. . ::Business Name: Zav itl�'GA> /t�G I ,�f, j'e' :jR12-. . - Street and Town: 1)� (1)o��t/3 bc�Stre � '� ft6/!--1 J Seminar held in: J (bUi1/a"(-- Town/City Education Regulation 3-)3 • • V.S.A.T.7§239 2012 LIQUOR LICENSE RENEWAL APPLICATION 1758-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated at Orlando , in the county of Orange , and State of Florida this 2 day of February , 2012 'gnature of authorized agent Signature of individual or partners of co ation, company club or association Colleen M. Hunter, Asst. Secretary Tim(Title) Are you making this application for the benefit of any other party? Yes IliNo Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED • / , Approved by Board of Control Commissioners of e City of ;�D, Total Membership , members present C' ', own Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: . DEPARTMENT co? LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town heard of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 GM RESTAURANTS OF VERMONT, INC. Sharlene Soto Legal Specialist Phone:(407)245-5378 Fax: (407)241-5921 February 02, 2012 VIA OVERNIGHT Express Donna Kinville, City Clerk City of South Burlington 575 Dorset Street South Burlington, Vermont 05403-6260 Re: Liquor License Renewal for GM Restaurants of Vermont Inc.: The Olive Garden Italian Restaurant#1520 1025 Shelburne Road South Burlington, VT 05403 Dear Ms. Kinville: Enclosed are the following items for renewal of the liquor license for the above referenced restaurant: • Two Checks in the amount of $100.00 each. One payable to the City of South Burlington and one payable to the Vermont Department of Liquor Control; • Liquor License Renewal Application • Certificate of First Class Seminar Attendance for Eugene J. Ward, Ill and Guy L. Barr. Once the licenses are issued, please return same, or a copy, to me in the enclosed pre-addressed, pre-paid envelope. yu I can be reached at 800/248-4918, extension 5378 if you have any questions. /,7411 / 0 Sincerely, 144 (54,6„4„._ Sharlene Soto Legal Specialist /ss Enclosures Cc: Eugene J. Ward, III, Esq. w/copy of Application w/attachment(via fax 802/863-4587) �4 ® City of South Burlington 0�®'441I City Clerk's Office .. 4 Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION 6.14). r or r'aMiorL- DOING BUSINESS AS/ TRADENAME On, : I - -fO ADDRESS moo d;r Dr /It'. FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE 1 ----<6-/—satc3--- SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. RUNG /FRE DEPT 3li q Iice_ Chief Douglas S. Brent Date SO. BURLINGTON TAX DEPT .77c&dkei_ -Yi 3/-7-//? Mart a Lyons, Deput Tax Collector Date sent to Montpelier: i 2012 LIQUOR LICENSE RENEWAL APPLICATION 1967-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0 0.0 0 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Stelex Corporation Doing Business As: One Flight Up Mailing Address: Burlington International 1200 Airport Drive Airport Burlington INT'L Airport South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 862-6410 PLEASE INCLUDE EMAIL ADDRESS: .61,4J .7/t_,L�C) y�itc-c, jcl,cuF1 Description of Premises: Lessor: Restaurant located on the 2nd floor of the Burlington International Burlington Internat. Airport Airport terminal and occupying 3500 sq. ft. and the mezzanine area of South Burlington VT 05403 800 sq. ft., and the first floor of the south terminal 800 sq ft, on the secure side of checkpoint, in the city of South Burlington, VT Last Enforcement Seminar: 08/17/2011 Fed. ID Number: 03-0331829 Incorporation Date: 12/12/1991 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Rolecek, Charles F. 38 Perry Road Bedford NH 03110 Director 2. Somers, Thomas 65 Ledgewood Terrace Montpelier VT 05602 Stockholder 3. Rolecek, Charles F. 38 Perry Road Bedford NH 03110 Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes A No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes K.No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 2798 Expiration Date: ?? ly 4-3 0 Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Rooms Cert./Acct. No.: 80929 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: XX Yes No Are there any changes to this Outside Consumption area?: Yes No (If yes, attach necessary information) Beer and wine service in a portion of the recently renovated Gates 1 and 2 area. Area consists of 700 square feet and has one access point for control. (Attachments : Sketch and letter of explanation. Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page. 2012 LIQUOR LICENSE RENEWAL APPLICATION 1967-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and clete. / Dated at S'. £ ,2i,.u�}-=,i✓ , in the county of ,1��n.L -. , and State of L/C4.sk co�fo this / S i day of / q.sLc_vf- 2.e)i'L Signature of authorized agent Signature of individual or partners of co ti. , :.n.any, club or association • fit L��-. �?. 44.)t-0(Af ene (Title) Are you making this application for the benefit of any other party? Yes KNo Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of : - City o f / Total Membership , members present ➢ CAC DAI Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commiissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 City of South Burlington �4074 City Clerk's Office VOTE OfFO i Donna Kinville, City Clerk ff . FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION Ge'mari , 1nc . DOING BUSINESSAS/ TRADENAME i1ic oy *i1DL2 , ADDRESS ig3D 0111114&brl...-5-4 - , 4111111111111110 SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE . T7 • �Q/0" ---• SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO RLINGTON FI.f.-RE DEPT 0 Chief Douglas S. Brent Date SO. BURLINGTON TAX DEPT tt ---7// 4_ Leg .4 7 Martha Lyons, Deputy Tax Collector Date sent to Montpelier: 3 • 2012 LIQUOR LICENSE RENEWAL APPLICATION 5830-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0 0.0 0 is paid to town/city $100.00 is paid to DIE Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: German, Inc. Doing Business As: German., Inc. Mailing Address: 1930 Williston Road 1930 Williston Road South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 862-3653 PLEASE INCLUDE EMAIL ADDRESS: \J CC�/CAN M A-DLICC *1 Description of Premises: Lessor: A Restaurant located in a one story wood frame building being Nancy Hadley approximately 2,000 square feet in size with a detached 24x24 foot 1900 Williston Road garage being 8 feet from the premise, located at 1930 Williston Road, South Burlington VT 05403 located in the City of South Burlington, Vermont. Last Enforcement Seminar: 09/21/2011 Fed. ID Number: 38-3729636 Incorporation Date: 11/17/2005 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Crrle Director 1. German!, Jr., Joseph J. 419 Bonaza Park Colchester VT 05446 Director 2. Fisk-Gernand, Lori 419 Bonanza Park Colchester VT 05446 Stockholder 3. German, Jr., Joseph J. 419 Bonaza Park Colchester VT 05446 Stockholder 4. .Fisk-Germani,._L.ot! 419 Bonanza Park Colchester VT 05446 Has any director or stockholder been convicted or,pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes ,k-!qo • If yes, please attach the following information:. Ind>vidual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes � No . If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 10847 Expiration Date: ?? /7/30/i L. Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 440-393729636E-01 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: XX Yes No Important: You MUST re-submit a new Non-profit Disclosure form yearly with your renewal application or your permit will be invalidated. ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full ccanpliance with a plan approved by the Caanissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that'I/We are in good standing with respect to child support or are in full ccspliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page STATE OF VERMONT DEPARTMENT OF LIQUOR CONTROL 13 Green Mountain Drive Montpelier Vermont 05602 Tel . (802) 828-2339 DISCLOSURE OF NONPROFIT ORGANIZATION FORM License# 5830-001-1RST-01 Licensee Germani, Inc. DBA Germani, Inc. Address 1930 Williston Road South Burlington VT 05403 Telephone Number: (802) 862-3653 Email address: -p/i4/Y)/W/ Co• �A04, iv, Name of Nonprofit Organization /1'l/55/D/c/5 402 Z/®'tpk,uP6uck, Address V35-7 O14x. /71/C 4_ Ri A.), L e./570,) 1"7 05 y9 Non-Profit Contact Person /2/92 y' 5,/Lp,4/26 Telephone Number/Email of Non-profit D2 999 —737 / /YJS/4f04i? 1/7-6 ,,f2c-,osr,A/A - Proof of Nonprofit Status 501C1 or 501C3 must be attached I certify that the information in this Disclosure is true and complete. Signature of Authorized Agent of the Nonprofit Organi ation /\\A Date ZZ I'Z-- Signatur of Licensee 4�.r Date //e2//// GENERAL REGULATION #9. Gambling on licensed premises: With the exception of Service Clubs, any licensee wishing to conduct game(s) of chance on licensed premises must first obtain a permit from the Vermont Department of Liquor Control using the prescribed form or format. Licensees applying for and/or receiving a permit shall be subject to financial disclosure to the Department for the purpose of verifying the disbursement of proceeds in accordance with applicable Vermont statutes and/or regulations. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. 0. BOX 2508 CINCINNATI, OH 45201 Date: NOV 19 2002 Employer Identification Number: 03-0372109 DLN: 102298018 MISSIONS FOR INDENDENCE INC Contact Person: C/0 MARY.SHEPARD MYRON L RANNEY ID# 75618 131 PATCHEN RD Contact Telephone Number: SOUTH BURLINGTON, VT 05403 (877) 829-5500 Accounting Period Ending: October 31 Form 990 Required: Addendum Applies: No Dear Applicant: Based on information supplied, and assuming your operations will be as stated in your application for recognition of- exemption, we have determined you are exempt from federal income tax under section 501(a) of the Internal Revenue Code as an organization described in section 501(c) (3) . We have further determined that you are not a private foundation within the meaning of section 509 (a) of the Code, because you are an organization described in section 509(a) (2) . If your sources of support, or your purposes, character, or method of operation change, please let us know so we can consider the effect of the change on your exempt status and foundation status. In the case of an amend- ment to your organizational document or bylaws, please send us a copy of the amended document or bylaws. Also, you should inform us of all changes in your name or address. As of January 1, 1984, you are liable for taxes under the Federal Insurance Contributions Act (social security taxes) on remuneration of $100 or more you pay to each of your employees during a calendar year. You are not liable for the tax imposed under the Federal Unemployment Tax Act (FUTA) . Since you are not a private foundation, you are not subject to the excise taxes under Chapter 42 of the Code. However, if you are involved in an excess benefit transaction, that transaction might be subject to the excise taxes of section 4958. Additionally, you are not automatically exempt from other federal excise taxes. If you have any questions about excise, employment, or other federal taxes, please contact your key district office. Grantors and contributors may rely on this determination unless the Internal Revenue Service publishes notice to the contrary. However, if you lose your section 509(a) (2) status, a grantor or,contributor may not rely on this determination if he or she was in part responsible for, or was aware of, the act or failure to act, or the substantial or material change on the Letter 947 (DO/CG) • -2- MISSIONS FOR INDENDENCE INC part of the organization that resulted in your loss of such status, or if he or she acquired knowledge that the Internal Revenue Service had given notice that you would no longer be classified as a section 509(a) (2) organization. Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for federal estate and gift tax purposes if they meet the applicable provisions of Code sections 2055, 2106, and 2522. Contribution deductions are allowable to donors only to the extent that their contributions are gifts, with no consideration received. Ticket pur- chases and similar payments in conjunction with fundraising events may not - necessarily qualify as deductible contributions, depending on the circum- stances. See Revenue Ruling 67-246, published in Cumulative Bulletin 1967-2, on page 104, which sets forth guidelines regarding the deductibility, as chari- table contributions, of payments made by taxpayers for admission to or other participation in fundraising activities for charity. In the heading of this letter we have indicated whether you must file Form 990, Return of Organization Exempt From Income Tax. If Yes is indicated, 'you are required to file Form 990 only if your gross receipts each year are normally more than $25,000. However, if you receive a Form 990 package in the mail, please file the return even if you do not exceed the gross receipts test. If you are not required to file, simply attach the label provided, check the box in the heading to indicate that your annual gross receipts are normally $25, 000 or less, and sign the return. If a return is required, it must be filed by the 15th day of the fifth month after the end of your annual accounting period. A penalty of $20 a day is charged when a return is filed late, unless there is reasonable cause for the delay. However, the maximum penalty charged cannot exceed $10,000 or 5 percent of your gross receipts for the year, whichever is less. For organizations with gross receipts exceeding $1, 000,000 in any year, the penalty is $100 per day per return, unless there is reasonable cause for the delay. The maximum penalty for an organization with gross receipts exceeding $1, 000,000 shall not exceed $50,000. This penalty may also be charged if a return is not complete, so be sure your return is complete before you file it. You are required to make your annual information return, Form 990 or Form 990-EZ, available for public inspection for three years after the later of the due date of the return or the date the return is filed. You are also required to make available for public inspection your exemption application, any supporting documents, and your exemption letter. Copies of these documents are also required to be provided to any individual upon written or in person request without charge other than reasonable fees for copying and postage. You may fulfill this requirement by placing these documents on the Internet. Penalties may be imposed for failure to comply with these requirements. Additional information is available in Publication 557, Tax-Exempt Status for Your Organization, or you may call our toll free number shown above. Letter 947 (DO/CO) -3- MISSIONS FOR INDENDENCE INC You are not required to file federal income tax returns unless you are subject to the tax on unrelated business income under section 511 of the Code. If you are subject to this tax, you must file an income tax return on Form 990-T, Exempt Organization Business Income Tax Return. In this letter we are not determining whether any of your present or proposed activities are unre- lated trade or business as defined in section 513 of the Code. You need an employer identification number even if you have no employees. If an employer identification number was not entered on your application, a number will be assigned to you and you will be advised of it_ Please use that number on all returns you file and in all correspondence with the Internal Revenue Service. If we have indicated in the heading of this letter that an addendum applies, the enclosed addendum is an integral part of this letter. Because this letter could help resolve any questions about your exempt status and foundation status, you should keep it in your permanent records. If you have any questions, please contact the person whose name and telephone number are shown in the heading of this letter. Sincerely yours, Lois G. Lerner Director, Exempt Organizations Letter 947 (DO/CG) • • 2012 LIQUOR LICENSE RENEWAL APPLICATION 5830-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated at } ,Q[/NGi0,4-/ in the county of �,t6.(j7./uPLIJ �lc and State of 2rn0(FT� this. / pday of /—heZill4ty Signature of authorized agent Signature of individual or partners of ration, company, c ub or association 1 X5/D)CIv (Title) Are you making this application for the benefit of any other party? Yes Xl-slo Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of a - City or own of b, illittP 4 Total Membership . , members present 4-test, --& C.ke..d}IvT'own Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 �® City of South Burlington �4oh&0 City Clerk's Office v OTEp Donna Kinville, City Clerk cg,.. :0- -= FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION tr)c.&1",44-h 61-5rer_ DOING BUSINESS AS/ TRADENAME '44941i,6 r`�1 ADDRESS 2 v_i--frill 1 i(3o1rxvL 0--cf- FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE 7 -,/: o / ' SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. BURLINO FIRE DE T/ Chief Douglas S. Brent Date SO. BURLINGTON AX DEPT i(e7/ Mart Lyons, Deputy Ta Collector Date sent to Montpelier: 2012 LIQUOR LICENSE RENEWAL APPLICATION 4766-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0 0.0 0 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: McGrath Enterprizes, Ltd. Doing Business As: Rotisserie, The Mailing Address: 1355 Williston Road #3 Butler Drive South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 658-1838 PLEASE INCLUDE EMAIL ADDRESS: Description of Premises: Lessor: A restaurant in a one story wood frame building situated on the Sean P. McGrath southerly side of Williston Road, east of Hinesburg Road at 1355, South Burlington Vt in the City of South Burlington, Vermont. Last Enforcement Seminar: 03/12/2011 Fed. ID Number: 10-0002289 Incorporation Date: 01/02/2002 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. McGrath, Sean 3 Butler Drive South Burlington VT 05403 Director 2. McGrath,' Brendan, 10 Dairy Lane "'';<:, ._ -South'Burlington - VT 05403 Director 3. McGrath, Keelin-'„`' ' a 33 Tamarack Lane Essex Junction VT '05952 Director 4a Jennifer Mr rsth, ifer 3 Butler Drive. a the South Burlington VT Stockholder 5. McGrath, Sean 3-Butler Drive ' - South"Bur'lington' VT 05403 Stockholder 6. McGrath, Brendan 10 Dairy Lane South Burlington VT 05403 Stockholder 7. McGrath, Keelin 33 Tamarack Lane Essex Junction VT 05452 i Stockholder 8. McGrath, Jennifer 3 Butler Drive South Burlington VT 1 Has any director or stockholder been convicted or pleaded guilty to any cr' 1 or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any electiv or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 2205 Expiration Date: ?? Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: K10057996F Important: Current food and/or lodging license expiration dates are required for license renewal. (as applicable) . Outside Consunption Permit?: XX Yes No Are there any changes to this Outside Consumption area?: Yes No (If yes, attach necessary information) 20x10 foot area on East side of restaurant, with two sides being fenced in and remaining sides are bordered by restaurant. Area is black top but not using parking spaces nor visible to parking lot. April 1st through November 1st 11:00 a.m. to 10:00 p.m. Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. Continued on next page I i 2012 LIQUOR LICENSE RENEWAL APPLICATION 4766-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Carmissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. I/We hereby certify that the information in this application is1�true and complete. Dated at 1 *t �d' 6 , in the county of t-i1% 1 f d, , and State of kr1 , this 1 day of rti(9 , 2C 1 1-- Signature of authorized a t Signature of individual or partners of corporatio , , 1 r sociation (Title) Are you making this application for the benefit of any other party? Yes V No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the cone issioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners o'41 ,•'.J of Total Membership Z5 , members present ee 'Irv:�-- > :v.,,,,,.