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Home My WebLink Aboutcoa.lu.tu.400 E Hopkins.0031.2019.ASLU►�1 COMMUNITY DEVELOPMENT CITY OF ASPEN CASE NUMBER 0031.2019.ASLU PROJECT ADDRESS 400 E HOPKINS PARCELID 27370733009 PLANNER GARRETT LARIMER CASE DESCRIPTION TEMPORARY FOOD VENDING REPRESENTATIVE ENRIQUE BIENKOWSKI DATE OF FINAL 10/1/2019 ACTION CLOSED BY LILLY CULVER 10/8/2019 CITY OFASPEN NOTICE OF APPROVAL FOR A TEMPORARY OUTDOOR FOOD VENDING LICENSE AT 406 E HOPKINS AVE., LEGALLY DESCRIBED AS LOT K, BLOCK 87 CITY OF ASPEN TOWNSITE, Parcel ID No. 273707330009 APPLICANT: Enrique J Bienkowski PO Box 536 Aspen CO 81612 PROPERTY OWNER: Isis Building, LLC 602 E Cooper #202 Aspen, CO 81611 SUBJECT & SITE OF APPROVAL: The applicant has requested renewal of an approval for a Temporary Outdoor Food Vending business at406 E Hopkins Avenue, near the entrance to the Radio Board Shop. SUMMARY: The applicant has requested approval to operate a temporary outdoor food/beverage business that will sell primarily shaved ice on private property at 406 E. Hopkins Ave. The temporary use is requested from June 1, 2019 through October 1, 2019. The shaved ice cart has received approval in the past under the same ownership. The applicant has the ability to renew once the time frame has expired. No more than one (1) temporary outdoor vending business may operate on a private property parcel at a time. STAFF EVALUATION: Pursuant to Section 26.470.090(H) of the City of Aspen Land Use Code (hereinafter the Code), Temporary Outdoor Food Vending is a temporary use by a restaurant or retailer on private property, private open space, or public property that is subject to a mall lease for food vending or outdoor restaurant seating in the Commercial Core (CC) Zone District and shall be approved, approved with conditions, or denied by the Community Development Director. The proposed location is within the Commercial Core Zone District, and the application has been reviewed against all applicable review criteria, and staff has found it to comply with all standards. A signed letter of approval has been provided from the property owner for this temporary outdoor food vending request. The applicant has indicated shaved ice will be the main item served. The hours of operation will be Monday through Sunday from 10:OOAM until 8:OOPM. The proposed food vending business will use a small food cart on wheels, the same cart that has been used in the past. The cart measures 3' wide and 6' long for a total size of 18 sq. ft., less than the 50-sq. ft. permitted by the Code. The temporary food structure is located on private property of the Isis building, near the 130 South Galena Street Aspen, CO 81611-1975 1 P: 970,920.5000 1 F: 970.920.5197 1 cityofaspen.com AA CITY OFASPEN entrance to the Radio Board shop that faces Hopkins Ave. If the normal operation of this business in any way impedes the movement of pedestrian traffic, the applicant will be asked to move the structure so that line queues and normal business shall not create interference. The cart has a chalkboard that's attached to the front of the food cart. The entire front of the cart is made of this chalkboard material. The Land Use Code allows only 50% of the surface area to be used for signage. If the Community Development Department receives any complaints relating to the signage, progressive enforcement protocol will be used until the signage meets the requirements of the code. The applicant is requesting approval from June 1, 2019 through October 1, 2019; however, the business is permitted to continue for a period of one year from the date of this approval without the need to renew with the City. No more than one outdoor vending business may operate on the property at a time. Significant changes to the menu must be vetted with the City's Environmental Health Department. Changes to the hours of operation should be reported to the City's Planning Department. The applicant has received initial approved by the City's Environmental Health Dept. for the proposed business; however, an inspection is required prior to the start of business and must be scheduled with that department. DECISION: Staff finds that the request for Temporary Outdoor Food Vending provided by the applicant, Enrique Bienkowski, shall be granted. The application complies with the review standards for Temporary Outdoor Food Vending in Section 26.470.090(H) of the Code. APPROVED BY: le sica Garrow Date , " mmunity Develpment Director Attachments: Exhibit A — Review Criteria Exhibit B —Application 130 South Galena Street Aspen, CO 81611-1975 1 P: 970.920.5000 1 F: 970.920.5197 1 cityofaspen.com Permit type laslu Aspen Land Use _ I Permit # 0031.2019.ASLU Address 400 E HOPKINS Apt1S uite City JASPEN State CO Zip 81611 Permit Information Master permit �— Project Description TEMPORARY FOOD MENDING PID 27370733009 Routing queue aslul5 Status pending Submitted 1ENRIQUE BIENKOSKI 9709483437 Clock Running Days Submitted via C O toner Applied 04/23/2019 --] Approved Issued u Closed/Final Expires 04}1712020� Last name SCOTT BUILDING CONDO First name L _ 400 E HOPKINS ASPEN CO 81611 Phone j - Address Applicant 0 Owner is applicant? Fj Contractor is applicant? Last name SCOTT BUILDING CONDO r j First name 400 E HOPKINS ASPEN CO 81611 Phone [ - Cust # 31250 Address E mail Lender Last name I First name Phone ( Address A- Unec`��- IOa� N� teS�roJ.s l f ff p c -.3 -✓ ! N V Div CITY OF ASPS Land Use Application Determination of Completeness Date: April 18, 2019 Dear City of Aspen Land Use Review Applicant, We have received your , land use application for 400 E. Hopkins, Temporary Outdoor Food Vending (PID 273707330091 and have reviewed it for completeness (and not compliance). X Your Land Use Application is complete: Please submit the following to begin the land use review process. 1) Digital pdf of the entire application (via thumb drive, emailed files, or file sharing) 2) Review deposit of $81.00 (to be billed hourly). Other submission items may be requested throughout the review process as deemed necessary by the Community Development Department. Please contact me at 429-2759 if you have any questions. Thank , nnifer Phel n eputy Planning Director City of Aspen, Community Development Department For Office Use Only: Mineral Rights N tice Required Yes Noz GMQS Allotme is Yes No Qualifying Applications: New PD Subdivision, or PD (creating more than 1 additional lot) Residential Affordable Housing Commercial E.P.F. Lodging x ��"t_ t' �i�i-lti,'.•. 1"t ,( 7 I�i`,.c el..itl C LAND USE APPLICATION Project Name and Address: 400 E Hopkins Ave, Aspen, CO 81611, temporary food stand Parcel ID # (REQUIRED) 27370733009 APPLICANT: Name: Enrique Bienkowski Address: 104 Williams Way, Aspen, CO 81611 Phone #: 970.948.3437 email: ebienkowskiahotmail.com v REPRESENTIVATIVE: Name: Enrique Bienkowski (same as above) and Misheel Chuluun Address: Misheel: 410 Paepcke Drive Unit 101, Aspen CO 81611 Phone#: Misheel: 970.300.2515 email: misheel.chuluun@gmail.com Description: Existing and Proposed Conditions Renewal requested for a shave ice stand that has existed for over 18 years. Review: Administrative or Board Review Required Land Use Review(s): Growth Management Quota System (GMQS) required fields: Net Leasable square footage Lodge Pillows Free Market dwelling units Affordable Housing dwelling units Essential Public Facility square footage Have you included the following? Pre -Application Conference Summary Signed Fee Agreement 0 HOA Compliance form All items listed in checklist on PreApplication Conference Summary FEES DUE: $ Owner Approval I (print name) /-7 -Z�A 0Yr Z7. /'141 Z Z� allow The Snowy Pineapple (shave ice stand) to temporarily use the space outside of Radio Board Shop at 400 E. Hopkins Ave Aspen CO, 81611, which is on private property and has 6 foot egress from building entrance/exits per city requirements. The shave ice stand will operate from June 1st, 2019 until October 1st, 2019. The hours of operation are 10 am to bottled water, and i Signature: Date: 4 • / S • 1 seven days a week, serving shave ice, 1 + j_ To apply, submit one complete copy of the following information: y 10 J Completed Land Use Application and signed fee agreement. 1 8 REC'0 E7 Pre -application Conference Summary (this document). :> ASPEN E� Applicant's name, address and telephone number in a letter signed by the applicant that states the name, address and telephone number of the representative authorized to act on behalf of the applicant. Ci Street address and legal description of the parcel on which development is proposed to occur. A 0 HOA Compliance form (Attached) D' A written description of the proposal and an explanation of how the proposed development complies with the review standards relevant to the development application § 26.470.060(8) Temporary Outdoor Food Vending (attached). 0' A drawing depicting the size of the temporary use (not to exceed fifty (50) square feet). ,f� A site plan depicting the location of the temporary use. Eft Proposed signage for the food vending operation. 153"' If applicable, a signed letter from the owner of the business that the temporary use will be operating by or in association with. Signed letters from those restaurant or retail businesses that the temporary use will be operating adjacent to. M/A signed letter from the property owner. Proof of approval from the Environmental Health Department for a food service plan. If the copy is deemed complete by staff, the following items will then need to be submitted: f 1 additional paper copy and one digital copy in PDF format of the complete application packet and Total deposit for review of the application. Disclaimer: The foregoing summary is advisory in nature only and is not binding on the City. The summary is based on current zoning, which is subject to change in the future, and upon factual representations that may or may not be accurate. The summary does not create a legal or vested right. 