�,_e= 2.1 C.k41J y own Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 I 1 r® City of South Burlington � �® ��. City Clerk's Office 1 , r°rE® Donna Kinville, City Clerk 4 � FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, �PPARTNERSHIP, CORPORATION r�_ ! Zr'VF• 'o(r • DOING BUSINESS AS/ TRADENAME rmoorl_ (-:#1."evr)... i��'ADDRESS 'gip toilli oor e - FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. ft INGTON FIRE DEPT C:: 32 311q/ — Chief Douglas S. Brent Date SO. BURLINGTON TAX DEP - 2R, ,- Martha Lyons, Deputy aector Date sent to Montpelier: 1-,7r, n„" t Cr,,,,,r e „t1, ai„-r,,,,+„„ \/T f1FA112 Qrv) OAP A1n ,I6,„,,.II,-,(nlnh,,-I 2012 LIQUOR LICENSE RENEWAL APPLICATION 3780-001-1HTL—01 FIRST CLASS HOTEL LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0 0.0 0 is paid to town/city $100:00 is paid to DIG Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Sheraton Vermont Corporation Doing Business As: Sheraton Vermont Corporation Mailing Address: 870 Williston Road 870 Williston Road South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 865-6600 kl , ^ / Jac l) PLEASE INCLUDE EMAIL ADDRESS: \i' Description of Premises: Lessor: Hotel in a four story vinyl clad block and concrete building being FelCor Suites Ltd. Partnership 250,000 square feet in size containing 2 restaurants, 2 lounges, pool 545 E. John ter Carper Express exhibition hall, conference and ballrooms at 870 Williston Road in Suite 1300 the city of South Burlington, Vermont. Irving TX 75062 Last Enforcement Seminar: 02/15/2011 Fed. ID Number: 03-0355208 Incorporation Date: 11/12/1997 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Karpinski, James Nichols Road Fairfax VT 05454 Stockholder 2. Itt Sheraton, Corporation 60 State Street Boston MA 02109 Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes /No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any electi or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes �yNo If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 2326 Expiration Date: ?? Vt. Dept. of Health Lodging No.: 4885 Expiration Date: ?? Vt. Tax Dept. Meals & Roars Cert./Acct. No.: 121971 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN If these premises are licensed as a Cabaret, I/We hereby certify that the receipts fran entertainment, dancing and sale of alcohol beverages are greater than the receipts from the sale of food. The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from • State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 2012 LIQUOR LICENSE RENEWAL APPLICATION 3780-001-1HTL-01 FIRST CLASS HOTEL LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated at 5\m_x N ^ .\.�t , in the county of U.,:kAkt..AA47 and State of v`(-(- this Z l day of &...KNA,44cr/, y 17‘Z Signature of authorized agent Signature of individual or partners �f�e rat' , lub or association Qo ? v2A C TI G.I`1 . (Title) Are you making this application for the benefit of any other party? Yes V "" Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of(�ie'City or)Town of,50. Total Membership 6 , members present Att t, 1 r u Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 2012 LIQUOR LICENSE RENEWAL APPLICATION 3780-002-1CAB-Ol FIRST CLASS CABARET LICENSE TO SETT, MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0 0.0 0 is paid to town/city $100.00 is paid to DLL Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Sheraton Vermont Corporation Doing Business As: Sheraton Vermont Corporation (c) Mailing Address: 870 Williston Road Valerie Hockert South Burlington VT 05403 870 Williston Road Telephone: (802) 865-6600 Sou Burl' ory� 05 PLEASE INCLUDE EMAIL ADDRESS: v(1`l,S-\ L , \,y U ..( /�/ Description of Premises: Lessor: A Caharet located in a one story section of Sheraton Vermont hotel Felcor Suites Ltd. Partnership located in the city of South Burlington, Vermont. 545 E. John Carpenter Freeway Irving TX Last Enforcement Seminar: 02/15/2011 Fed. ID Number: 03-0355208 Incorporation Date: 11/12/1997 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Karpinski, James Nichols Road Fairfax VT 05454 Stockholder 2. Itt Sheraton, Corporation 60 State Street Boston MA 02109 Has any director or stockholder been convicted or pleaded guilty to any crirl or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held an electi or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? ( Yes V_No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 2326 Expiration Date: ?? Vt. Dept. of Health Lodging No.: 4885 Expiration Date: ?? Vt. Tax Dept. Meals & Rooms Cert./Acct. No.: 121971 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN If these premises are licensed as a Caharet, I/We hereby certify that the receipts from entertainment, dancing and sale of alcohol beverages are greater than the receipts from the sale of food. The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Ca[missioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page • 2012 LIQUOR LICENSE RENEWAL APPLICATION 3780-002-1CAB-01 FIRST CLASS CABARET LICENSE TO cF.T.T, MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and cceplete. ' Dated at )\ L t' -b ``��(,\ , in the county of C�<' '�, lrr-, and State of 1U t C this 21 day of 1..\ li..V.1!•(-1 7j°`Z. Signature of authorized lagent Signature of individual or partners • . •. y, club or association ► 6•h• (Title) Are you making this application for the benefit of any other party? Yes Ao Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title most be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of 4111101t •wn of ,f5t), Total Membership 5 , members present t44. 1 s • ) C'fir own Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 d► City of South Burlington � �® ��. City Clerk's Office Yo1E® ' Donna Kinville, City Clerk , „. ,., ..,--- FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION ke)f_ it.. ..),D .f-- )a riei , ri DOING BUSINESS AS/ TRADENAME / / , ADDRESS ' D r -, FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE r ]a te-k ICI, 0).2"-' SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. �URLINGTO -FIRE DEPT Uk (IT Chie , Douglas S. Brent Date SO. BURLINGTON TAX DEPT 'g1// Mart a Lyons, De u Tax Collector l y p Date sent to Montpelier: J 2012 LIQUOR LICENSE RENEWAL APPLICATION 7695-002-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $100.00 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Apple New England LLC Doing Business As: ApplehPe's Mailing Address: 155 Dorset Street 155 Dorset Street South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 862-2818 PLEASE INCLUDE EMAIL ADDRESS: .,5i2( k{? dsQ/JC70/I)Pf)/4a,CD Description of Premises: Lessor: Restaurant in the center entrance to a single story shopping mall Finard & CO knon as "University Mall" consisting of a dining room with bar, Attn William Finard kitchen & storage. Located on the west side of Dorset Street. 155 Dorset Street Designated as #155 in the city of South Burlington VT S Burlington VT 05403 Last Enforcement Seminar: 06/28/2011 `/ l�j-- V ,/�f , Filed Articles of Organization: Yes Date Filed: 06/08/2011 ✓ Federal ID Number: 9392' 83- Majority of Members are US Citizens: Y e s ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Limited Liability Company Name Address Town/City State Zip Code Member 1. Krebsbach, Daniel Victor 7304 259th Place Northeast St. Cloud MN 98053 Member 2. Flynn, Gregory Grant 3821 Jackson Street San Fransisco CA 94118 Member 3. Shigeru, Ronald Igarashi 920 Eastlake Drive Eastlake OH 44095 Member 4. Cortina, Lorin Michael 2110 Redington Road Hillsborough CA 94010 Has any person been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes .../No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any person held any elecive or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes I./No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 10780 Expiration Date: 11/01/2012 Vt. Dept. of Health Lodging No.: Expiration Dat �3 Vt. Tax Dept. Meals & Roams Cert./Acct. No.: - .� �� 5 94 f`7 A Important: Current food and/or lodging license e iration�dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page Vermont Department of Liquor Control Certificate of First Class Seminar Attendance Name (print): &cecat� "'.1 .�.v.\\s-zec ' -,Signature: �' G/ � m Date: (-°i /\\ (expires years from above dale) " �. Investigator's Signature: �, A i'l \, ._ ----------` �' ii 'li1 Certificate of First Class Seminar Attendance '•._r ‘I Category (circle one): Owner Director Partner Cl anager-) Employee Licensee Name: e\-.)ec` N . d/b/a: P\x\ebFe. ('' NE 4.4,,xti C! 1.J,a � C.\`\/� VI—Address: a \ -.tier j`j f-e\'' `.tetra\1r� �_. t\•.•r��a Y.- - C AC 'S Education Regulation 3-B V.S.A.T.7 §239 DLC:10M:01/07:SC 1 I r I , 2012 LIQUOR LICENSE RENEWAL APPLICATION 7695-002-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELF MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and canplete. Dated at , in the county of /4 "-O, and State of ( L'Z) /�r�/�j�,� this WA day of �i�I� [4 , (�f Signature of authorized agent Signature of individual or partners of corporation, c o ssociation l 6141'1 (7itle) Are you making this application for the benefit of any other party? Yes No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license maybe granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual ca missioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED e Approved by Board of Control Commissioners of Kr-City or . 0.. 1 Total Membership 5 , members present At b A j t=1tf' Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 i ,•0K City ©f South ur�ii Eton ��®� � City Clerics Office °E`° ,k Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION DOING BUSINESS AS/ TRADENAME C k1 I Jr� 2t4 rre'6444D!'t - . ::) ADDRESS (_.), -fro)0a-c _flota2Thi___47211 , FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE v/ 9 SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. B LINGTON FIRE/ DEPT Chief ouglas S. Brent Date SO. BURLINGTON TAX DEPT C<—ui 7'aff-2/1"0 _.,, - r 2- MarthalLyons, Deputy Ta C P yollector Date sent to Montpelier: i 1 -/G n—,-,,+ c+,—+ c,,,.+i, Q,,.-i;,,,,+,,., k/T nzana aril Qna A1nG ,ii,,.,,,;ii.,01..1,,,.i ,.,..,. • • 2012 LIQUOR LICENSE RENEWAL APPLICATION 2396-023—SECN-01 SECOND CLASS LICENSE TO SRT.T MALT AND VINOUS BEVERAGES Page 1 Fee: $100.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $50.00 is paid to town/city $50.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this fonm, indicating any changes in the spaces provided. Applicant: Wesco, Inc. Doing Business As: Champlain Farms - Exxon Mailing Address: 801 Williston Road 32 San Remo Drive South Burlington VT 05403 South Burlington VT 05403-6310 Telephone: DE2) : Ce``C \ (o m� �b PLEASE INCLUDE EMAIL ADDRESS: �l�l, (`S�CS.y v-\-- Description of Premises: Lessor: A convenience store and gas station located in a brick building Wesco Oil approximately 900 square feet in size and located on the south side So. Burlington Vt of Williston Road due north of Spillaines Mobil at 801 Williston Road in the city of South Burlington, Vermont. Last Enforcement Seminar: 11/02/2011 Fed. ID Number: 03-0273319 Incorporation Date: 09/21/1979 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. �L Corporation Name Address GVVI QC Town/City State Zip Code Director 1. Simendinger, David VT 05ns"), Director 2. Simendinger, William 12 Whiteface Street S Burlington VT 05403 Stockholder 3. Simendinger, David 15 Ha nrjari, z esegt-.. Stockholder 4. Simendinger, William 12 Whitefa e eet elcriminalBurlington VT 05403 Has any director or stockholder been convicted or pleaded ty o criminal motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective r appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following information: Individual's name, office and jurisdiction Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page I Health License Expires WESCO, INC. S FARM E --) 2012 Liquor/Tobacco License Renewal Change of Address: David Simendinger 88 Calloway Dr Williston,VT 05495 Traffic Tickets: William Simendinger Connecticut Superior Court Speeding 05/11/2011 William Simendinger State of New Hampshire, Sullivan County Newport District Court Speeding 05/20/2011 2012 LIQUOR LICENSE RENEWAL APPLICATION 2396-023-SECN-01 SECOND CLASS LICENSE TO SEll MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated a , in the county of\,..)/Irkr6j2,r\ , and State of 4,2_,0rn this 1-1 day of ,V Signature of authori agent Signature of individual or partners of corporat' ompany, club or associat' n • WQsCo)\ c_ krQs� (Title) Are you making this application for the benefit of any other party? Yes ✓o Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their reconn?ndation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED i Approved by Board of Control Commissioners of City ..- of�a 4ie IN0,Total Membership z3 members present '°_ C.• A C l4 ' tmnn Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 • • 2012 TOBACCO LICENSE RENEWAL APPLICATION 2396-023—TOBC—01 TOBACCO LICENSE TO SFTJ TOBACCO Page 1 Optional Fee: $10.0 0 of which License Year Beginning May 1, 2012 ending April 30, 2013 $10.0 0 is paid to town/city $0.0 0 is paid to DLC Fee due only if licensee does not have a liquor license Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Wesco, Inc. Doing Business As: Champlain Farms - Exxon Mailing Address: 801 Williston Road 32 San Remo Drive South Burlington VT 05403 South Burlington VT 05403-6310 Telephone: (802) 860-5850 PLEASE INCLUDE EMAIL ADDRESS: 2Ce.,,\ C\nar( V\al mS,U;m Description of Premises: Lessor: A convenience store and gas station located in a brick building Wesco Oil approximately 900 square feet in size and located on the south side So. Burlington Vt of Williston Road due north of Spillaines Mobil at 801 Williston Road in the city of South Burlington, Vermont. Last Enforcement Seminar: 11/02/2011 Fed. ID Number: 03-0273319 Incorporation Date: 09/21/1979 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Sinendinger, David 15 Hagan Drive Essex VT 05452 Director 2. Simendinger, William 12 Whiteface Street S Burlington VT 05403 Stockholder 3. Simendinger, David 15 Hagan Drive Essex VT 05452 Stockholder 4. Simendinger, William 12 Whiteface Street S Burlington VT 05403 Has any director or stockholder been convicted or pleaded guilty to criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any electivyor appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes V No If yes, please attach the following information: Individual's name, office and jurisdiction ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page • • 2012 TOBACCO LICENSE RENEWAL APPLICATION 2396-023-TOBC-01 TOBACCO LICENSE TO SF.r,r, TOBACCO Page 2 I/We hereby certify t,,haat�+''the information in this application is true and complete. Dated at 1 A , in threw county of�\-\\troln , and State of \ei V O A , this , day'of V , V 1?j Signature of authors ed agent Signature of individual or partners of corporation, canpany, club or as ciation `� , (Title) Are you making this application for the benefit of any other party? Yes �"o l Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of City of Total Membership 4 , members present t s NCN,- Q _A% j Town Clerk ) TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control carnissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a tobacco license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 1 : 41 City of South Burlington Sj�� City Clerk's Office Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION DOING BUSINESS AS/ TRADENAME karr ;YL r�mS ADDRESS 1011 1Eorr�e� rG . 6.1_,'11°16(616 —:) FIRST CLASS SECOND CLASS) CABARET DATE RECEIVED BY CLERK'S OFFICE SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple — Date SO. URLINGTONFIRE DEPT 3/L1/0.- Chief Douglas S. Brent Date ` SO. BURLINGTON TAX DEPT � Mart a Lyons,y Deputy rector Date sent to Montpelier: :-7F R...i;.,,,+,,,, \/T nGnnQ Qno_Qnf nine 2012 LIQUOR LICENSE RENEWAL APPLICATION 2396-032-SECN-01 SECOND CLASS LICENSE TO SFTT MALT AND VINOUS BEVERAGES Page 1 Fee: $100.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $50.00 is paid to town/city $50.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Wesco, Inc. Doing Business As: Champlain Farms Mailing Address: 1041 Shelburne Road 32 San Remo Drive South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) I CPA B C\n \aj n- .,, PLEASE INCLUDE EMAMAILL CLUDE ADDRESS: c,AnS.coh,) Description of Premises: Lessor: Store in a one story brick and wood framed building being Wesco Corp. approximately 500 square feet in size and located on the West side of South Burlington VT 05403 Shelburne Road, designated as 1041 Shelburne Road, in the City of South Burlington, Vermont. Last Enforcement Seminar: 09/17/2011 Fed. ID Number: 03-0273319 Incorporation Date: 09/21/1979 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: 'Des ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. y� a 1 Corporation Name Address gg Town/City State Zip Code Director 1. Simendinger, David u u=gan ,,,-,_ ,S•Sser. Director 2. Simendinger, William 12 Whiteface Street S Burlington VT 05403 Stockholder 3. Simendinger, David �.� u�q�n T* *•e nsas� Stockholder 4. Simendinger, William 12 Whiteface� u Streen Burlington VT 05403 e�g6' air Has any director or stockholder been convicted or ple y f' cr or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective r appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following information: Individual's name, office and jurisdiction Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page Health License Expires / /2012 WESCO, INC. PARS 2012 Liquor/Tobacco License Renewal Change of Address: David Simendinger 88 Calloway Dr Williston,VT 05495 Traffic Tickets: William Simendinger Connecticut Superior Court Speeding 05/11/2011 William Simendinger State of New Hampshire, Sullivan County Newport District Court Speeding 05/20/2011 1 , 2012 LIQUOR LICENSE RENEWAL APPLICATION 2396-032—SECN-01 SECOND CLASS LICENSE TO SF11 MALT AND VINCUS BEVERAGES Page 2 . I/We hereby certify that the information in this application is true and complete. Dated atS:). b1/461'l AY\OWN , in the county ofe.. \ -ems , and State of\J€,( Aov\ c' this l l day of , ea c)v Signature of authoriz agent Signature of individual or partners of corporation, canpany, club or association (Title) Are you making this application for the benefit of any other party? Yes No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the conmiissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual camiissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of own of�Jl/. /. Total Membership , members present - - • C.I 1‘.Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control coimdssioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or j second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 2012 TOBACCO LICENSE RENEWAL APPLICATION 2396-032-TOBC-01 TOBACCO LICENSE TO SETA, TOBACCO Page 1 Optional Fee: $10.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0.0 0 is paid to town/city $0.0 0 is paid to DLC Fee due only if licensee does not have a liquor license Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Wesco, Inc. Doing Business As: Champlain Farms Mailing Address: 1041 Shelburne Road 32 San Remo Drive South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 864-0157 PLEASE INCLUDE EMAIL ADDRESS: eC�4)(2)c\1r 103,A nNS.C_p YYI Description of Premises: Lessor: Store in a one story brick and wood framed building being Wesco Corp. approximately 500 square feet in size and located on the West side of South Burlington VT 05403 Shelburne Road, designated as 1041 Shelburne Road, in the City of South Burlington, Vermont. Last Enforcement Seminar: 09/17/2011 Fed. ID Number: 03-0273319 Incorporation Date: 09/21/1979 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. �1G � Corporation Name Address ! u Town/City State Zip Code Director 1. Simendinger, David .15 Nnga.. D.i,,.. ----tram-- - vT u5452' Director 2. Simendinger, William 12 Whiteface Street S Burlington VT 05403 Stockholder 3. Simendinger, David 15 Ragan Beiva --Nesex� -Ti uc452,.. Stockholder 4. Simendinger, William 12 Whiteface Street S Burlington VT 05403 Has any director or stockholder been convicted or pleaded guilty to criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? V Yes No I If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following information: Individual's name, office and jurisdiction ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contribution's due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 1 1 1 2012 TOBACCO LICENSE RENEWAL APPLICATION 2396-032-TOBC-01 TOBACCO LICENSE TO SFTJ, TOBACCO Page 2 I/We hereby certify� that the information in this application is true and complete. Dated at ..) • \ .A , in�thee�county ofb 4e.f( , and State of \1 �/\, this `I day of JV , l� Signature of author ed agent Signature of individual or partners of corporation, company, club associ 'on (25C,0,�'n QS\ (Title) Are you making this application for the benefit of any other party? Yes No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recanmendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of tytgiCity of 1/p1if n i Total Membership 5 members present C. a is i � � 'awn Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a tobacco license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 1 ' City ©f South Burlington .itil ; City Clerk's Office °o;0,, f Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET ILICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION ch r1 e, or ,r)r , , LL ____ DOING BUSINESS AS/ TRADENAME c ) ► Irk , 1 rl 4/, ADDRESS ; i I DJI rJ. , FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE a'(. 7,,,, D l�--- SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. 3 J li/,t URLINGTO FIRE DEPT Ch ouglas S. Brent Date • SO. BURLINGTON TAX DEPT -1/aajka._, MMtila Lyons, Deputy x Collector P Y Date sent to Montpelier: 2012 LIQUOR LICENSE RENEWAL APPLICATION 6798-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 License Year Beginning May1, 2012 endingFee: $1 0 0.0 0 of which g g April 30, 2013 $100.00 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Charlie's on Fire, ro.r. Doing Business As: Charlie's on Fire, LLC Mailing Address: 1160 Williston Road 1160 Williston Road S. Burlington VT 05403 S. Burlington VT 05403 Telephone: (802) 862-1211 \ PLEASE INCLUDE EMAIL ADDRESS: �"( 50(p OAO.(\ QV - Li3 r(\ Description of Premises: Lessor: Restaurant in a single story strip mall on the north side of Williston Precourt Investment Co. Road designated as #1160 unit #2, 1/4 mile east of 189 off ramp in Shelburne VT 05482 the city of South Burlington, VT Last Enforcement Seminar: 10/20/2010 Filed Articles of Organization: Yes Date Filed: 02/14/2000 Federal ID Number: 03-0365684 Majority of Members are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Limited Liability Company Name Address Town/City State Zip Code Member 1. Kinstantonis, Taso M2 Stonehedge Dr S. Burlington VT 05403 Member 2. Intini, Lori S M2 Stonehedge Drive S. Burlington VT 05403 Member 3. Farmer, Patricia M 7 Stonehedge Drive S. Burlington VT 05403 Member 4. Fisher, David 25 Pheasant Way S. Burlington VT 05403 Member 5. Hudson, Dennis N9 Stonehedge Dr S. Burlington VT 05403 Has any person been convicted or pleaded guilty to any criminal or motoor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes , No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes ve o If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 12416 Expiration Date: ?? Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Rooms Cert./Acct. No.: 440-030365684E-01 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Ccamissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 2012 LIQUOR LICENSE RENEWAL APPLICATION 6798-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated a. (7. \AV j s- _(\ , in the county of 1 A1.QA(I.Q A , and State of VR4A11.014 this 'Z,L\}\i\ day of -2\-)i\ CI,,( 1 Signature of authorized agent Signature of individual or partners of corporation, company, club or association (Title) Are you making this application for the benefit of any other party? Yes ,/No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recamiendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. • APPROVED DISAPPROVED • Approved by Board of Control Commissioners of - City o. • . of Total Membership S , members present �kKt A `~ c�� 1 ,Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall.notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 I • 44 City © South Burlington # .' City Clerk's Office VOTE Donna Kinville, City Clerk p' r. FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION Goriza . 1AoG'oiP - DOING BUSINESS AS/ TRADENAME ecorZ01.s. ADDRESS ) D >>I/:o oar FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE_ Y) ri'11 f of iG ia SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. B R NGTON FIRE DEPT A-Air 3 IL 7//1- Chief Douglas S. Brent Date SO. BURLINGTON TAX DEPT /z-011,27,--- Ae/c Mart a Lyons, Deput ax Collector Date sent to Montpelier: • a y . 2012 LIQUOR LICENSE RENEWAL APPLICATION 6462-002-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $100.00 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING • Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Gonzo's Indoor Golf Club & Academy, LLC Doing Business As: Gonzo's Indoor Golf Club & Academy, LLC (S. Burl) Mailing Address: 1860 Williston Road South 2 2 Cardinal Lane South Burlington VT 05403 Essex VT 05452 Telephone: (802) 881-0660 ` PLEASE INCLUDE EMAIL ADDRESS: ST V E-e- 6bAlli53614/0)4a))-110/21 Description of Premises: Lessor: Restaurant in a single strip mall consisting of approx 5400 sq ft South Burlingotn Realty Co located on the north side of Williston Road. Designated as #1860 Williston VT Suite #2 in the city of South Burlington, VT Last Enforcement Seminar: 11/28/2011 Filed Articles of Organization: Yes Date Filed: 09/13/2007 Federal ID Number: 71-1039478 Majority of Members are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Limited Liability Company Name Address Town/City State Zip Code Member 1. Gonsalves, Stephen 2 Cardinal Lane Essex Junction VT 05452 Has any person been convicted or pleaded guilty to any criminal or�°jtor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes �C No If yes, please attach the following information: Individual's name,,c`ourt/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes Y No If yes, please attach the following info ion: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 14389 Expiration Date: ?? Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Rooms Cert./Acct. No.: 440-711039478E-01 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full canpliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 2012 LIQUOR LICENSE RENEWAL APPLICATION 6462-002-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We her c/rtify that the information in this application is true d ccmplete. Dated at 3/ G .�/ , in the county of t/ ► ' G4 , and State of Vcrotto\)7 , this 17 day of / 1ifi2Cb1 , 01010? Si. .-ur of authorized agent Signature of individual or partners 1 ••i ti. , company, c or association (Title) Are you making this application for the benefit of any other party? Yes ,No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual catmissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of�me City o #J015 r J, 41,0 , T Total Membership 6 , members present A est, T '- 1 G,�I 14, Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selecL❑wn or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 i 0111,111tb HURIIN°lpN,YC .yOti City of South Burlington ` hF vt 1/ 575 DORSET STREET 4 94/4��''� #') SOUTH BURLINGTON,,44.0. �% dr G ON, VERMONT 05403 G260 �J' •eb A`�y shf� TOWN M' . RN FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION DOING BUSINESS AS/TRADENAME 6 r� il oT) 4)n v f )'.1.6-46 1 ADDRESS 4'01 Por -)', FIRST CLASS SECOND CLASS CABARET I DATE RECEIVED BY CLERK'S OFFICE 6a r. Q�Zk/f , `� '' South Burlington Police Department Chief Trevor S. Whipple Date S Burlington Fire Department Chief Douglas S. Brent Date South Burlington Tax Department )(A/ 46QA Martha Lyons, Deputy Tax Collector Date Date Sent to Montpelier: 1 • j 2012 LIQUOR LICENSE RENEWAL APPLICATION 4073-001-1CAB-01 FIRST CLASS CABARET LICENSE TO SELT, MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $100.00 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Hart Hotels of Vermont, Incorporated Doing Business As: Green Mountain Suites Hotel Mailing Address: 401 Dorset Street 401 Dorset Street South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 860-1212 T LeSrar,ck c hat-4- hotels,col') PLEASE INCLUDE EMAIL ADDRESS: Description of Premises: Lessor: A Cabaret in a one story wood frame building at 401 Dorset Street in Dorset Hote/Hart Land Company the city of South Burlington, Vermont. So. Burlington Vt Last Enforcement Seminar: 04/21/2010 Fed. ID Number: 03-0359487 IncoLpuration Date: 10/26/1998 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip CrriP Director 1. Deslauriers, Charles 60 Stockbridge Road Charlotte VT 05445 Director 2. Hart, David 39 Edgewater Drive Orchard Park NY 14127 Director 3. Scott, Christopher 401 Dorset Street S. Burlington VT 05401 Stockholder 4. Hart, David 39 Edgewater Drive Orchard Park NY 14127 Has any director or stockholder been convicted or pleaded guilty to any cr' 1 or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? YesNo If yes, please attach the following information: Individual's name, court traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any electi or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 11906 Expiration Date: ?? 17-I '3 1� .0 1 2. Vt. Dept. of Health Lodging No.: Expiration Date: )A 3i) ZO 1 2- Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 11102717 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: XX Yes No Are there any changes to this Outside Consumption area?: _Yes X No (If yes, attach necessary information) A veranda/patio area that is off from the lobby area; The area is totally enclosed, fran 5:00 p.m. to 8:00 p.m...Properly supervised. Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN If these premises are licensed as a Cabaret, I/We hereby certify that the receipts from entertainment, dancing and sale of alcohol beverages are greater than the receipts fran the sale of food. The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/we are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 2012 LIQUOR LICENSE RENEWAL APPLICATION 4073-001-1CAB-01 FIRST CLASS CABARET LICENSE TO SFT,7, MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated at S0u4� bur - U1\ , in the county of (b4 6 en , and State of \JQ-1'vi I this I`Fh day of,j uar , 20 I 2_ S tur authorized agent Signature of individual or partners •• at n y, club or association Aerie/al- m G�II e-v (Title) Are you making this application for the benefit of any other party? Yes ?(No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual canni.ssioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED • Approved by Board of Control Caiani.ssioners of 4iiiipr To Total Membership 5 , members present Att -� c /K. 1 Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 • City of South Burlington / ��►�1� I� 575 DORSET STREET 6,-.r!��'1A t;./ ',' SOUTH BURLINGTON, ��;� ��, O , VERMONT 05403-6260 Vie— J4O��yY `'444 A TOWN M'*a~1 FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION oCineKi DOING BUSINESS AS/TRADENAME _baglloo__,p_________LD_ ADDRESS 43/ 1i Dy ra FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE____6_ _jtaica--—' South Burlington Police Department Chief Trevor S. Whipple Date Sou urllingto�ire Department 3 Ill in_ Chief Douglas S. Brent Date South Burlingtonon Tax Dep rtment `/C6,('�NLO� 1 1 tt/// -" Martha Lyons, Deputy Tax Collector Date Date Sent to Montpelier: • 2012 LIQUOR LICENSE RENEWAL, APPLICATION 406-007-SECN-01 SECOND CLASS LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $100.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $50.00 is paid to town/city $50.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Jolley, Bruce & Robert/Jolley Associates Doing Business As: Short Stop #105 Mailing Address: 1314 Williston Road P.O. Box 671 South Burlington VT 05403 St. Albans VT 05478-0671 Telephone: (802) 658-4635 PLEASE INCLUDE EMAIL ADDRESS: smitchell@sbcjolley.com Description of Premises: Premises: XX Owned Leased Grocery store in a one story building approx. 936 sq. ft. located on the northwest corner of intersection of Williston Rd. & Patchen Rd. designated as 1314 Williston Rd., City of South Burlington, VT. Last Enforcement Seminar: 10/26/2011 ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Partnership Name Address Town/City State Zip Code Partner 1. Jolley, Bruce 180 Overlake Drive Colchester VT 05446 Has any person been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes XX No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes XX No If yes, please attach the following information: Individual's name, office and jurisdiction Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and ayiees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. I/We hereby certify that the information in this application is true and caplete. Dated at St. Albans , in the county of Franklin , and State of Vermont this 18th day of January , 2012 Signature of authorized agent Signor . - . individual •'r part,:rs of corporation, company, club or association / . fitAar (Title) Are you making this application for the benefit of any other party? Yes XXNo Continued on next page Health License Expiration: 01/31/2013 • 2012 LIQUOR LICENSE RENEWAL APPLICATION 406-007-SECN-01 SECOND CLASS LICENSE TO SETJ. MALT AND VINOUS BEVERAGES Page 2 Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of the Cit or Town o 5a� ;�� • i/jj'o Total MembershipE5r members present Att �i C.k.'` , Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 2012 TOBACCO LICENSE RENEWAL APPLICATION 406-007-TOBC-01 TOBACCO LICENSE TO SELL TOBACCO Page 1 Optional Fee: $1 0.0 0 of which License Year Beginning May 1, 2012 ending April 30, 2013 $10.0 0 is paid to town/city $0.0 0 is paid to DLC Fee due only if licensee does not have a liquor license Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Jolley, Bruce & Robert/Jolley Associates Doing Business As: Short Stop #105 Mailing Address: 1314 Williston Road P.O. Box 671 South Burlington VT 05403 St. Albans VT 05478-0671 Telephone: (802) 658-4635 PLEASE INCLUDE EMAIL ADDRESS: smitchell@sbcjolley.com Description of Premises: Premises: XX Owned Leased Grocery store in a one story building approx. 936 sq. ft. located on the northwest corner of intersection of Williston Rd. & Patchen Rd. designated as 1314 Williston Rd., City of South Burlington, VT. Last Enforcement Seminar: 10/26/2011 ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Partnership Name Address Town/City State Zip Code Partner 1. Jolley, Bruce 180 Overlake Drive Colchester VT 05446 Has any person been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes XX No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes XX No If yes, please attach the following information: Individual's name, office and jurisdiction ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. I/We hereby certify that the information in this application is true and complete. Dated at St. Albans , in the county of Franklin , and state of Vermont this 18th day of January , 2012 Signature of authorized agent Signature of dividua or pa s of corporation, company, club or association (Title) Are you making this application for the benefit of any other party? Yes XX No Continued on next page Health License Expiration: 01/31/2013 2012 TOBACCO LICENSE RENEWAL APPLICATION 406-007-TOBC-01 TOBACCO LICENSE TO SETT TOBACCO Page 2 Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Con nissioners of - .wn of5D. Total Membership , members present - _ a 44 C' ' Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control carmissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a tobacco license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 I • ll ro City of South Burlington ► g at®® O City Clerk's Office VOTE °EEO Donna Kinville, City Clerk LJ FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION ____ _Lekl,00/Z1 , GL' DOING BUSINESS AS/ TRADENAME '--'Y)D6 (4DU-kk t ri // ADDRESS Ifo 001):140rV-4gA FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE ,, )/i7 CRD / SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. BURLLINGTON�F-�RE DEPT [-)) )/k/ abL„/,2 Chief Douglas S. Brent Date SO. BURLINGTON TAX DEPT 33�11 Martha Lyons, De ax Colle ctor Deputy p y Date sent to Montpelier: 2012 LIQUOR LICENSE RENEWAL APPLICATION 5867-001-1RST—01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 License Year Beginning May 1, 2012 ending April 30, 2013 Fee: $1 0 0.0 0 of phi $100.00 is paidh to town/city $100.00 is paid toDLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Blythewold, Tar Doing Business As: Moe's Southwest Grill Mailing Address: 1150 Williston Road 7 Green Tree Drive South Burlington VT 05403 Suite 4 Telephone: (802) 985-0185 Squth Burlington VT 05403 PLEASE INCLUDE EMAIL ADDRESS: COrc C_,PC\O (Unr\ Description of Premises: Lessor: A Restaurant located within a one story brick and steel constructed Precourt Invesment Company LLC building with an approximate size of 2,800 square feet and designated 215 Maple Leaf Lane as 1150 Williston Road, located in the City of South Burlington, Shelburne VT 05402 Vermont. Last Enforcement Seminar: 10/27/2011 Filed Articles of Organization: Yes Date Filed: 09/21/2004 Federal ID Number: 20-1706015 Majority of Members are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Limited Liability Company Name Address Town/City State Zip Code Member 1. Wood, Philip 56 Wildwood Court Shelburne VT 05482 Member 2. Wood, SueAyn 56 Wildwood Court Shelburne VT 05482 Has any person been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 13931 Expiration Date: ?? Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 440-201706015F-01 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: XX Yes No Are there any changes to this Outside Consumption area?: Yes No (If yes, attach necessary information) Outside patio in front of restaurant, roped off, being i2x10 feet in size, with surveillance system in use at all times. May 1 through October 30th. 11:00 a.m. to 11:00 p.m. Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 2012 LIQUOR LICENSE RENEWAL APPLICATION 5867-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated at ,,, r 1, , in the county of(k, 1 , and State of \J fmU wck this� J day of ��'"_ ^c 1� Signature of authorized agent Sinature of indivi ual r er of corporation, company, club or association (Title) Are you making this application for the benefit of any other party? Yes No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Veunuut Statutes Annotated, as amended, have been fully met by the applicant, the ccamissioners will endorse their recamrnendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual camuissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Camuissioners of the City or Town of Total Membership members present Attest, , Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control carenissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or • second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 • Y' 10101p yoy. � City of South Burlington f �II� '�� 575 DORSET STREET ��)�`---��it SOUTH 6URLINGTON, VERMONT 05403-6260 Bh.D TOWN FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION DOING BUSINESS AS/TRADENAME fri ---- --- k0-kV (40'Thi ADDRESS I/ f 1 yr r, , FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE c� . South Burlington Police Department Chief Trevor S. Whipple Date Soa3urprre Department Chief Douglas S. Brent Date ____2/jSouth B rlington Tax Dep tment a-C.Aa, 6C22 /b1/.77 -. Marth Lyons, Deputy Tax Collector Date Date Sent to Montpelier: 2012 LIQUOR LICENSE RENEWAL APPLICATION 241-018—SECN—01 SECOND CLASS LICENSE TO SRT,T MALT AND VINOUS BEVERAGES Page 1 Fee: $100.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $50.00 is paid to town/city $50.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Price Chopper Operating Co. of Vermont, Inc. Doing Business As: Price Chopper # 228 Mailing Address: l ,: 41 Hinesburg Road 5OT'D�esburg-Ro d 1f�41 No jrYe tt S. Burlington VT 05403 legal Dept. Telephone: (802) 864-9176 Schenectady NY-1-2306 PLEASE INCLUDE EMAIL ADDRESS: I a '{;1, Description of Premises: Lessor: `/ Store in a single story brick building within a strip mall on the Antonio B Pa erleau LLC south west corner of Hinesburg Road & Williston Road designated Burlington VT as #41 Hinesburg Road in the city of South Burlington, VT Last Enforcement Seminar: 03/02/2011 Fed. ID Number: 14-1565927 Incorporation Date: 02/13/1975 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Iannotti, Patrick A. 116 Mcguire Street N. Bennington VT Director 2. Newkirk, Michael A. 66 Meetinghouse Lane Weybridge VT Director 3. Golub, Neil M 1021 Rosendale Road Schenectady NY 12309 Stockholder 4. The Golub Corp., 501 Duanesburg Road Schenectady NY 12306 Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes x No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes X No If yes, please attach the following information: Individual's name, office and jurisdiction Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/FFe are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page • onI , ted4 do ) e'. ...!.'..::....:,..... . . . .... .*::.•:... ., :::' :.........!.:: •aiiiYl� Corti .. • fkate. of'.Second..Class.: .Namet . •(pr int):: t Signature: . ..bate:. . , • 3/2;.l,.r • • ' •.. •k (dp��s hw yei hom'wbove date, "•' . . tnvestigator's.Signature: :"-2.. e ,.; •... T .► -.7• . . Certificate of Second Class Sein►inrar•,Attendance Category (circle one):. OGwner' Director. Partner. � • . , . . C 'Employee• ,, • Licensee Name al .. b fP�w'd'"t-p f ,:; I. Address: �1 •��n�s} . • � ,: . •�� •. -�------. .�- f&d. 3 — Sa �t�i�Yl;ne�frors Z28 Education Regulation 31. . . T:7§239 i' s. .4:VS.A: 900/1.00 d ct O# LO.9l 3GOZ/8G/G0 . 