2 Agreement to Pay Application Fees An agreement between the City of Aspen ("City") and Please type or print in all caps Address of Property: 400 E Hopkins Ave, Aspen, CO 81611, temporary food stand Property Owner Name: Enrique Bienkowski Representative Name (if different from Property Owner) Billing Name and Address - Send Bills to: PO Box 536, Aspen CO 81612 Contact info for billing: e-mail: ebienkowski@hotmail.com Phone: 970,948,3437 understand that the City has adopted, via Ordinance No. 30, Series of 2017, review fees for Land Use applications and payment of these fees is a condition precedent to determining application completeness. I understand that as the property owner that I am responsible for paying all fees for this development application. For flat fees and referral fees: I agree to pay the following fees for the services indicated. I understand that these flat fees are non-refundable. $. 81 flat fee for GMOS - Outdoor FOOS Vending_ flat fee for $. flat fee for flat fee for For Deposit cases only: The City and I understand that because of the size, nature or scope of the proposed project, it is not possible at this time to know the full extent or total costs involved in processing the application. I understand that additional costs over and above the deposit may accrue. I understand and agree that it is impracticable for City staff to complete processing, review and presentation of sufficient information to enable legally required findings to be made for project consideration, unless invoices are paid in full. The City and I understand and agree that invoices mailed by the City to the above listed billing address and not returned to the City shall be considered by the City as being received by me. I agree to remit payment within 30 days of presentation of an invoice by the City for such services. I have read, understood, and agree to the Land Use Review Fee Policy including consequences for no -payment. I agree to pay the following initial deposit amounts for the specified hours of staff time. I understand that payment of a deposit does not render and application complete or compliant with approval criteria. If actual recorded costs exceed the initial deposit, I agree to pay additional monthly billings to the City to reimburse the City for the processing of my application at the hourly rates hereinafter stated. $ NA deposit for hours of Community Development Department staff time. Additional time above the deposit amount will be billed at $325.00 per hour. $ NA deposit for hours of Engineering Department staff time. Additional time above the deposit amount will be billed at $325.00 per hour. City of Aspen: Jessica Garrow, AICP Community Development Director City Use: Fees Due: $ Received $ Case # Signature: PRINT Name: Enrique Bienkowski Title: Owner Authorized Representatives) Our names are Enrique Bienkowski and Misheel Chuluun. We will be opening the shaved ice stand in front of Radio Board Shop called The Snowy Pineapple at 400 E. Hopkins Ave. Aspen Colorado, 81611. All mail will be sent to OscarRose LLC at PO Box 536 Aspen CO, 81612. Enrique's telephone number is 970.948.2427 and Misheel's is 970.300.2515. We are the representatives and will be acting on behalf of OscarRose LLC. Print namE Signature: Date: C ,////,P Print Signa- Date: Street Address and Legal Description of Parcel 400 E. Hopkins Ave. Aspen CO, 81611 Legal Description- Lot K, Block 87 Parcel ID Number- 273707330009 Homeowner Association Compliance Policy All land use applications within the City of Aspen are required to include a Homeowner Association Compliance Form (this form) certifying the scope of work included in the land use application complies with all applicable covenants and homeowner association policies. The certification must be signed b th1! e property owner or Attains n-resenting the propertypMperty owner. Property Name: Enrique Bienkowski Owner rl"): Email: ebienkowski@hotmail.com Phone No.: 970.948.3437 Address of 400 E Hopkins Ave Property: Aspen, CO 81611 (subject of application) I certify as follows: (pick one) ® This property is not subject to a homeowners association or other form of private covenant. ❑ This property is subject to a homeowners association or private covenant and the improvements proposed in this land use application do not require approval by the homeowners association or covenant beneficiary. ❑ This property is subject to a homeowners association or private covenant and the improvements proposed in this land use application have been approved by the homeowners association or covenant beneficiary. I understand this policy and I understand the City of Aspen does not interpret, enforce, or manage the applicability, meaning or effect of private covenants or homeowner association rules or bylaws. I understand that this document is a public document. Owner signature: Owner printed name: El Attorney signature: Attorney printed name: uz date: 4/16/2019 Enrique Bienkowski date: Summary of Intent and Written Description Enrique Bienkowski 104 Williams Way Aspen