0 , ,.. . . ,-. . . Vermont Department of Liquor Control , Certificate of Second Class Seminar Attendance . • Name (print): : Peter.. -.. •• . • . . . • •• Signature: 4),Z '12***t-. ., . . : . . . .. I . • , •-• •-• • Date: : 31:2/"21) 1 i • . , .. .• .,. , • ••. .. • . .• .•t . • . • ,:,;!..ii,,,,o years from above date).. ' • • #.7.7...........,.. ,............"'"°/ ' • Investigator's Signature: . . . ; t Certi mate of Second Class Sentiner Attendance Category (circle one): Owner Director Partner . ag---,er ) Employee .•... ' .'1 • Licensee Name: : 19-71 c-e— a/NA^) e--r— 6 ol(.(..\:) (. -tilticii-, • ; • ,.!` d/b/a , , i , . ..:; : . • : .• '•.A,,, , -' Address; Pi-[1 1 t OCe-Sk(7?e-f- 4f* I.‘..:1( ''''''' C" 114 Irn 04'. I. : . Edition Regulation 348 .. ., ;0:*;•! 1 , 1 • , • ,: VS*7.7§239 . ' ny r.innir i lin-7 n•-, 1.0:91. 11;:iz/81./Lo c00/800 'd cVZO: I j•. I r, Y d'1 , S 5. {71� • 1 yc • St y ,��•' •�' �">r f� • .ate_ ',T'ti ,a!Y.'.:r'6 ,1:1. ter' ... ... CERTIFICATE OF COMPLETION W.f• This is to certify that • • • , Erik Stumpf � ` has completed the course '+ --_-�-- Training g -- 2nd Class Certification • March 17,2011 j11:** • y,+ DEPARTMENT OF LIQUOR CONTRCP. wotr2y2 �� .,a •}�_ ,-±p': :�"".r �ryt .,."If f}�q. 1 !. ' `{ 5' ` '. y a :: f'ti." is t.).„ • a . 900/c00 d 4VZ0# 30 9l ZIOZ/SI/LO 2012 LIQUOR LICENSE RENEWAL APPLICATION 241-018-SECN-01 SECOND CLASS LICENSE TO SF.TJ MALT AND VINCUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete. Dated atSchenectady NY , in the county of Schenectady , and State of New York this 13th day of January , 2012 Signature of authorized agent Signature of individual or partners corppration,,c , lub or association. Christine C. Daniels, Corp. Secretary (Title) Are you making this application for the benefit of any other party? Yes X No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED r � Approved by Board of Control Commissioners of e City or a Total Membership , members presen A st ��- ) e 14.+ , Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 2012 TOBACCO LICENSE RENEWAL APPLICATION 241-018-TOBC-01 TOBACCO LICENSE TO SF1a TOBACCO Page 1 Optional Fee: $10.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $10.00 is paid to town/city $0.0 0 is paid to DLC Fee due only if licensee does not have a liquor license Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Price Chopper Operating Co. of Vermont, Inc. Doing Business As: Price Chopper # 228 Mailing Address: 41 Hinesburg Road i*Mlit Mk kaSiIX 461 Nott Street S. Burlington VT 05403 Legal Dept. Telephone: (802) 864-9176 Schenectady NY 12308 PLEASE INCLUDE EMAIL ADDRESS: Description of Premises: Lessor: Store in a single story brick building within a strip mall on the Antonio B Pamerleau LLC south west corner of Hinesburg Road & Williston Road designated Burlington VT as #41 Hinesburg Road in the city of South Burlington, VT Last Enforcement Seminar: 03/02/2011 Fed. ID Number: 14-1565927 Incorporation Date: 02/13/1975 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Iannotti, Patrick A. 116 Mcguire Street N. Bennington VT Director 2. Newkirk, Michael A. 66 Meetinghouse Lane Weybridge VT Director 3. Golub, Neil M 1021 Rosendale Road Schenectady NY 12309 Stockholder 4. The Golub Corp., 501 Duanesburg Road Schenectady NY 12306 Has any director or stockholder been convicted or pleaded guilty to any criminal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes XNo If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes X No If yes, please attach the following information: Individual's name, office and jurisdiction ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. I/We hereby certify that the information in this application is true and complete. Dated at Schenectady NY in the county of Schenectady New York and State of this 13th day of January 2012 1 Signature of authorized agent Signature of individual or partners of orvtion, cmpany, c or associlitio ,L PChristine C. Daniels; Corp. Secretary (Title) Are you making this application for the benefit of any other party? Yes X No Continued on next page t 2012 TOBACCO LICENSE RENEWAL APPLICATION 241-018-TOBC-01 TOBACCO LICENSE TO SRT,T, TOBACCO Page 2 Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Veinuut Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of e City or o Total Membership , members present A et, �L " ' G‘K Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a tobacco license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 • • �P'ice Chopper® www.pricechopper.com January 19, 2012 City of South Burlington 575 Dorset Street South Burlington, Vermont 05403 RE: Price Chopper#228 Alcohol/Tobacco License Dear Sir/Madam: Enclosed please find renewal application, certificates of seminar and payment regarding the above referenced licenses. When the licenses are issued please forward it to the following address: The Golub Corporation Legal Department 461 Nott Street Schenectady,New York 12308 ATTN: Lisa A. Durant We will be sure that the licenses are forwarded and posted to the proper place. Thank you for your help. If you need any further information, please do not hesitate to contact the undersigned at (518) 379-1421. Very truly yours, Lisa A. Durant Legal Department /lad Encl. A Golub Corporation Company 461 Nott Street, Schenectady,New York 12308 ,i T ,. ta Cite of South Burlington 1r®4�� City Clerk's Office YOTEiP Donna Kinville, City Clerk FIRST, COND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION .Z h Va rl (a '-4E4a Ural- God - DOING BUSINESS AS/ TRADENAME / Vr - a)ac i- ADDRESS lam) i/CD111/' 0 --mod . IRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE +' _ . ___ , SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date i-- • SO. NGTON FIRE DEPT r2:, Chief Douglas S. Brent Date SO. BURLINGTON TAX DEPT G t,l�'�(¢�"CX 414/J . '. r��OZ Mart a Lyons, Deputy Tax Collector • Date sent to Montpelier: I F7F llnrcot Ctroot Cnuth Rnrlinntnn 1/T n4nn1 QnV.ana_ninG Al.;.,,,;ll.,rnl,.h,,.1 ....... 2012 LIQUOR LICENSE RENEWAL APPLICATION 1969-001-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 License Year Beginning May1, 2012 endingFee: $1 0 0.0 0 of whichd g g April 30, 2013 $100.00 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Szechuan East-Restaurant Corp. Doing Business As: Silver Palace Mailing Address: 1216 Williston Road 1216 Williston Road South Burlington VT 05403 South Burlington VT 05403 Telephone: (802) 864-0125 PLEASE INCLUDE EMAIL ADDRESS: r 63 3 0144 .CO PIA Description of Premises: Lessor: Restaurant in a 1 story cement block building on the north side of Merrill Jarvis Rt. 2 (Williston Rd.) designated as 1216 Williston Rd., in the City 1210 Williston Road of South Burlington, VT. South Burlington VT 05403 Last Enforcement Seminar: 03/23/2011 Fed. ID Number: 03-0304864 Incorporation Date: 07/03/1986 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. Lee, Edward E-9 Stonehedge Dr. South Burlington VT 05403 Director 2. Ng, Kin Ting 135 Sadler Road Williston VT 05495 Director 3. Wong, Ken 177 Sadler Lane Williston VT 05495 Stockholder 4. Lee, Edward E-9 Stonehedge Dr. South Burlington VT 05403 Stockholder 5. Lee, Kenneth 350 Spear St. South Burlington VT 05403 Stockholder 6. Chu, Wai King L-6 Stonehedge Dr. South Burlington VT 05403 Stockholder 7. Ng, Nang 328 Sander Circle Erie CO 80516 Stockholder 8. Louie, Hung 291 Sander Circle Erie CO 80516 Additional stockholders are on file Has any director or stockholder been convicted or pleaded guilty to any crimiAl or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes V No If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any electiy4 or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes V No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 1427 Expiration Date: ??- 11I3 o%.oly Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 15615 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 2012 LIQUOR LICENSE RENEWAL APPLICATION 1969-001-1RST-01 FIRST CLASS ESSTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that� the information in this application is true and complete. Dated at 5o i I/i /3v�/fAJ ft c_ , in the county of C41#ei d&-t , and State of 1/e/1v/04- this 7 - day of Tel,Yvar , 2 a I2_ Signature of authorized agent Signature of individual or partners of corporation, company, club or association e..;:hda. !` S?Crefa (Title) J / Are you making this application for the benefit of any other party? Yes �/ No Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED • Approved by Board of Control Commissioners of ity own of Total Membership members present tJown Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control camrdssioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 til 4 City ©f South Burlington Lor&Lw o City Clerk's Office ,. Donna Kinville, City Clerk r� &II° FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION 1)56tr11 ; L .r. DOING BUSINESS AS/ TRADENAME Sv ar r ADDRESS 30 G�1-orr) z'r- --6-4 . q i FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE L1 TC/l SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date S . BURLINGTON FIRE DEPT Q3/2,/,L Chief Douglas S. Brent Date SO. BURLINGTON TAX DEPT4 ?4/Q . T271 O(4.;:egi." - 4//0 c2//0//e9— Marth Lyons, Deputy `�olector Date sent to Montpelier: o 20 FIRST/SECOND CLASS LIQUOR LICENSE AND TOBACCO APPLICATION License Year: May 1"through April 306 of following year Please file application in duplicate .v (S/1g p 1..L C PrintkItName of Perlon,Partnership,Corporation,Club or LLC G rS/1 A Doing Bu ' ess As-T de Name 30 Co1»+,70n ly On re, She. `l Street and street number oPpremises covered by this application 50. B,ri�n�},�,�/ VT' 059C 3 Town or City&Zip ate �goz� 32J-7ggs Telephone Number Mailing Address(if different from above) Email Address: abbey 1-h esn q,Ovt, CO rn FIRST CLASS [`]SECO.\D CLASS TOBACCO )) Fee for ANY FIRST class license paid to town/city$100.00/Fee to DLC $100.00 i RESTAURANT Fee for ANY SECOND class license paid to town/city$50.00/Fee to DLC $50.00 ❑ HOTEL Fee for TOBACCO ONLY license paid to town/city $10.00 ❑ CABARET ❑ CLUB TO THE CONTROL COMMISSIONERS OF THE TOWN/CITY OF 5,9vi''' Q..4 i'nq-}ve) ,VERMONT Application is hereby made for a license to sell malt and vinous beverages under and in accordance with Title 7, Vermont Statutes Annotated, as amended, and certify that all statements, information and answers to questions herein contained are true; and in consideration of such license being granted do promise and agree to comply with all local and state laws; and to comply with all regulations made and promulgated by the Liquor Control Board. Upon hearing,the Liquor Control Board may, in its discretion, suspend or revoke such license whenever it may determine that the law or any regulations of the Liquor Control Board have been violated,or that any statement,information or answers herein contained are false. MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE,AFTER NOTICE AND HEARING. If this premise was previously licensed,please indicate name I/we are applying as: ❑ INDIVIDUAL Jr LIMITED LIABILITY COMPANY PARTNERSHIP 0 CORPORATION Please fill in name,address,and place of birth of individual,partners,directors or members. LEGAL NAME STREET/CITY/STA IL pLi g 2 \11 ) gy_ 6 ree,„ r1,�� I-001 ✓r- 05108 G r;Writll, ='f} lob ri- s'''�rt �l`� 6 guy � � � � �ial� vT 0566 � Taw ('+y , T,} Are all of the above citizens of the UNITED STATES? tZ Yes No (Note: Resident Alien is not considered a U.S. Citizen) ' If naturalized citizen,please complete the following: Name Court where naturalized(City/State/Zip) Date CORPORATE INFORMATION: If you have checked the box marked CORPORATION, please fill out this information for stockholders (attach sheet if necessary). LEGAL NAME STREET/CITY/STATE Date of incorporation • Is corporate charter now valid? Corporate Federal Identification Number Have you registered your corporation and/or trade name with the Town/City Clerk? and/or Secretary of State? (as required by VSA Title 1141621,1623&1625). ALL APPLICANTS HAVE ANY OF THE APPLICANTS EVER BEEN CONVICTED OR PLED GUILTY TO ANY CRIMINAL OR Iv,IQL��R VEHICLE cNSE IN ANY COURT OF LAW (INCLUDING TRAFFIC TICKETS BY MAIL) YES NO If yes,please complete the following information: (attached sheet if necessary) Name Court/Traffic Bureau Offense Date Do any of the ats hold any elective or appointive state,county,city,village/town office in Vermont?(See VSA,T.7,Ch. 9,4223) YES I C I NO If yes,please complete the following information: Name Office Jurisdiction Please give name, title and date attended of manager, director, partner or individual who has attended a Liquor Control Licensee Education Seminar,as required by Education Regulation No.3: NAME: r41:454, TITLE: %,ender) (4rirter DATE: ►—I -?.OI (If you have not attended an Education Seminar prior to making application, please contact the Liquor Control Investigator in your area regarding this mandatory training.) FOR ALL APPLICANTS:DESCRIPTION/LOCATION OF PREMISES (Section 4) Description of the premises to be licensed: CA- ' ;/5;etc. a coteorn¢e.. }' [5.5 ps,V Does applicant own the premises described? No If not owned,does applicant lease the premises? ye 5 If leased, name and address of lessor who holds title to property: 3o Commu,v 7 04, e_ L L C 5S Co, in.vn►'J y Drive. So. 4��►��fon, vT O5'iO3 Are you making this application for the benefit of any other party? No FIRST CLASS APPLICANTS ONLY: No first class license may be issued without the following information. HEALTH LICENSE#: Food J`� 0 Lodging (if licensed as a Hotel) VERMONT TAX DEPARTMENT: Meals&Rooms Certificate/Business Account# y y 0-S)0 y 6)y 3 9 F-o. Business is d oted primarily to: (Circle one) FOO restaurant) ENTERTAINMENT(cabaret) HOTEL CLUB If you are considering Outside Consumption service on decks, porches, cabanas, etc. you must complete an Outside Consumption Permit. Please request this form from your Town/City or from the Department of Liquor Control. CABARET APPLICANTS ONLY: Applicant hereby certifies that the sale of food shall be less in amount or volume than the sales of alcoholic beverages and the receipts from entertainment and dancing; if at any time this should not be the case, the applicant/licensee shall immediately notify the Department of Liquor Control of this fact. Signature of Individual,Partner,authorized agent of Corporation or LLC member ALL APPLICANTS MUST COMPLETE AND SIGN BELOW The applicant(s)understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal repositories prior to acting on this application. I/We hereby certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA,Title 32,§3113). In accordance with 21 VSA, §1378 (b) I/VVe certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. If applicant is applying as an individual: I hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or am in full compliance with a plan to pay any and all child support payable under a support order. (VSA,Title 15,§795). Dated at 2- 9 -201 a in the County of Cl„'+1-e04n and State of VT this 9 clay of Fehr✓ar ,20 i Corporations/Clubs:Signature of Authorized Agent Individuals/Partners: (All partners must sign) Please complete and include with your liquor license application Please fill in for Individual, Partners, or Directors Applicant/s Personal Information Legal Name: /Q b i n Dui- Address: 8 2 v;Ji, 9 e 0 4 Date of Birth y-) 8-j 9 3o Place of Birth G,-i•,n e 11 c ri Sex 1=- SS# y8/-o a-1 a 6 6 Legal Name: Ro ber- S mint Address: -71 q &"` RON P141‘^ ei v7 6,L Date of Birth y-28-116 6- Place of Birth Zo i C,'j, -��} Sex /Y SS# Sao- 94- 82 y o oS Legal Name: Address: Date of Birth Place of Birth Sex SS# Legal Name: Address: Date of Birth Place of Birth Sex SS# Legal Name: Address: Date of Birth Place of Birth Sex SS# Legal Name: Address: Date of Birth Place of Birth Sex SS# Stockholder's Personal Information: Legal Name: Address: Date of Birth Place of Birth Sex SS# Legal Name: Address: Date of Birth Place of Birth Sex SS# Legal Name: Address: Date of Birth Place of Birth Sex SS# Attach additional sheet if necessary (Title) Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated,as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon,before any license may be granted. For the information of the Liquor Control Board, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. ,_So,f6)d-11Tbacii4t, g--- Town/City Date APPROVED DISAPPROVED Approved/Disapproved by Board of Control Commissioners •'t e City or '•wn (circle one)of �// Cr\ Total Membership_ members present .., C tat IC Attest, City or Town Clerk TOWN OR CITY CLERK SHALL MAIL APPLICATION DIRECTLY TO THE DEPARTMENT OF LIQUOR CONTROL, 13 Green Mountain Drive, Montpelier, VT 05602. If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class application shall be considered binding except as taken or made at an open public meeting. VSA Title 14312. NOTICE: After local action, all new applications are investigated by the Enforcement and Licensing Division prior to approval/disapproval of the license by the liquor Control Board. SECTION 5111 AND 5121 OF THE INTERNAL REVENUE CODE OF 1954 REQUIRE EVERY RETAIL DEALER IN ALCOHOLIC BEVERAGES TO FILE A FORM ANNUALLY AND PAY A SPECIAL TAX IN CONNECTION WITH SUCH SALES ACTIVITY. FOR FURTHER INFORMATION,CONTACT: THE BUREAU OF ALCOHOL,TOBACCO&FIREARMS (1 1 B) (513) 684-2979 DEPARTMENT OF THE TREASURY 550 MAIN STREET,CINCINNATI,OH 45202 el11410*Q {) City of South Burlington ��.i��I;) 575 DORSET STREET c(�t/: 1`1� Sty 4 SOUTH BURLINGTON, VERMONT 05403-6260 e<seFO4 ruwN M�"`.0'. IRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION -resel, eilaii cDrp. DOING BUSINESS AS/TRADENAME C / 4.i � ami 1,Y"-cAa ly ("Jar* ADDRESS / O710 W;ii Q1--6 , FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICEQ_ii, i��oro----' South Burlington Police Department Chief Trevor S. Whipple Date So h Bur inggton Fire Department Fi So .3/21,/L Chief Douglas S. Brent Date South Burlington Tax De artment Martha Lyons, Deputy Tax Collector Date Date Sent to Montpelier: .....- 2012 LIQUOR LICENSE RENEWAL APPLICATION 413-002-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $100.00 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Tygate Motel Corporation Doing Business As: Windjammer Restaurant Mailing Address: 1076 Williston Road Sara TPheau South Burlington VT 05403 1076 Williston Road Telephone: (802) 862-6585 1' U�' South Burlington 05403 PLEASE INCLUDE EMAIL ADDRESS: DA',,„k e. Description of Premises: 17J� "��S Prises: XX Owned Leased Restaurant on the ground floor, lounge on 2nd floor, of a 2 story steel and wood frame building on northerly side of Williston Rd. east of the Best Western Inn & Conference Center at 1076 Williston Rd in the city of South Burlington, Vt. Last Enforcement Seminar: 11/07/2011 Fed. ID Number: 03-0264469 Incorporation Date: 07/27/1977 Valid Charter?: Yes State of Charter: Vermont Majority of Directors are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Corporation Name Address Town/City State Zip Code Director 1. O'Connell, Laura L. 154 Sutton Farm Drive Williston VT 05495 Director 2. O'Connell, Bernard T. 154 Sutton Farm Drive Williston VT 05495 i Stockholder 3. O'Connell, Laura L. 154 Sutton Farm Drive Williston VT 05495 Stockholder 4. O'Connell, Bernard T. 154 Sutton Farm Drive Williston VT 05495 Has any director or stockholder been convicted or pleaded guilty to any crimifal or motor vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes VNo If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any director or stockholder of the corporation held any electi or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes No If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 1570 Expiration Date: ?? Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 44074 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . i Outside Consumption Permit?: XX Yes No / Are there any changes to this Outside Consumption area?: _Yes'"1'_No (If yes, attach necessary information) 70x50 fenced in carol area with 8-10 tables May 1st to October 1st 11:00 a.m. to 11:00 p.m. I IDisclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Commissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) 1 In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page 1✓ 2012 LIQUOR LICENSE RENEWAL APPLICATION 413-002-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this applica ion is true and complete. 1,( Dated at C{M , in the county of , and State of 1 O -1r 04 this 1 - day of , pI Signatur of autho 'zed agent Signature of individual or partners of corporation, company, club or association l� Title) Are you making this application for the benefit of any other party? Yes '✓o Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recommendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Pnard, all applications shall carry the signature of each individual commissioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of e City o, Town of Total Membership 5 members present to 4-4 G t�&Town Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control coma ssioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 :tot City of South Burlington ®' 0 City Clerk's Office � Donna Kinville, City Clerk FIRST, SECOND CLASS AND CABARET LICENSE APPLICATION FULL NAME OF PERSON, PARTNERSHIP, CORPORATION .- ;i1/4D1-1*00A e) ,a__ ILtc_ , DOING BUSINESS AS/ TRADENAME 7giarare 4,6D FIRST CLASS SECOND CLASS CABARET DATE RECEIVED BY CLERK'S OFFICE , / cD /c SO. BURLINGTON POLICE DEPT Chief Trevor S. Whipple Date SO. URLL)INGGjTONNFFIRE DEPT f�' `� 3/l 1//L Chie ,, Douglas S. Brent Date SO. BURLINGTON TAX DEPT -2 r).(A=VGCL- __________cg0 Mart a Lyons, Deputy actor Date sent to Montpelier: 2012 LIQUOR LICENSE RENEWAL APPLICATION 4294-002-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 1 Fee: $200.00 of which License Year Beginning May 1, 2012 ending April 30, 2013 $1 0 0.0 0 is paid to town/city $100.00 is paid to DLC Town: 04065 - SOUTH BURLINGTON MISREPRESENTATION OF A MATERIAL FACT ON ANY LICENSE APPLICATION SHALL BE GROUNDS FOR SUSPENSION OR REVOCATION OF THE LICENSE, AFTER NOTICE AND HEARING Applicant: Review all of the information presented on this form, indicating any changes in the spaces provided. Applicant: Williston Road Pizza, LIE Doing Business As: Zachary's Pizza (sb) Mailing Address: 1250 Williston Road 8 White Street South Burlington VT 05403 South Burlington VT 05403-5713 Telephone: (802) 864-9817 PLEASE INCLUDE EMAIL ADDRESS: Description of Premises: Lessor: A restaurant approximately 13,000 square feet in size located in a one Farmoore, LLC story brick and steel frame building north of Al's French Fries and 8 White Street designated as 1250 Williston Road in the city of South Paurlington, South Burlington VT 05403 Vermont. Last Enforcement Seminar: 04/20/2011 Filed Articles of Organization: Yes Date Filed: 03/10/2000 Federal ID Number: 03-0364382 Majority of Members are US Citizens: Yes ATTACH AN ADDITIONAL SHEET TO THIS APPLICATION NOTING ANY NECESSARY CORRECTIONS OR CHANGES AND UPDATES THAT HAVE OCCURRED DURING THE PAST YEAR. Limited Liability Company Name Address Town/City State Zip Code Member 1. Moore, John 132 Allen Drive Milton VT 05468 Member 2. Farrell, Shawn 26C West Street Essex Junction VT 05452 Has any person been convicted or pleaded guilty to any criminal or motox vehicle offense in any court of law (including traffic tickets by mail) during the last year? Yes y o If yes, please attach the following information: Individual's name, court/traffic bureau, offense and date In the past year has any person held any elective or appointive state, county, city, village or town office in Vermont (See VSA, T.7, Ch.9, Sec. 223)? Yes c4 o If yes, please attach the following information: Individual's name, office and jurisdiction Vt. Dept. of Health Food License No.: 247 Expiration Date: ?? Vt. Dept. of Health Lodging No.: Expiration Date: Vt. Tax Dept. Meals & Roans Cert./Acct. No.: 11878801 Important: Current food and/or lodging license expiration dates are required for license renewal (as applicable) . a I '3 - v,-e Outside Consumption Permit?: Yes XX No Disclosure of Non-profit Organization?: Yes XX No ALL APPLICANTS MUST COMPLETE AND SIGN The applicant understands and agrees that the Liquor Control Board may obtain criminal history record information from State and Federal record repositories. I/We hereby certify, under the pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan approved by the Caanissioner of Taxes to pay any and all taxes due the State of Vermont as of the date of this application. (VSA, Title 32, Section 3113) I/We hereby certify that I/We are not under an obligation to pay child support or that I/We are in good standing with respect to child support or are in full compliance with a plan to pay any and all child support payable under a support order. (VSA, Title 15, Section 795) In accordance with 21 VSA, Section 1378(b), I/We certify, under pains and penalties of perjury, that I/We are in good standing with respect to or in full compliance with a plan to pay any and all contributions or payments in lieu of contributions due to the Department of Employment and Training. I/We have registered the trade name of these premises with the Secretary of State. Continued on next page • 2012 LIQUOR LICENSE RENEWAL APPLICATION 4294-002-1RST-01 FIRST CLASS RESTAURANT LICENSE TO SELL MALT AND VINOUS BEVERAGES Page 2 I/We hereby certify that the information in this application is true and complete.Dated at So v N) PA)r\`,v)t{¢6)t 1 , in the county of L/t/), T y P N i/P 11, and State of ✓C Y WI Q,l 7L this i 1-1-- day of h e hrod , I Si t of authorized agent Signature of individual or partners of corpora ion company, club or association CraAr ... (Title) Are you making this application for the benefit of any other party? Yes ,/ O Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the commissioners will endorse their recamiendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual cc m issioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of - - ity or l.wn o (/t1Jf Total Membership `J" members present Attest $f� 1 F4 i_Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control commissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a first or second class license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 'zH- 2012 TOBACCO LICENSE RENEWAL APPLICATION 7413-001-TOBC-01 TOBACCO LICENSE TO SELL TOBACCO Page 2 Upon being satisfied that the conditions precedent to the granting of this license as provided in Title 7 of the Vermont Statutes Annotated, as amended, have been fully met by the applicant, the consnissioners will endorse their recatsnendation on the back of the applications and transmit both copies to the Liquor Control Board for suitable action thereon, before any license may be granted. For the information of the Liquor Control Control Board, all applications shall carry the signature of each individual ccmni.ssioner registering either approval or disapproval. Lease or title must be recorded in town or city before issuance of license. APPROVED DISAPPROVED Approved by Board of Control Commissioners of e City or Town of 0, Total Membership _, members present Attst, c • ? C.\4 4To2n Clerk TOWN OR CITY CLERK SHALL MAIL APPROVED RENEWAL DIRECTLY TO: DEPARTMENT OF LIQUOR CONTROL 13 GREEN MOUNTAIN DRIVE MONTPELIER, VT 05602 If application is disapproved, local control catmissioners shall notify the applicant by letter. No formal action taken by any agency or authority of any town board of selectmen or city board of aldermen on a tobacco license application shall be considered binding except as taken or made at an open public meeting. VSA T-1,Sec.312 • CITY COUNCIL 14 MARCH 2012 The South Burlington City Council held a reorganizational meeting on Wednesday, 14 March 2012, at 6:00 p.m., in the Conference Room, City Hall, 575 Dorset St. Members Present: S. Dooley, P. Mackenzie, H. Riehle, P. Engels, R. Greco Also Present: S. Miller, City Manager; R. Rusten, Deputy City Manager; D.Kinville, City Clerk; J>Barlow, VLCT; B. Stuono, G. Maille 1. Election of Officers: Mr. Miller presided over the election of a City Council Chair. He opened the floor for nominations. Ms. Dooley nominated Ms. Greco. Ms. Riehle seconded. There were no further nominations, and Ms. Greco was elected unanimously. Ms. Greco presided over the remainder of the meeting. She opened the floor for nominations for Vice Chair. Ms. Dooley nominated Ms. Riehle. Mr. Engels seconded. There were no further nominations, and Ms. Riehle was elected unanimously. Ms. Riehle then nominated Ms. Mackenzie for Clerk. Mr. Engels seconded. There were no further nominations, and Ms. Mackenzie was elected unanimously. 2. Set dates and time for regular meeting from March 2012 through February 2013: Mr. Miller noted the changes in the regular meeting schedule to accommodate Monday holidays and other conflicts. Members then agreed to hold executive sessions at 5 pm and regular meetings at 6 p.m. Members also agreed to schedule 2 meetings a month during the summer and to cancel one of the meetings if it is not needed. 3. Annual Appointments to be made by a majority of City Council pursuant to City Charter, Chapter 13, Section 301(2): Mr. Engels questioned the combined position of City Clerk/City Treasurer and noted that the city auditor had said these positions should not be held by the same person based on the job descriptions. Mr. Miller noted the issue had been the job descriptions and suggested having revised job descriptions and then making a decision as to whom to appoint. He added that he would review this with the auditor and will suggest possible staffing options. CITY COUNCIL 14 MARCH 2012 PAGE 2 Ms. Kinville said she had a conversation with the auditor and went over his concerns. He indicated to her that it wasn't clear which position a task applied to. He also suggested a different person go to the bank with deposits. Ms. Kinville also noted that if the positions were held be different people, there is a question as to who would be collecting taxes, since her staff is the only staff there. Mr. Miller recommended holding off on appointing an Assistant Treasurer as well. Ms. Greco then read the list of appointments as follows: City Attorney: Stitzel & Page Zoning Administrator Ray Belair Assistant Zoning Administrator Cathyann LaRose Auditor RHR Smith& Company First Constable Sgt. Paul Edwards Second Constable Sgt. Andrew Chaulk Grand Juror Sanford Miller City Agent & Trustee of Public Funds Sanford Miller Ms. Dooley moved to appoint the list of appointments as presented. Ms Riehle seconded. Motion passed unanimously. Mr. Miller said he would aim for the meeting on 2 April for a draft of the Treasurer's job description. 4. Designate Official Paper of Record: Mr. Miller advised that the current official paper is The Other Paper with Seven Days and the Burlington Free Press as back-up. He said the city is very happy with this arrangement. Ms. Riehle moved to designate The Other Paper as official paper of record with Seven Days and The Burlington Free Press as back-ups. Mr. Engels seconded. Motion passed unanimously. 5.Designate Official Depositories Mr. Miller said the official depository is now the Merchants Bank, and they are outstanding to work with. Ms. Riehle moved to designate the Merchants Bank as official depository. Ms. Mackenzie seconded. Motion passed unanimously. CITY COUNCIL 14 MARCH 2012 PAGE 3 6. Training for City Council: Mr. Barlow reviewed what the Vermont League of Cities and Towns (VLCT) does, including providing insurances (liability,health, Workers Compensation, etc.), representing the interests of municipalities at the State House, and providing a municipal assistance center. Mr. Barlow explained that the town is the basic statutory model with at least 16 elected officers. A select board (city council) fills all of the roles of the executive, legislative and quasi-judicial. Their responsibilities include public safety, public works, highways, etc., basically everything that isn't assigned to anyone else. Mr. Barlow commented that this model doesn't"scale"well from the perspectives of time, expertise, perspective, resources, and administrative support. To solve this,many municipalities of all sizes have gone to a"municipal manager" form of government. Fifty-two municipalities in the State of Vermont have municipal managers; of these, South Burlington is the second largest. About half the people in the state live in a municipality with a manager. The City Manager reports to the City Council, and it is the City Council's responsibility to see that the City Manager carries out his/her responsibilities. Mr. Barlow then addressed the difference between"what is management and what is policy?" He said that policy issues include: should Police use tasers, should there be a local option tax, should certain services be shared with another community, should there be new facilities, are there conflicts of interest, etc. Management includes all accounting,budget preparation, enforcement of ordinances, etc. The City Manager has the authority to delegate responsibilities. A city manager can be removed from his position with 90 days written notice. Mr. Barlow said the key to functioning successfully with this model is communication, both formal and informal. He stressed the importance of having an annual work plan and an annual evaluation of the City Manager by the City Council. He also commented that the South Burlington City Charter is among the best written charters in the State of Vermont. Mr. Barlow then addressed the issue of meetings and the open meeting law. He stressed that meetings "in the public" are different from "meetings of the public." He advised that rules of procedure for running meetings be developed. Mr. Barlow then addressed the open meeting law. He said that a meeting is defined as a quorum of the members of a pubic body for the purpose of discussing the business of the public body or for the purpose of taking an action. Ms. Greco asked if a quorum of Council members can go out to dinner together. Mr. Barlow said they can. Mr. Miller noted the issue of what the public CITY COUNCIL 14 MARCH 2012 PAGE 4 perceives. Mr. Barlow said members should "err on the side of caution" Mr. Barlow noted that any committee or board that is appointed is also a public body and is also subject to the open meeting law. Such meetings must be warned and minutes must be taken. All meetings must be open to the public at all times except: 1. Site inspections for tax appeals 2. Routine day to day administrative matters that do not require action by the public body(this does not apply to South Burlington) 3. Deliberations in conjunction with quasi-judicial proceedings (a case in which the legal rights of person/persons are being adjudicated and which will result in a written decision which is appealable. 4. Grievances/personnel matters 5. Tax appeal hearings 6. Vicious dog hearings. With regard to executive sessions, Mr. Barlow noted that a motion is needed to go into an executive session. The motion must include the nature of the business, and only that business may be discussed. Any vote which results from an executive session must be recorded in minutes. No action may be taken in an executive session (a straw vote is OK, but is not binding) except for actions to secure real estate options. Other topics which may be discussed in executive session include: contracts, arbitration, labor relations, appointments, evaluations of a public officer or employee„ disciplinary or dismissal action against a public officer or employee, civil actions,mediations, prosecutions or situations of clear, imminent peril to public safety, and discussion or consideration of records or documents (communications from an attorney) where premature general public knowledge would place the state,municipality or other public body or person involved at a substantial disadvantage. Mr. Barlow said a good rule is if there is doubt about going into executive session, stay out. Mr. Barlow advised caution in the use of e-mail. A meeting can be conducted by audio conference or other electronic means. E-mail should be used to disseminate information, not for discussion or decision making. E-mail is a public record. A city council meeting is not a town meeting. At a city council meeting the public should have a reasonable opportunity to express its opinions as long as order is maintained. Mr. Barlow noted that only 2 pages of Roberts Rules apply to small boards such as city councils. VLCT has a model or rules for small meeting procedures. Mr. Maille asked how something gets on an agenda. Mr. Barlow said that can be decided by the City Council. Ms. Dooley asked if everyone who comes to a public hearing should be offered CITY COUNCIL 14 MARCH 2012 PAGE 5 the opportunity to speak. Mr. Barlow said it is the council's responsibility to foster public participation at some time. Limits can be set(e.g., no one speaks twice till everyone has spoken once). He added that no one has constitutional right without limitation at a City Council meeting. Ms. Mackenzie said she felt the public has the right to know the rules up front. Ms. Greco asked about non-residents speaking. Mr. Engels added these are non-resident tax- payers. Mr. Barlow said there is no rule for that. He felt the council needs to be sensitive to it. There is no rule that says non-residents can't speak. Mr. Engels said he went to Jim Condos' "transparency"meeting at which Allan Gilbert said an executive session shouldn't be in the public warning. Mr. Barlow said the warning puts the public on notice to expect the executive session. There is nothing unlawful about that. Mr. Rusten asked about"daisy chaining" among City Council members. Mr. Barlow said there is nothing that says serial conversations equal a meeting. Ms. Greco asked about"consent agendas." Mr. Miller said non-controversial items can be grouped together to save time. He said staff can do that if the council wishes. Mr. Barlow then addressed the issue of public records He noted that if a person requests a public record, he/she must get action. The courts will view this very liberally in favor of disclosure. If the records aren't produced, the city must also pay the attorney's fees of the applicant for the records. There are also fines and jail sentences for the destroying a public document. Mr. Barlow stressed that this is a very broad net. Mr. Barlow stressed that there are no location limits to public records, including home computers, laptops,portable electronic devices, e-mail, etc. If something is produced in the course of public agency business, even if it is not produced or acquired as a result of an official action, it is a public document, even if it is produced or acquired away from the municipal office. Mr. Barlow did note that there are 39 general exemptions from the designation of public records for things that can be designated as"confidential." Mr. Barlow noted there are guidelines for the handling of public records. Trevor Lewis of VSARA can assist municipal in the managing of public records. He said the best advice is to err on the side of caution. Warn members of the public that e-mail discussions may be a public record. Mr. Rusten questioned whether notes a councilor takes at a meeting are public record. Mr. Barlow said the wisdom is that they are not. Mr. Miller added that if these notes are retained, CITY COUNCIL 14 MARCH 2012 PAGE 6 they may be subject to disclosure. 7. Discuss possible dates for Council review of Interim Zoning applications: Mr. Miller noted there are 4 applications now. He felt that after next Monday's training the Council will be prepared to hear those applications. He recommended doing 2 at a time at a supplemental meeting. He also recommended developing rules of procedure for these hearings. 8. Other Business: Mr. Miller noted that an e-mail sent by Rick Hubbard urged members of 2 communities to attend the next Council meeting as "complete streets"could be on that agenda. He felt the tone of the e- mail made it feel that the City Council was being"hi-jacked." Mr. Miller noted that Justin Rabidoux does have additional information regarding other projects and costs that may be incurred. He also noted that the city doesn't yet have the cost of studies which would determine if an experiment should be continued. He added that the Regional Planning Commission/MPO has said that estimates regarding the Colchester Avenue project were greatly understated. Ms. Greco agreed to talk personally with Rick Hubbard, and Mr. Miller will deal with the Front Porch Forum message. 9. Executive Session: Ms. Mackenzie moved that the Council meet in executive session to discuss personnel, contract negotiations and litigation. Ms. Riehle seconded. Motion passed unanimously. 10. Regular Session: Council returned to regular session. As there was no further business Ms. Greco moved for Council adjournment. Mr. Engels seconded. Motion passed unanimously. Council adjourned. Clerk CITY COUNCIL 19 MARCH 2012 The South Burlington City Council held a regular meeting on Monday, 19 March 2012, at 5:00 p.m.,in the Conference Room, City Hall, 575 Dorset St. Councilors Present: R. Greco, P. Mackenzie, H. Riehle, P. Engels, S. Dooley Also Present: S. Miller, City Manager; R. Rusten, Deputy City Manager; P. Conner, Director of Planning& Zoning; J. Rabidoux, Public Works Director; T. Barritt, B. Stuono, M. Behr, • Development Review Board; G. Baxter, VLCT; J.Dinklage, R. Hubbard, L. Bresee, M. Emery, L. Ravin, S. Dopp, E. Goldberg, M. Young, J. Floyd, M. Conner, M. Mittag, M. Townsend 1. Executive Session: Ms. Riehle moved the Council meet in executive session to discuss personnel, contract negotiations, and litigation. Mr. Engels seconded. Motion passed unanimously. Regular Session: Ms. Mackenzie moved the Council exit executive session. Ms. Riehle seconded. Motion passed unanimously. 1. Agenda Review: No changes were made. 2. Comments & Questions from the audience not related to Agenda items: No issues were raised. 3.Announcements & City Manager's Report: Mr. Miller reported on attending a legislative breakfast at which the Lt. Governor and others reported on health insurance, tax policy, and other issues. The School District will be organizing the city's next legislative breakfast scheduled for 2 April Mr. Miller will attend the VLCT Board meeting on 22 March. Mr. Engels advised that last Thursday he met with the Eastwood Commons Condo Association. He commented that it is a great idea t talk with people in neighborhood associations. They feel a distance from city government and expressed issues with traffic and green space. Mr. Engels also attended the Shelburne Rd. Corridor Study meeting. He felt it was an excellent CITY COUNCIL 19 MARCH 2012 PAGE 2 brainstorming sessions with very thoughtful people and good input. Mr. Engels also attended the CCTV Channel 17 advisory board meeting of which Ms. Emery is chair. She will remain as chair and Mr. Engels will serve as alternate. He noted that the city is allotted about 84 programs during the year. Last year, the city left 11 of these unused. He felt things such as budget meetings could have been televised and that the meeting schedule should be checked to be sure the city takes full advantage of these opportunities. 4. City Council Training re: Acting as a Deliberative Body in Reviewing Interim Bylaw Applications: Mr. Baxter explained that the City Council will become a quasi-judicial board for land use hearings. In this capacity they will interpret and apply land use regulations to specific applications. The parties involved in the application can present evidence and the Council can cross-examine the witnesses. The Council must then issue a written decision which is appealable. Mr. Baxter stressed that opinions must not affect the decision making process. The Council must determine compliance with applicable by-laws and state law, levy only conditions authorized by by-laws and state law, and grant approvals to projects that meet the applicable by- laws and state law. Interim Bylaw applications differ from other hearings in that the City Council acts much like a court. There are specific statutory notice requirements (the applicant can be asked to pay for notice to newspapers and to abutting property owners), and the hearings are about the parties (the applicant and interested parties). The hearings result in a written decision which may be appealed to the Environmental Court. Mr. Baxter noted the difference between"interest persons" and"persons who are interested. Interested persons include the landowner(s), the municipality that has a bylaw at issue, those persons owning property in the immediate neighborhood, any group of 10 voters/property owners who allege the permit will not be in accordance with the bylaws, and an agency of the State if it owns property in the community, and the Agency of Commerce and Community Development. Mr. Baxter stressed that protecting due process is critical and that there must be fair and impartial decision making free from conflict of interest. Similarly situated applicants must be treated the same. There must also be rules of procedure and rules of ethics. Mr. Baxter also stressed that the parties involved must have the opportunity to present testimony and evidence to an impartial and unbiased decision maker. For oral evidence, a record must be kept of who spoke and what was said. Use of a tape recorder is allowed as are written notes. CITY COUNCIL 19 MARCH 2012 PAGE 3 Mr. Baxter then addressed conflicts of interest. He noted that these may include direct or indirect financial interests and direct or indirect personal interests. Conflicts of interest should be identified and conflict declared. The person with the conflict must then state whether he/she can act in an unbiased manner. The test should be whether"a reasonable person would believe that a conflict exists." If the answer is yes, then that person should recuse him/herself from the decision making process. Mr. Baxter also noted that prejudice or bias is any"inclination that inhibits impartial judgment." The focus must be on a fair and consistent hearing, the fundamental objective of which is to determine whether the application meets the requirements set forth in the provisions of zoning or subdivision bylaw or might do so with reasonable conditions." Mr. Baxter then addressed the issue of ex parte communication. He defined this as direct or indirect communication between a board member and any party, party's representative, party's counsel or any person interested in the outcome of any quasi-judicial proceeding which occurs outside the proceeding and concerns the substance or merits of the proceeding. The key to managing this is disclosure. Any such communication should be disclosed and noted in the minutes and provided to all parties to the proceeding. Discussion and consideration of recusal should follow and be recorded. Mr. Baxter cautioned the Council to err on the side of caution. Mr. Baxter next reviewed exemptions to interim bylaws including: alterations to single and 2- family dwellings, alterations to existing structures used for commercial or industrial purposes that don't increase square footage or building footprint, development for which there is a Master Plan; development on property currently involved in litigation, amendments to site plans involving a principal permitted use, PUDs or an approved conditional use if meeting one or more of certain criteria, and amendments to site plans involving enlarging of an existing building used for commercial or industrial purposes if the proposed amendment meets certain criteria. The standard of review shall consist of a finding by the City Council that a proposed use is consistent with the health, safety and welfare of the City and shall not result in an"undue adverse effect" on any of the following: 1. The capacity of existing planned community facilities, services or lands 2. The existing patterns and uses of development in the area 3. Traffic on roads and highways in the vicinity 4. Environmental limitations of the site or area and significant natural resource areas and sites 5. Utilization of renewable energy resources 6. Municipal plans and other municipal bylaws, ordinances or regulations in effect. CITY COUNCIL 19 MARCH 2012 PAGE 4 Mr. Baxter then addressed the terms "adverse" and"undue." He noted that an impact is "adverse"when it is not in harmony with its surroundings and does not fit the context within which it will be located. An"adverse impact"is "undue"if the project violates a clear, written community standard intended to preserve the aesthetics or scenic natural beauty of the area; or if the project, when viewed as a whole, offends the sensibilities of the average person; or if the applicant fails to take generally available mitigating steps to improve the harmony of the project with its surroundings. Mr. Baxter then addressed the hearing process, including the roles of those involved in the hearing. He stressed the need to steer clear of"personalities" and history, including prior violations. These cannot be addressed at a hearing. The order of the proceeding should be as follows: 1. Request for presentation by the applicant 2. Questions from the City Council 3. Evidence from the public and response from applicant 4. Additional City Council questions 5. Final comments 6. Close of hearing. Mr. Baxter's presentation was interrupted at this time for a scheduled public hearing. 5. Public Hearing on Amendments to the Land Development Regulations: Mr. Conner noted these amendments had been inadvertently left off the last package of amendments considered by the City Council. However, there was an error in the public hearing announcements (an e-mail got lost in transit), so the warning is defective. Mr. Conner therefore asked the Council to postpone this hearing to 16 April to allow for full public knowledge. Ms. Dooley moved to open the public hearing. Ms. Riehle seconded. Motion passed unanimously. Ms. Mackenzie then moved to continue the public hearing until 16 April 2012. Ms. Riehle seconded. Motion passed unanimously. Mr. Baxter's presentation was then continued as follows. CITY COUNCIL 19 MARCH 2012 PAGE 5 The City Council serves as both judge and jury in interim zoning hearings. They may ask factual questions which must be relevant to the application and to the bylaws. Councilors should not answer their own questions. The Council has 45 days from the close of a hearing to make a decision. Failure to issue a written decision within that time results in the application being approved. Should this occur, the Council should still render a written decision. The appeal time of a decision is 30 days from the date of the written decision. Mr. Baxter recommended that the Council deliberate in private. A deliberative decision need not be warned and no minutes are needed. Three votes (for or against) are required for a decision. Mr. Baxter cautioned against giving applicants an oral decision at the end of a hearing. The decision must indicate how the decision was arrived at, and the applicant must be given the appeal procedure. Decisions should be sent to the applicant via certified mail and to other interested parties by regular mail. Mr. Conner noted there will be both City Council and Development Review Board hearings, and a zoning permit may be issued only if both boards approve an application. Mr. Engels asked if the DRB ever has split decisions. Mr. Stuono said it is rare but it does happen. Ms. Dooley asked if the DRB uses deliberative sessions. Mr. Stuono said this is also uncommon. Ms. Riehle asked who can be present at a deliberative session. Mr. Baxter said that in addition to the City Council there can be staff and legal counsel. Mr. Engels asked who drafts DRB decisions. Mr. Connor said it is a combination of himself, Ray Belair and Cathy LaRose. Mr. Miller said the Council can ask staff to draft a decision for them. Mr. Stuono noted that using the"undue adverse impact" criteria is very challenging. Mr. Baxter suggested the City Attorney may be helpful in this regard. 6. Interim Zoning Bylaw- Report on Studies and Committees: A. Economic Analyses and Steering Committee B. Sustainable Agriculture C. Affordable Housing With regard to the economic analyses, Mr. Miller said that for each of the study elements they CITY COUNCIL 19 MARCH 2012 PAGE 6 have identified at least one firm interested in pursuing the study. Prices range from$7500 (which would involve considerable staff assistance)to $60,000. Mr. Miller noted there is probably not a lot of staff assistance available with current staffing. Mr. Miller asked the Council if they want to proceed with studies and whether RFPs should be issued. He noted that the firms that responses anticipated an RFP process. If RFPs are to be issued, this should be done in the next few weeks in order to expect a response by early May. Ms. Mackenzie asked what is the risk of not utilizing an RFP. Mr. Miller said the city might not be able to negotiate successfully with a firm. Mr. Rusten also noted that they had asked for a broad scope of costs, and there may be a higher or lower figure. You also don't have a fair comparison between companies without an RFP. Ms. Dooley asked if it is clear whether the city will need more assistance. She said she was uncomfortable dealing with this piecemeal. Mr. Miller said he felt there is a need for at least 3 more studies (form-based codes, affordable housing, etc.). Mr. Engels said he didn't think they should wait on the RFP until they can do everything. Mr. Miller cited the need for additional Council meetings to work all of this out, including additional staff resources. He stressed that they are already short staffed and need additional resources now. He recommended the Council meet every Monday for the next few months at least, as this is too much for regular meetings. He added that getting the RFPs out will take a few weeks and he would report back by 7 April that they are going out. Mr. Rusten said the question where the money for all of these studies is going to come from. Mr. Dinklage suggested it would be prudent to decide how much staff the city is willing to contribute before they do an RFP. Ms. Goldberg asked what the Council has allotted for studies and the costs of interim zoning. She said she has heard nothing about the cost of all of this. Mr. Miller said staff identified an estimated cost of one cent on the tax rate or about $280,000. The City Council did not identify any cost for this work. City Council consensus was to issue the RFP. Ms. Mackenzie said the Council will also need an estimate of staff time. Mr. Miller said they won't know the full scope until RFPs are received, but they do know some of the needs already. Ms. Riehle asked if the RFP could include the limited amount of staff time available. Mr. Miller suggested asking for quotes with 3 different levels of staff support. CITY COUNCIL 19 MARCH 2012 PAGE 7 Regarding sustainable agriculture, Ms. Greco said there are 31 organizations and individuals willing to partner with the city on this. Staff assistance will have to be determined. Mr. Miller reviewed Mr. Knapp's response regarding affordable housing. It will take to the beginning of April to put together the particulars. A number of individuals have expressed willingness to serve. The study will include looking at the demand for various types of housing and at financial institutions that are funding the purchase of homes. Members then reviewed a basic outline of the studies and study groups (staffing and financing) related to interim zoning. These include: 1. Economic Analysis Studies: a. Economic analysis of interim zoning (financial impact on city budget and on citizens, residents and businesses in the city b. Economic analysis on the cost of development in terms of cost of city services c. economic analysis of the costs of all services and infrastructure (including maintenance, upgrades, etc.) based on total build-out now allowed under land development regulations d. economic analysis of associated costs of pollution mitigation and environmental cleanup (air, water, land) resulting from build-out allowed under current land development regulations. 2, 3 &4. Sustainable Agriculture Committee; Affordable Housing Committee, and Form Based Codes: a. studies to be completed as required under interim zoning b. update of regulations c. additional non-regulatory studies to be completed d. possible need for consultants to committee 5. Planning & Zoning Department: a. Project review: application administration, project staff review and Council notes, preparation of Council decision, appeals management b. Committee and project oversight(RFP preparation and management,management of consultants, review of studies, management of public process, project mapping and data analysis, implementation CITY COUNCIL 19 MARCH 2012 PAGE 8 6. City Council: a. finalize goals and activities of subcommittees and steering committee b. determine required studies c. review and possibly approve additional staffing needs d. review and approve subcommittee needs re: consultants e. review staff recommendations and possibly approve location of money to fund interim zoning 7. Consider Complete Streets Proposal: Ms. Greco reviewed the background including a study done by a consultant focusing on"livable streets." Mr. Miller noted that one issue that arose is how the city might evaluate the process if it goes ahead with the experiment. He added there are no funds in the FY13 budget for this. Mr. Rabidoux said the aim is to try to take advantage of the state's paving project to see if a "complete streets" concept can work on Williston Rd. east of Hinesburg Rd. Feedback will be needed by the end of March to get"no cost" changes in the paving project. Mr. Rabidoux noted that testimony of staff and the Regional Planning Commission is that this project will induce increased congestion. One option is to implement the experiment and observe what happens and to assess the public level of tolerance of the increased congestion. Anticipated problems include people becoming frustrated with the congestion and going off Williston Road into the residential side streets and affecting the quality of life and the safety of children on these streets. Mr. Rabidoux noted that this project has been compared to the Burlington project on Colchester Avenue. However, in Burlington there were far fewer side streets involved. Mr. Rabidoux proposed that if the Council decides to implement this, they could direct staff to come back with a proposal as to how to measure the results (this would be done in conjunction with the City of Burlington, Local Motion, etc.). Mr. Engels asked about business on Williston Road and whether anyone has talked to them. Mr. Rabidoux said they can do some direct solicitation. CITY COUNCIL 19 MARCH 2012 PAGE 9 Mr. Engels observed that the thought of 4 lanes ending at Hinesburg Road and going into one lane is "frightening." Mr. Rabidoux noted there is no dedicated space for left turners at Hinesburg Rd. Ms. Mackenzie asked if a"flushed out process"is brought back to the Council, can the Council say no. Mr. Rabidoux said they can,but depending on the timing, there could be a cost to a change order. Mr. Engels asked what happens if it is an obvious failure in 2 months. Mr. Rabidoux said they would do this before a top course is put on. Mr. Engels noted that the consultant does not recommend this course of action. Mr. Rabidoux acknowledged it will induce congestion,but there are also quality of life issues. Mr. Engels also noted that everything the Council has heard has been from one advocacy group. He said this is one of the two main traffic corridors in Chittenden County. Ms. Dooley said it sounds like ideal conditions for a test. Ms. Riehle moved to go forward with the pilot. Ms. Dooley seconded. Public comment was then solicited: A resident of Myers Court was concerned his street will be the "backup street," and there are families with kids. Ms. Dooley said it is a good idea to try it. They will have to gauge the reaction of everyone involved. She suggested possibly surveying people through the Other Paper. Ms. Townsend was concerned with the Airport/White Street/Airport Parkway/Patchen Road neighborhood which already has problems. Ms. Conner supported the pilot. A Burlington resident said people need to use other means to get around. He felt there would be more people walking and biking. Mr. Mittag supported the experiment. CITY COUNCL 19 MARCH 2012 PAGE 10 Ms. Ravin said she prefers not to use her car to access Williston Rd. She encouraged people to find an alternative to "one person/one car." Ms. Emery said people from the potential "cut through" streets contacted her via Front Porch Forum to express concern with giving consideration to Chamberlin neighborhood. She said this is the most vulnerable neighborhood for"cut throughs," and it is a neighborhood with a"Safe Routes to School"initiative with children walking and biking. She felt CCTA should be brought into the discussion because if there are backups,buses will also be backed up. She stressed that painting lines on a road does not insure safety. Buses will be cutting into bike lanes to pick up and drop off passengers putting bikers at risk. She wanted to see a designated bus lane and something to protect bikes. Mr. Floyd noted that the route to Essex Junction was made"more civilized"by last year's project. He saw the possibility of such a line of cars that people won't be able to get out of Mayfair Park. But he still wanted to try it. Mr. Hubbard said the Rec Path Committee supports this. He understood there will be negative affects but also possible advantages. The purpose is to see if the advantages outweigh problems. He noted there are now no pedestrian crossings from Hinesburg Rd. on. He noted that the Rec Path Committee is willing to work with Justin Rabidoux to help get good evidence on which to base a decision. Dr. Luria said that from a health standpoint it is important to encourage other ways to get around. Mr. Young asked whether the city has the money if this doesn't work. He noted the city is just getting out of a situation where it spent money it didn't have. He felt people will be making turns and not knowing where they are going and using driveways to turn around to find another route. He also asked what will happen to cyclists when they have to go from Hinesburg Rd. to Dorset Street. A show of hands in the audience revealed overwhelming support for the pilot. In the vote that followed, the motion passed 4-1 with Mr. Engels voting against. 8. Consider Authorizing Re-financing of a Stormwater Mitigation Grant Application Note for$200,000: Mr. Miller asked to table this item. CITY COUNCIL 19 MARCH 2012 PAGE 11 9. Consideration of Approval of Entertainment Permits: Mr. Miller presented an entertainment permit application from Magic Hat Brewing Co. for three events: a benefit concert for Big Heavy World(19 May), an Urban Arts Competition (25 August), and a free community concert (14 July), and the annual entertainment permit of Franny O's. Ms. Mackenzie moved to approve the entertainment permits as presented. Ms. Riehle seconded. Motion passed unanimously. 10. Liquor Control Board: Ms. Dooley moved the Council convene as Liquor Control Board. Ms. MacKenzie seconded. Motion passed unanimously. Mr. Miller presented 2012-2013 annual liquor and/or tobacco license renewals from the following: Burlington Moose Lodge#1618 Doubletree Hotel Franny O's Gracey's Store Gracey's Liquor Store Hannaford Food & Drug Healthy Living Hong Kong Jade Chinese Restaurant Interstate Shell Kinney Drugs Night Flight, Inc. Maplefield's @ Airport Mill Market&Deli Short Stop#104 Uno's Restaurant Van Phan Sports Vermont National Golf Course Vermont Sportsgrill Walgreen's #11526 Waterfront Catering Group CITY COUNCIL 19 MARCH 2012 PAGE 12 Ms. Mackenzie moved to approve the renewals as presented. Mr. Engels commented that he is not thrilled with approving tobacco licenses,but he wasn't sure the Council has the right not to. Mr. Miller said he would research this. Mr. Engels also noted he has been told some places sell alcohol and/or tobacco products to minors. Mr. Miller said if Mr. Engels or anyone else knows specifics of this to let him know and staff will pass the information along to the state. In the vote that followed, the motion passed unanimously. Ms. Mackenzie moved to adjourn as Liquor Control Board and reconvene as City Council. Mr. Engels seconded. Motion passed unanimously. 11. Consider use of Consent Agenda as part of City Council Agenda: Mr. Miller said this could be done for non-controversial items such as Minutes or warrants. An item could be taken off a consent agenda by request. Members were OK with trying this. 12. Consider Dates to Review Development Applications Subject to Interim Bylaw: Mr. Miller drew attention to warning requirements. He said the Council will need to determine procedures,policies, etc., prior to holding application reviews. He suggested special meetings on 26 March, 9 April, 30 April and 14 May. 13. Sign Disbursements: Disbursement orders were signed. 14. Other Business: No issues were raised. 15. Review and Approve Minutes of 21 February and 5 March 2012: It was noted that in the minutes of 21 February, page 2, last paragraph, the figure should be 1.5%. On page 8, paragraph 6, the word"con" should read"can." Ms. Riehle moved to approve the Minutes of 21 February as amended. Ms. Mackenzie CITY COUNCIL 19 MARCH 2012 PAGE 13 seconded. Motion passed unanimously. Mr. Engels moved to approve the Minutes of 5 March as written. Ms. Riehle seconded. Motion passed unanimously. As there was no further business to come before the Council, the meeting was adjourned at 9:30 p.m. Clerk .11 9!? *sea Fl 4 '2 w^.t 7.414 d.�r�} ,q VERMONT ENTERTAINMENT LICENSE APPLICATION Type of Application f( Annual Permit Date of Application: T . i Z ❑ Special Event Permit Name of Establishment: ►c30N 2ouv.1 Address of Establishment: [ u. STan} ' D ova-\<\ VT- 0S'4O3 Name Owner: k F\I i R _ i14r( t tZ- Address of Owner: 502 ACC 1J t; WA T -(ERkA42y VT 0907(0 Name of Operator: SAME Address of Operator: S-Prm Complete Description of Show: U V E M U S i C CO I(CG�l-S , CO Y71EI6V St-toc,L-5 , t�J ‘5 L7PKNCe-Pn4411E5 i PeitPta-ice l/t(\fun° S T\ FUC-1�l1'S Date(s) of Show and Hour(s) of Operation: Date(s): (Y1bN-SU.tJ (ONL-q OPEN 1)rA`15‘ •TtfP-T Pc St-{ou-') tS SC{-tcOLcLC Hours(s): M - 1✓ 6 PM - 2AM, ) 5 - S ►2 NaoN -2k \, Security Provisions: iN& ygpVt 6E 1 cEC.twiT'-) EU&.v Q{ T12(AS . Wirt{ pc ) 1n t^HEc_i 0i"t Nr -tLoNr ibisR- _ As applicant,I have read and understand the provision of the South Burlington Ordinance Regarding Licensure of Regulation of Circuses, Carnivals and Other Shows. I also understand that only the specific type of entertainment applied for in this license is permitted and that additional types of entertainment will require an addition l pplication. Applicant's Signature: Date: a/ I /2---- " iA/ -/4= Mi,lu`� 1®� �'rI �1 mix v. �'1 E! i.i t' a c ! >c ,�n ' NI ,x), Pam,' r . i..' 4v ix 4�ki;,jF VERMONT ENTERTAINMENT LICENSE APPLICATION Type of Application V'Annual Permit Date of Application: L (-7.--1, 117 i ❑ Special Event Permit Name of Establishment: 6 V-C.ea-kb ,- , C u-C Vt e"--e6 v k � r__1_., Address of Establishment: -1 0 LAY, cV,,1-A (2-- -e... 0 d ^VL \i„ w< ; ,>%-- 0<21 D3 Name Owner: - ` IA) C - :,.-eNt '---1-c--- ),,z-) Address of Owner: 5-6 5' F , , .0 L�. Lam-- p,� / C --c-6, _L-;, &--i if c. c5d Name of Operator: 5LL c IN LC ,-.-- - (.9D-c— o Address of Operator: '1 Q W) V L `�� 4) — 4\ ._. 4) 0-)8/L. A u._< , A--1) / Complete Description of Show: li`^V • Z- , 1 V v-. c 4 at L0 t ,� IM V(j Date(s) of Show and Hour(s) of Operation: f 1 / t - Date(s): J U L 1�..A--W i ,--r] L 1. nip, -5`-) `\ U-�-- a 0411 c Hours(s): 1D4- K CA)D D . k , �— ' V-Os Security Provisions: W.A. \ �--t, 0 uk i, y t ( a"�c-.i/.__IA l3 L, L uc..."S"-A\ri ---S—o c .--o-,\ As applicant,I have read and understand the provision of the South Burlington Ordinance Regarding Licensure of Regulation of Circuses, Carnivals and Other Shows. I also understand that only the specific type of entertainment applied for in this license is permitted and that additional types of entertainment will require a al appF catio,_ Applicant's Signature: Date: 1 /r/21 2 City of South Burlington Ott® City Clerk's Office Donna Kinville, City Clerk SPECIAL EVENT(ENTERTAINMENT) OR CATERING PERMIT D ) 191O'1 �J arPC/'‘ FULL NAME OF PERSON, PARTNERSHIP OR CORPORATION: tom ►-r� i,�� c kU rck- CONTACT PHONE NUMBER OR E-MAIL: (y,tbrYsct ADDRESS: DATE RECEIVED BY CLERK'S OFFICE: POLICE APPROVED: a ! , FIRE APPROVED: . DATE: ZONING APPROVED: DK, DATE: // 1/eV iO— RECREATION APPROVED: DATE: HIGHWAY/HEALTH DEPT APPROVED: , DATE:400Q0 CITY COUNCIL DATE: DATE SENT TO MONTPELIER: • "411 4' out t':(' 4 0113 'I 1111.14,f t,tt.01.1 P.: «It)). •• tk 9 VERMONT ',h., . ` ,t� ENTERTAINMENT LICENSE APPLICATION " , ' ' l� Type of Application 0 Annual Permit Date of Application: 3 - / 0Z - / c (42 Special Event Permit Name of Establishment: CV Oil Yh vyI (---7 Si2 b/c 014 i/v'L 4 tea- ac,3 --13 ? C. Address of Establishment: c>2 0 a. 5- lArt ( I C c'r--0 (4. eR C\ Ca ii Svr1; 15-"/kJ / lT o..c- /O 3 Name Owner: S44 _ qj f L c'VC- Address of Owner: S¢)/Y /‘3 q tk)(/'e_- Name of Operator: (D4i/(e.1 q bile vtt ---CjZ . 8-6'a -3 515--- S( co) Address of Operator: 55 AVM jj_ tirkw,--ivio / VT 7 qo Complete Description of Show: Ccy 5ti --R9 r 5 O •- ?'O egvS 0 /o f}- a fez r -( T , c" c; ( _c vv= �0 0C—�, s-�gf4 94 . v1 c y, c -tr,c cats-(vo ) / F N(es ccr-c-: -P c-i4.,/;4[es 1 1J0 //e to Date(s) of Show and Hour(s) of Operation: St1-vra,. �`, /(2 -f-h ao/a. Date(s): <5�-i-vy^dicy/ -'ul y 7 +11 o?r/a._ -j R., 1,1 k-1--� i Hours(s): 7 /4 Ai a ) /L'i SecurityProvisions: �� ^� C U , �v�� -Pca� � She�, / 1J..e.c�/�i�� l��C it c_ @cv4d ( --2vs Pc(-171(f As applicant, I have read and understand the provision of the South Burlington Ordinance Regarding Licensure of Regulation of Circuses, Carnivals and Other Shows. I also understand that only the specific type of entertainm t applied for in th' license is permitted and that additional types of entertainment will requi e a additional app c tion. Applicant's Si Date: ) - r D- - / D, e • Laura From: Trevor Whipple [twhipple@sbpdvt.org] Sent: Wednesday, March 14, 2012 11:33 AM To: Laura Subject: RE: Community Bible Church All set on this one. Trevor S.Whipple Chief of Police City of South Burlington 19 Gregory Drive South Burlington,VT 05403 (802)846-4155 twhipple(n sbpdvt.orq From: Laura [mailto:lkimball©sburl.com] Sent: Wednesday, March 14, 2012 11:26 AM To: Trevor Whipple; Justin Rabidoux; ray; Doug Brent Subject: Community Bible Church Hello all- They had this permit last year for a car show at 2025 Williston Rd. let me know if there are any issues. Laura Doug &Trevor-still waiting on the ok for ALS event Sunday, Sept. 23, 2012. fiq *too 4041040000.141* Laura Kimball Deputy City Clerk City of South Burlington 575 Dorset Street South Burlington,Vt. 05403 lkimball@sburl.com 1 • Laura From: Doug Brent Sent: Wednesday, March 14, 2012 4:23 PM To: Laura Subject: RE: Community Bible Church Laura -All OK with Fire debt for this event. Doug From: Laura Sent: Wed 3/14/2012 11:25 AM To: Trevor Whipple; Justin Rabidoux; ray; Doug Brent Subject: Community Bible Church Hello all- They had this permit last year for a car show at 2025 Williston Rd. let me know if there are any issues. Laura Doug&Trevor-still waiting on the ok for ALS event Sunday, Sept. 23, 2012. Laura Kimball Deputy City Clerk City of South Burlington 575 Dorset Street South Burlington, Vt. 05403 IkimballPsburl.com 1 Laura From: Justin Rabidoux Sent: Wednesday, March 14, 2012 11:27 AM To: Laura Subject: RE: Community Bible Church OK with me From: Laura Sent: Wednesday, March 14, 2012 11:26 AM To: Trevor Whipple; Justin Rabidoux; ray; Doug Brent Subject: Community Bible Church Hello all- They had this permit last year for a car show at 2025 Williston Rd. let me know if there are any issues. Laura Doug&Trevor-still waiting on the ok for ALS event Sunday, Sept. 23, 2012. 40 eq if Laura Kimball Deputy City Clerk City of South Burlington 575 Dorset Street South Burlington,Vt. 05403 lkimball@sburl.com 1 • ' Laura From: ray Sent: Monday, March 19, 2012 3:21 PM To: Laura Subject: RE: Community Bible Church No zoning issues. Ray Belair Administrative Officer City of So. Burlington 802-846-4106 From: Laura Sent: Wednesday, March 14, 2012 11:26 AM To: Trevor Whipple; Justin Rabidoux; ray; Doug Brent Subject: Community Bible Church Hello all- They had this permit last year for a car show at 2025 Williston Rd. let me know if there are any issues. Laura Doug&Trevor-still waiting on the ok for ALS event Sunday, Sept. 23, 2012. 4 t Arta Laura Kimball Deputy City Clerk City of South Burlington 575 Dorset Street South Burlington,Vt. 05403 Ikimball@sburl.com 1 :u, City of South Burlington ►O 0 City Clerk's Office VOTE - Donna Kinville, City Clerk a�� ,9 f9 f. SPECIAL EVENT(ENTERTAINMENT) OR CATERING PERMIT FULL NAME OF PERSON, PARTNERSHIP OR CORPORATION: )Orval OCi CONTACT PHONE NUMBER OR E-MAIL: ADDRESS: 5. -1.1acki .a--- DATE RECEIVED BY CLERK'S OFFICE: -q D1 POLICE APPROVED: DATE: 3'QA 7-p2U FIRE APPROVED: 107 / . DATE: .3c4/- 2Dia ZONING APPROVED: ‘X, DATE: aD SDI RECREATION APPROVED: —_ DATE: --� HIGHWAY/HEALTH DEPT APPROVED: O t , DATE: --16(--,c; Dle9' CITY COUNCIL DATE: O li-- DATE SENT TO MONTPELIER: nnn nnr A,nr ^Tr4,f .,*74'46:Y1 (3'dil*4411 h Pe,o1 3, p A ' k•NP VERMONT PERMIT APPLICATION FOR USE OF PUBLIC STREETS Date of Application: / ! Application#: Name of Group Requesting Permit: ‘Vulytecia---(As -- - Contact Person with Group: Group Name: jjOrkOntrl I A4 30e_ot.,4‘, - ( ° Contact Person: Address: I fA\LL4 Col-t(n IA) 14,01W\ 1/1AA- 01 Phone 4: Home: "Al 03, -71.S—?( ci)k- •g66 0-S-5 Description of Event(including Route, Time, Date): ck-6-11,-, VO r IA Calqus% Scr+ / • Estimated Number of Participants: I 1S Marshalling and Dispersal Areas in South Burlington: Sanitation Provided: (k)07A4L. Public Notice Provided: Route Marking Proposed: Y-QS. Public Safety Provided: j I0?,;"- N 41fQ (c -PA- 6,Q44AA-k CccD'i_AstIss\-otr\ (0--0 ct (Cb \obtr\ V11 .1/ Liability Insurance Provided: \TQS Signature of Applicant: Date: 1C3112— • National Multiple Sclerosis Society Greater New England Chapter Mr. Sanford Miller February 29,2012 City Manager 575 Dorset St. South Burlington,VT. 05403 Dear Mr.Miller, We will be holding our 2012 Green Mountain Getaway MS Bike Ride on August 11th and 12th,2012.This two day, 150 mile ride attracts 200 participants who take part to raise funds for Multiple Sclerosis.Multiple Sclerosis is a disease that has hit Vermont especially hard.Nearly 1 in every 400 Vermont residents has MS,a per capita rate that is about 70%higher than the nation as a whole.The funds we raise through special events such as the Green Mountain Getaway pay for our programs and services,in addition to funding research for a cure. Each day the ride will start and finish at the University of Vermont(Burlington) campus,where the riders will also overnight on Saturday.We respectfully ask permission from the City of South Burlington to use city roads for our annual two day event. Our cyclists will be passing through town on Saturday and Sunday between 8am—4pm. I have included route cue sheets for your review,and we will thoroughly mark the route and have police details where appropiate.Please let me know if there are additional steps,permits or permissions I must take to assure approval for the event. We operate a support team consisting of medical personnel,bicycle mechanics,and amateur(HAM)radio operators. Our lead HAM radio operator monitors all emergency radio frequencies,so that we can close or redirect our route should that become necessary. If we can have your permission,please fax or return one signed copy of this letter to me.Please feel free to call or email me if you have any questions or concerns.Thank you for your consideration and for your support.We greatly appreciate it Best Regards, Drew Davis E/ Logistics Manager �1 NMSS Greater New England Chapter , (w)781-693-5158 l� (f) 781-890-2089 / a ; ) Drew.davis@nmss.org *Signature: *Date: *Printed Name: 101A First Avenue Waltham MA 02451 tel+1 800 344 4867 fax+1 781 890 2089 www.MSnewengland.org DRAFT ( 1/28/2012 2012 Bike MS Green Mountain Getaway - Saturday 50 mile Net Control: Miles Direction Description Go Town: 0.0 R South on Spear St 0.0 S. Burlington 6.9 R Irish Hill Rd 6.9 Shelburne 8.5 S Cross Rt. 7 onto Bostwick Rd 1.6 10.3 BL Road turns left and becomes Greenbush Rd. 1.8 13.8 S REST Stop at the Old Lantern 3.5 Charlotte 19.7 BR Route 7 - Stay on shoulder 5.9 21.1 L Little Chicago Rd. 1.4 Ferrisburgh 22.0 L Botsford Rd 0.9 24.1 S Becomes Comfort Hill Rd - caution steep downhill 2.1 24.5 L Water St. - up short STEEP hill 0.4 Vergennes 24.6 R Main St. - Rt. 22A 0.1 25.0 R Panton Rd. 0.4 25.3 S REST STOP at Goodrich 0.3 25.6 L Main St. - Rt. 22A 0.3 25.9 L Water St. 0.3 26.2 R Comfort Hill Rd. 0.3 28.5 R Little Chicago Rd. 2.3 Ferrisburgh 29.4 L Rt. 7 0.9 33.6 R Old Hollow Rd 4.2 34.1 L Mount Philo Rd 0.5 34.5 BR Spear St. 0.4 Charlotte 41.9 S REST STOP in East Charlotte 7.4 51.9 L Finish at UVM 10.0 S. Burlington Route closes at 4:30PM DRAFT 1/28/2012 2012 Bike MS Green Mountain Getaway - Saturday 80 mile Net Control: Miles Direction Description Go Town: 0.0 R South on Spear St 0.0 S. Burlington 6.9 R Irish Hill Rd 6.9 Shelburne 8.5 S Cross Rt. 7 onto Bostwick Rd 1.6 10.3 BL Road turns left and becomes Greenbush Rd. 1.8 13.8 S REST Stop at the Old Lantern 3.5 Charlotte 19.7 BR Route 7 - Stay on shoulder 5.9 21.1 L Little Chicago Rd. 1.4 Ferrisburgh 22.0 L Botsford Rd 0.9 24.1 S Becomes Comfort Hill Rd - caution steep downhill 2.1 24.5 L Water St. - up short STEEP hill 0.4 Vergennes 24.6 R Main St. - Rt. 22A 0.1 25.0 R Panton Rd. 0.4 25.3 S REST STOP at Goodrich 0.3 29.3 BL Onto Jersey St. 4.0 Panton 29.8 R Pease Rd. 0.5 30.7 L Lake St. 0.9 36.6 S Rt. 17 5.9 Addison 38.5 R Cross Champlain Bridge 1.9 39.2 R LUNCH at Crown Point State Historic Area 0.7 Crown Point 39.2 L Cross Champlain Bridge 39.9 L Rt. 17 0.7 42.1 BR On Rt. 17 2.2 44.3 S Onto Jersey St. 2.2 45.4 R Goodrich Rd. - There is 0.8 miles of unpaved road 1.1 46.5 L Onto Jersey St. 1.1 Panton 50.2 R Panton Rd. 3.7 54.1 S REST STOP at Goodrich 3.9 Vergennes 54.4 L Main St. - Rt. 22A 0.3 54.7 L Water St. 0.3 55.0 R Comfort Hill Rd. 0.3 57.3 R Little Chicago Rd. 2.3 Ferrisburgh 58.2 L Rt. 7 0.9 62.4 R Old Hollow Rd 4.2 62.9 L Mount Philo Rd 0.5 63.3 BR Spear St. 0.4 Charlotte 70.7 S REST STOP in Charlotte 7.4 80.7 L Finish at UVM 10.0 S. Burlington L=Left, R=Right, X=Cross, S=Straight, B=Bear, @=at DRAFT • 1/28/2012 2012 Bike MS Green Mountain Getaway - Saturday 100 mile Net Control: Miles Direction Description Go Town: 0.0 R South on Spear St 0.0 S. Burlington 6.9 R Irish Hill Rd 6.9 Shelburne 8.5 S Cross Rt. 7 onto Bostwick Rd 1.6 10.3 ' BL Road turns left and becomes Greenbush Rd. 1.8 13.8 S REST STOP at the Old Lantern 3.5 Charlotte 19.7 BR Route 7-Stay on shoulder 5.9 21.1 L Little Chicago Rd. 1.4 Ferrisburgh 22.0 R Hawkins Rd 0_9 25.2 L Sand Hill Rd 3.2 31.9 S Water St. - up short STEEP hill 6.7 Vergennes 32.0 R Main St. - Rt. 22A 0.1 32.4 R Panton Rd. 0.4 32.7 S REST STOP at Goodrich 0.3 33.9 R Basin Harbor Rd. 1.2 38.3 L Button Bay Rd 4.4 42.3 BL Onto Jersey Rd. 4.0 Panton 42.8 R Pease Rd. 0.5 43.7 L Lake St. 0_9 49.6 S Rt. 17 5.9 Addison 51.5 R Cross Champlain Bridge 1.9 52.2 R LUNCH at Crown Point State Historic Area 0.7 Crown Point 52.2 L Cross Champlain Bridge 52.9 R Rt. 125 0.7 56.5 L Basin Harbor Rd. 3.6 57.9 Becomes Jersey St. 1.4 61.2 BR On Rt. 17 3.3 63.4 S Onto Jersey St. 2.2 _ 64.5 R Goodrich Rd. -There is 0.8 miles of unpaved road 1.1 65.6 L Onto Jersey St. 1.1 Panton 69.3 R Panton Rd. 3.7 73.2 S REST STOP at Goodrich 3.9 Vergennes 73.5 L Main St. - Rt. 22A 0.3 73.8 L Water St. 0.3 74.1 R Comfort Hill Rd. 0.3 76.4 R Little Chicago Rd. 2.3 Ferrisburgh 77.3 L Rt. 7 0.9 81.5 R Old Hollow Rd 4.2 82.0 L Mount Philo Rd 0.5 82.4 BR Spear St. 0.4 Charlotte 87.7 S REST STOP in Charlotte 5.3 98.4 L Finish at UVM 10.7 S. Burlington Route closes at 4:30PM L=Left, R=Right,X=Cross, S=Straight, B=Bear,@=at 2012 Bike MS Green Mountain Getaway - Sunday 45 mile Miles Direction Description Go Town: 0.0 R South on Spear St 0.0 S. Burlington *0.0 2.0 L Swift St. - stay on the road 2.0 2.0 2.6 R Dorset St. 0.6 0.6 6.5 L Shelburne Falls Rd. 3.9 Shelburne 3.9 12.0 S Cross Rt 116 at traffic light on CVU Rd. 5.5 Hinesburg 5.5 12.0 BR REST STOP at CVU 12.6 S On Richmond Rd. 0.6 Richmond 0.6 18.6 L East Hill Rd. (Fays Corner) 6.0 19.0 R East Hill Rd. 0.4 20.6 R South Rd. 1.6 Williston 21.9 L Oak Hill Rd. 1.3 28.8 S Richmond Rd. 6.9 29.7 L Rt 116 0.9 Hinesburg 0.9 29.9 R Charlotte - Hinesburg Rd 0.2 0.2 30.0 R REST STOP - Town Hall Parking Lot 0.1 0.1 34.2 R Spear St. 4.2 Charlotte 4.2 43.8 L Finish at UVM 9.6 S. Burlington 9.6 Route closes at 4:00PM 27.6 -Note: Eliminating the Williston loop yields a 28 mile loop but only one rest stop would be available in Hinesburg. DRAFT 1/28/2012 2012 Bike MS Green Mountain Getaway - Sunday 75 mile Net Control: Miles Direction Description Go Town: 0.0 R South on Spear St 0.0 S. Burlington 2.0 L Swift St. - stay on the road 2.0 2.6 R Dorset St. 0.6 6.5 L Shelburne Rd. 3.9 Shelburne 12.0 S Cross Rt 116 at traffic light on CVU Rd. 5.5 Hinesburg 12.0 BR REST STOP at CVU 12.6 S On Richmond Rd. 0.6 18.6 R Hinesburg Rd. at Fays Corner 6.0 Richmond 20.1 R Huntington Rd. - toughest climb of the day 1.5 25.7 S REST STOP - Huntington 5.6 Huntington 31.7 S Hanksville 6.0 34.2 R Rt 17 2.5 Starksboro 36.5 S Top of hill 2.3 41.2 L Rt 116 4.7 Bristol 44.5 LUNCH STOP - Bristol Green 3.3 44.5 R North St 53.4 R Tyler Bridge Rd. at Monkton Ridge 8.9 Monkton 56.5 L Rt 116 3.1 Hinesburg 60.8 L Charlotte - Hinesburg Rd 4.3 60.9 R REST STOP - Town Hall Parking Lot 0.1 65.1 R Spear St. 4.2 Charlotte 74.7 L Finish at UVM 9.6 S. Burlington Route closes at 4:00PM L=Left, R=Right, X=Cross, S=Straight, B=Bear, @=at 1 DRAFT 1/28/2012 2012 Bike MS Green Mountain Getaway - Sunday 100 milblet Control: Miles Direction Description Go Town: 0.0 R South on Spear St 0.0 S. Burlington 2.0 L Swift St. - stay on the road 2.0 2.6 R Dorset St. 0.6 6.5 L Shelburne Rd. 3.9 Shelburne 12.0 S Cross Rt 116 at traffic light on CVU Rd. 5.5 Hinesburg 12.0 BR REST STOP at CVU 12.6 S On Richmond Rd. 0.6 18.6 R Hinesburg Rd. at Fays Corner 6.0 Richmond 20.1 R Huntington Rd. - toughest climb of the day 1.5 25.7 S .REST STOP - Huntington 5.6 Huntington 31.7 S Hanksville 6.0 34.2 R Rt 17 2.5 Starksboro 36.5 S Top of hill 2.3 41.2 L Rt 116 4.7 Bristol 44.5 REST STOP - Bristol Green 3.3 44.5 Continue west on Rt. 116 45.4 L On Rt. 116 at blinking red light 0.9 51.1 R Quarry Rd 5.7 Middlebury 53.2 S Seminary St - straight thru and up hill. 2.1 54.4 R High St - No street sign 1.2 54.8 R Rt 7 0.4 57.2 R River Rd 2.4 New Haven 61.5 S New Haven Mills 4.3 62.3 S Rt 116 0.8 Bristol 63.8 R Hewitt Rd 1.5 64.7 R Lovers Lane 0.9 64.8 L South St. Follow CLOSED BRIDGE signs 0.1 65.1 S Closed Bridge - WALK ACROSS 0.3 65.4 L LUNCH STOP - Bristol Green 0.3 65.4 S North St 74.3 R Tyler Bridge Rd. at Monkton Ridge 8.9 Monkton 77.4 L Rt 116 3.1 Hinesburg 81.7 L Charlotte - Hinesburg Rd 4.3 81.8 R REST STOP - Town Hall Parking Lot 0.1 86.0 R Spear St. 4.2 Charlotte 95.6 L Finish at UVM 9.6 S. Burlington Route closes at 4:00PM Laura From: Justin Rabidoux Sent: Monday, March 19, 2012 1:40 PM To: Laura Subject: Re: Ok with me. On Mar 19, 2012, at 1:32 PM, "Laura" <lkimballOsburl.com> wrote: > Hello all- > > National MS Society bike ride on Aug 11 & 12, 2012. > Let me know... > Laura > Laura Kimball > Deputy City Clerk > City of South Burlington > 575 Dorset Street > South Burlington, Vt. 05403 > lkimball(asburl.com > <20120314111906681.pdf> > <image001.1pg> i • Laura From: ray Sent: Tuesday, March 20, 2012 8:15 AM To: Laura Subject: RE: No zoning issues. Ray Belair Administrative Officer City of So. Burlington 802-846-4106 From: Laura Sent: Monday, March 19, 2012 1:32 PM To: Trevor Whipple; Justin Rabidoux; ray; Doug Brent Subject: Hello all- National MS Society bike ride on Aug 11 & 12, 2012. Let me know... Laura 40 Laura Kimball Deputy City Clerk City of South Burlington 575 Dorset Street South Burlington,Vt. 05403 lkimball@sburl.com 1 • Laura From: Doug Brent Sent: Wednesday, March 21, 2012 1:21 PM To: Laura Subject: RE: This should not be a problem. Doug From: Laura Sent: Mon 3/19/2012 1:31 PM To: Trevor Whipple; Justin Rabidoux; ray; Doug Brent Subject: Hello all- National MS Society bike ride on Aug 11 & 12, 2012. Let me know... Laura • Laura Kimball Deputy City Clerk City of South Burlington 575 Dorset Street South Burlington,Vt. 05403 lkimball@sburl.com i • Laura From: Trevor Whipple [twhipple@sbpdvt.org] Sent: Tuesday, March 27, 2012 11:07 AM To: Laura Subject: RE: I'm fine with the MS bike ride. They are currently making arrangements to hire off duty officers. Trevor Trevor S.Whipple Chief of Police City of South Burlington 19 Gregory Drive South Burlington,VT 05403 (802)846-4155 twhipple(a�sbpdvt.orq From: Laura [mailto:Ikimball@sburl.com] Sent: Monday, March 19, 2012 1:32 PM To: Trevor Whipple; Justin Rabidoux; ray; Doug Brent Subject: Hello all- National MS Society bike ride on Aug 11 & 12, 2012. Let me know... Laura t Laura Kimball Deputy City Clerk City of South Burlington 575 Dorset Street South Burlington,Vt. 05403 IkimballtS sburl.com 1 City Of South Burlington, Grant Request Form Prior to applying for a grant please complete this form and submit to Assistant City Manager.. Please submit at lean two weeks prior to City Council approval meeting. Extenuating circumstances which do not permit two weeks notice should be brought to the attention of the Assistant City Manager as soon as possible. Please attach actual grant application form—either blank or completed Douglas Brent, Chief of Fire and EMS Name and title of person completing this form(ProjectManager) _2/14/12_ Date 1. Name/title of grant and submittal deadline date: VLCT Equipment Grant April 30, 2012 2. What specifically is the grant's purpose? VLCT PACIF grant to purchase equipment which will directly reduce work related injuries. 3. What does the grant fund and not fund(be specific)? Powered Ambulance Cot 4. Total Project Cost: $13,330.26 a. Amount of grant: $5,000.00 b. Is there a City match required, how much and in what fiscal year(s)? $8330.26 FY12-13 c. Are there other grants"tied into"or being used as a match for this grant of which are matching funds for this grant?No 5. From what budget line will match be paid, and is there unencumbered money to pay it?Medical Equipment P 6. Is there a cost to the city upon grant conclusion, and if yes,please describe?no 7. Is grant for stand alone project, and if no,how does grant fit into another project(describe in some detail)? YES 8. Length of grant-will the grant cross fiscal year(s)? NO 9. Who will apply for grant(name/title)? Douglas Brent, Chief of Fire/EMS 10. How much time will it take to complete grant application form? 10 mins 11. How likely is it that we will receive grant? Quite Likely 12. Who will manage(project manager)grant and grant paperwork if approved(if different person than who is filling out this-form), what are any grant compliance requirements,how much time will this take and how i that time available? Are there funds available in the grant to pay for our administrative costs? san in-kind service be used as part of the City match?Douglas Brent, No Administrative Costs, No hi-Kind 13. Describe grant payment process—method of cash flow: We purchase,reimbursement upon proof of purchase - 14. Should a Council-appointed Committee, Board, or Commission review this request? If yes,please update status: NO 15. In terms of priority, with 5 being into our rim highest and 1 being lowest, please rate this grant in terms of how it fits Y p ary mission as approved by City Council and current projects to complete that mission: 5 Reviewed by Asst. City M a r,Date Ifapproved,grant money will be in this fund 3 -3o -/Y" Approved by City Manager,Date Not Approved By City Manager,Date Approved By City Council,Date Not Approved By City Council,Date NC, South BurlingtonFire Department f Ri IVGKIU �uU11 �x.\RL1 NG 1-04, 575 Dorset Street South Burlington, VT 05403 (802) 846-4110 � ' IIRI DII'I " 11R1 DI-PI' Fax (802) 846-4125 To: Bob Rusten, Deputy City Manager From: Douglas Brent, Chief of Fire and EMS 6)1 Date: February 16, 2012 Re: VLCT Grant Program Attached is the signed paperwork for the VLCT Equipment Grant program for the powered ambulance cot. As I'm sure you remember, we have this purchase as part of the FY 12/13 budget and have anticipated the awarding of this grant into our purchase price. Let me know which City Council meeting you will need me to attend to discuss this request. If you have any further questions let me know. VLCT 2012 PACIF VLCT USE ONLY Equipment Grant Application Proposed Grant Amount Round A program exclusively for PACIt'Members Date Completed 1 or 2 Reviewed By Reviewed By Member(Municipality): City of South Burlington Applicant Name: Applicant Title: South Bulington Fire Department Fire Chief Preferred Contact Name (Optional): Preferred Contact Title: Douglas Brent Fire Chief Address (Street,City, State,ZIP): 575 Dorset Street, South Burlington, VT 05403 Primary Phone: Secondary Phone: 802-846-4110 802-846-4154 Email: Fax: dbrent@sburl.com 802-846-4125 If you have not read all of the instructions, please do so now. 1. Itemize the equipment requested and cost for each item or groups of like items. Additional items should be listed on the Equipment Itemization Worksheet. A single quote containing multiple items may be listed on one line. Item Description (and price per item if purchasing more than 1) Expected Purchase Date Total Cost Stryker Power Pro Ambulance Cot#6500 07/01/2012 $ 13,330.26 $ $ $ 2. What is the total quoted cost for the equipment/service you propose to purchase? $ 13,330.26 3. Why is this equipment needed and how will it reduce potential claims?Attach additional pages if necessary: See attached sheet 4. Has your municipality committed funds for your portion of this purchase? Appll ant ige• Yes ® No El r . Date: Senior Municipal Official Signature: Date: Senior Municipal Official Printed Name: Senior Municipal Official Title: Please check the Application Item Checklist on page 3 before submitting this application. Submit this completed application to VLCT,Attn: Shawna O'Neill. Email to soneill(a�vlct.orq; fax to 802-229-2211; or mail to VLCT, 89 Main Street, Suite 4, Montpelier, VT 05602-2948. Contact Shawna O'Neill if you have questions at (800)649-7915 ext. 1935. ft South Burlington Fire Department �tiL1F11NCi f(1,� O 575 Dorset Street South Burlington, VT 05403 {Os ~';m (802) 846-4110 '`�06 IIRI l>11'.1 FIRE DFPI Fax (802) 846-4125 Historically, it has been reported that injuries within the EMS industry have indicated that four in five EMS workers have experienced some kind of injury or medical condition as a result of their work. Almost one in two have sustained back injuries while performing their duties. National studies have shown that EMS personnel experience frequent spinal load due to repetitive motions such as lifting, lowering, carrying, loading and bending. South Burlington Fire Department Ambulance responds to approximately 1900 medical calls per year. We believe that the purchase of a Stryker Power Pro ambulance cot will be a proactive injury prevention tool as our calls for service continues to increase. We have done our research including borrowing a demonstrator unit from the manufacturer for a month of trial runs to seek input and opinions of our crew members. It is our feeling that the purchase of the power cot would be an extreme benefit to our employees. ` �� D��~�� ^ � . -'�', - _--_~~ ~~~��~=° " 5OOO Tuttle Crossing Blvd Dublin,OM43O1§ Date: I1/I4/201I Phone:uno'sus-0szs Fax:uon-2s7-57zy Valid Until: 3/31/2012 ouotation#: 111411JF-02 .Account Name: South Burlington Fire Department Account Number: 212971 BILL TO:, SHIP TO: ' Contact Name: Chief Doug Bren t Phone No: 802-846-4110 Account Manager Ship Method Payment Terms Jerry Flanagan / No Freight Net 3ODays ' Item Number BTM's Description U/M Price Quantity Extended Price 3211'475620 sTnvxcn POWER PRO COT osoo 3265'I00I58 STRYKcR EQUIPMENT HOOK EA $� 12'097.70 1 $ 12'097.70 ' 3265'100052 sTRYK[RDUALAUSTABLEVyHEEL LOCK OpT0N EA � 42�53� l � 4Z�53 0 13l65'l»Ol7O � RYKER3 �G�|VpOLE(pAT/ENTR/GHT) EA � 9z�95 l g 9I�9S � B\ $ 283.91 I $ ZO3�9I 3265'100154 �8YKERPO[KETED8A[KRESTpOUCH EA $ 212.64 1 $ 2I2.64 3265'100158 STKYKER FOWLER OZ BOTTLE HOLDER(65OO) �� Z�s�7y z $ 213.79 Merchandise Total: $ zz'euz.sz Sales Tax will be applied to customers who are not tax e,em[t Shipping charges wU|be prepaid and added to the invoice unless othenv�estated. ' ( 3c,m 5,1-7- . '�� //y,a-_ � � , ' ' ^ ` ` Page zofI ` I ` VLCT 2012 PACIF Equipment Grant uProgram A program exclusively for MCP Members 8y , the PACIF Equipment Grant Program has awarded over$300,000 in grants to PACIF members. This year, funding has been increased to $250,000. The goals of the program are unchanged,in that the grants are intended to provide financial assistance to members seeking to purchase equipment that will directly reduce the potential for future insurance claims. Interested members need to submit applications that define the equipment, explain its intended purpose, and provide cost details in the form of a quote. All applications received within either application period (see below)will be considered, as long as they contain all of the required information and are approved by a senior municipal official (i.e. municipal manager/administrator, selectperson or director). Grants will be awarded or declined, at the sole discretion of the Awards Committee,which is comprised of VLCT Risk Management Services managers. The Awards Committee will award grants in May and September of each year,issuing as many grants as possible without exceeding the annual budget. Awardees will be notified in writing. Please read this entire document for program rules, limitations and application guidance. Use the attached application for 2012 if you chose to apply. Contact your Loss Control Consultant or call VLCT's Safety&Health Division at 1-800-649-7915 if you have further questions. PACIF Equipment Grant Program Guidelines I. Equipment Requests The equipment outlined in the application must have a legitimate beneficial impact on loss exposure(s) and -reduce the potential for future losses. The equipment purchased with a PACIF grant should not be something that would be required for normal business operations (i.e.weapons for police officers). Likewise,routine operating expenses (i.e. equipment repair,licensing expenses, central station monitoring fees, etc.) or disposable personal protective equipment(i.e. hardhats, safety shoes, gloves, hearing protection or glasses) would not qualify for a PACIF grant. Members are encouraged to seek competitive pricing to control program costs. For certain equipment (i.e. sign packages),VLCT may have preferred pricing available, so contact us for details. Given that the spirit of this program is to help defray high cost items, each item requested should have a value ofatleast $200, except as noted in the list of qualifying equipment below. In any event, the minimum grant award request must be $200 or greater. Note that AEDs no longer qualify for the PACIF Equipment grant program. Examples of equipment/items that do qualify for the program include: • Ergonomic patient handling equipment such as powered ambulance cots, stair chairs,roller boards, etc. • Ergonomic office equipment such as office chairs,keyboards and trays, etc. • Material handling equipment such as manhole buddies,hydraulic lifting tailgates, truck cranes, tank bosses,powered pallet jacks,miscellaneous lifting equipment, fire hose rolling equipment, drum grasps for forklifts, etc. • Traffic safety equipment such as sign packages, auto flagger devices, cones and lighting units. • General safety equipment such as flammable liquids cabinets and equipment related to lockout/tag out, confined space entry, fall protection and machine guarding. • Personal protective equipment (PPE) such as turnout gear, chain saw chaps and helmets, ballistic vests,ANSI Class II vests and related high visibility outerwear. • Trench protective systems such as trench boxes and shoring. • Video cameras for sewer pipeline inspection to prevent sewer back-ups. • Centrally monitored building protection and/or security systems such as fire/alarm systems and other theft deterrents such as job boxes.. • Equipment purchases and/or system upgrades noted in VLCT loss control recommendations. II. Grant and Award Amounts Members are eligible to win an award of up to 50 percent of the anticipated cost of qualifying equipment up to a maximum of$5,000 per grant. All applicants will receive an award letter or rejection letter to outline maximum award amounts or reasons why the application was rejected. Amounts noted in the award letter will be based on the quote detail provided in the application and supporting documents. Should actual expenditures on approved items exceed the quoted costs;the grant will only pay up to 50% of the awarded (quoted) amount. If the purchase cost is less than the quoted amount, the award will pay 50% of the actual cost of the items. Grant award checks will also be adjusted to account for items that were applied for,but ultimately not purchased. III. Eligibility and Application Schedule Only current PACIF members are eligible to participate. Each member is allowed to receive only one grant award each calendaryear, so equipment requests from multiple departments should combined and submitted as a single application. Should you wish to complete the application electronically,it is available for download,along with a companion form at: www.vlct.org/rms/pacif/ Grant applications must be received within either of the 2012 application periods,as listed below. Requested equipment should not be purchased prior to receiving a grant award letter, except in unusual or high hazard situations; as there is no guarantee that a grant will be awarded. If special circumstances exist where equipment is needed to address a high hazard or imminent danger situation,you are encouraged to contact your loss control consultant who will help you evaluate the issue and bring it to the Awards Committee for immediate consideration. After committee review, the member will be notified of the award decision. Grant awards will be valid for one year from the date the letter was issued to the member, as long as the. recipient remains a PACIF member. Each member is eligible to apply for one grant each calendar year, unless a previously awarded grant remains unspent. In this situation,members must complete the purchase of items from a previous grant award or elect to close out the prior application without purchase (i.e. waive the grant award) before a new application will be entertained. Requests to close out a previous grant award must be made in writing by a senior municipal official. All applications will be evaluated and grants awarded at the sole discretion of the Awards Committee. VLCT PACIF will announce equipment grant awards via letter to the applicant in May aitd September according to the following application schedule: o UpvItia7�et ads cei e. date x `LL 14:�aar.® vc tip` ,erger�e January 1-April 30, 2012. May 2012 May 1-August 31,2012 September 2012 • VLCT 2012 PACT Equipment GrantProgram Rules and Guidelines Page 2 of 3 IV. Application Guidelines • Completed applications and all appropriate supporting documentation must be received by Shawna O'Neill at VLCT according to the schedule provided in Section III above. Documents may be faxed,mailed or mailed. All documents must be legible. • Supporting documentation must include a description of the equipment requested and vendor price quotations. Freight costs may be included. • Explain why this particular equipment is needed and how it will aid in reducing the frequency and/or severity of workers' comp,property, and/or casualty/liability claims. • The application must be signed by a senior official of the municipality. V. Application Checklist Prior to sending in your completed application,please complete the following checklist to expedite the approval and administration process. Using this checklist will help ensure that your application is completed properly. This checklist should not be included with the completed application. 1. Have all questions on the application been answered? — n 2. Has the application been signed by a senior municipal official? ' El I l 3. Has a senior municipal official confirmed the commitment of funds (on the application) for your portion of the requested equipment? El 4. Is your municipality a current PACIF member? C ❑ 5. Have you provided appropriate contact information should we need to obtain additional information about the application or requested equipment? n 6. Has the equipment itemization section of the application been completed with clear item descriptions and cost information? ❑ ❑ 7. Have you included the cost of freight,if applicable? ❑ n 8. If items are not on the list of previously approved items in the grant literature,have you contacted VLCT or loss control to discuss the item? ❑. ❑ 9. Has your municipality consolidated equipment requests from multiple departments into a single application (if applicable)? ❑ ❑. 10. Is the grant award request more than $200? ❑ ❑ If you answer no to any question,review the application and these guidelines to ensure you qualify for the program and that all submission requirements have been met. Incomplete applications are subject to rejection!! VI. Obtaining Reimbursement after the Purchase After the equipment has been purchased within the required timeframe, proof of purchase AND payment must be provided to obtain reimbursement. Clear descriptions of all items purchased and pricing details such as an invoice must be provided. Key items include: • A copy of the cancelled check(s) paying for qualifying items is needed as proof of payment. Ideally,it should reference the vendor's invoice (which should also be included). • Purchased items must be identical to or of equivalent quality to items that were submitted via the application process; otherwise they may not qualify for reimbursement. Reimbursements may be adjusted where actual purchases are different than what was listed in the application. • Requests for reimbursement should only be made after all desired items are purchased. VLCT 2012 PAQQ Equipment Grant Program Rules and Guideknes Page3of3 April 2nd CC Agenda: • VLCT Equipment Grant Application from Fire Department. • Continue Public Hearing on Amendments to the Land Development Regulation Amendment. • Adopt a street lighting standard and incorporate into our City Ordinance—Justin will introduce this draft ordinance language. • Appoint Town Service Officer • Consider funding recommendations by Social Services Committee. • Additional Liquor Permits and,probably, entertainment permits. • Executive Session: Discuss job descriptions for Treasurer and City Clerk and legal and personnel implications related to departmental organization,tax collection,etc. April 16th CC Agenda: • Channel 17 Update(per CCTV request). • Public Hearing on US2 Widening/Sheraton 3rd lane-Project's ROW plans&appraisals.