Co, 81611 970-948-3437 ebienkowski@hotmail.com The Snowy Pineapple 400 East Hopkins Ave. Aspen CO, 81611 26.470.060.8 Temporary outdoor vending development for shave ice stand at 400 East Hopkins Ave. a. The shave ice stand at 400 East Hopkins will operate from June 1, 2019 until October 1, 2019. b. Operation hours for the shave ice stand will be 10:OOAM to 8:00 PM seven days a week. c. The counter area of the shave ice stand is (18) square feet. d. The shave ice stand at 400 East Hopkins Ave. is in association with Radio Board Shop Aspen and has the approval from the owner of the property, and the adjacent renters. e. The shave ice stand has obtained approval from the Environmental Health Department as of 06-08-09 C.J. The shave ice stand will have a waste disposal container that is emptied daily and stored inside 400 East Hopkins Ave. at night and when the stand is not in operation. f. The shave ice stand at 400 East Hopkins Ave. is a temporary vending application. g. The shave ice stand at 400 East Hopkins Ave. shall abide by all public health and safety codes, fire codes, sign/ lighting codes and sales tax license regulations. H. Foods being offered at The Snowy Pineapple a. Shave Ice b. Canned soda c. Bottled water d. Iced Coffee W4 W p •�'µ � �� pry, � M j X ��. .•y ��r p i J i Signage The sign being used is the chalkboard on the front of the cart (see picture). The chalkboard is less than 20 sq. ft. CL >1 0 1 2 it w >!= Current Renter Approval. I (print name) yst, &14 allow the Snowy Pineapple (shave ice stand) to temporally use the space outside Radio Board Shop at 400 East Hopkins Ave. Aspen. Co. 81611. Signature G Date C % coLoRAoo Department of Public License to Operate: Retail Food Establishment Health & Environment License must be posted at the following location, in a conspicuous place: This certifies that licensee shown hereon is 400 E Hopkins Ave Aspen, CO 81611 Issue date: 2/21/19 License Valid until: 12/31/19 Snowy Pineapple PO Box 536 ASPEN, CO 81612 Issued By: Aspen Environmental Health Department authorized and licensed to engage in business in accordance with the provisions of the laws and regulations of the Colorado Department of Public Health Et Environment. Any alterations to this license will automatically make it null and void. Sales Tax ID: License Type: Limited Current Renter Approval. 13.,c <:-c i-,; 1-2 1(print name) _ 1 �^�� U ` s '41 allow the Snowy Pineapple shave Pp ( ice stand) to temporally use the space outside Radio Board Shop at 400 East Hopkins Ave. Aspen. Co. 81611. Signature �� ti Date 7� /� C� Adjacent Business Approval. I (print name) � _ 0 give permission to The Snowy Pineapple (shave ice stand) to temporally use the space adjacent to La Creperie du Village and Peter Lik Gallery. The stand will be in front of RadioBoard shop at 400 E. Hopkins. Aspen.Co.81611 Print Name: 1 d Signatu rp--' Print Name: Signature Date t/—) 7 Date — % — 1 ) Date Date Agreement to Pay Application Fees An agreement between the City of Aspen ("City") and Please type or print in all caps Address of Property: 400 E Hopkins Ave, Aspen, CO 81611, temporary food stand Property Owner Name: Enrique BienkoWski Representative Name (if different from Property Owner) 9'� Billing Name and Address - Send Bills to:. PO Box 536, Aspen CO 81612;' C�% Contact info for billing: e-mail: eblenkOWSkI@hotmall.COm Phone: 970.948.3437 I understand that the City has adopted, via Ordinance No. 30, Series of 2017, review fees for Land Use applications and payment of these fees is a condition precedent to determining application completeness. I understand that as the property owner that I am responsible for paying all fees for this development application. For flat fees and referral fees: I agree to pay the following fees for the services indicated. I understand that these flat fees are non-refundable. $. 81 flat fee for GMQS - Outdoor Food Vending flat fee for flat fee for flat fee for For Deposit cases only: The City and I understand that because of the size, nature or scope of the proposed project, it is not possible at this time to know the full extent or total costs involved in processing the application. I understand that additional costs over and above the deposit may accrue. I understand and agree that it is impracticable for City staff to complete processing, review and presentation of sufficient information to enable legally required findings to be made for project consideration, unless invoices are paid in full. The City and I understand and agree that invoices mailed by the City to the above listed billing address and not returned to the City shall be considered by the City as being received by me. I agree to remit payment within 30 days of presentation of an invoice by the City for such services. I have read, understood, and agree to the Land Use Review Fee Policy including consequences for no -payment. I agree to pay the following initial deposit amounts for the specified hours of staff time. I understand that payment of a deposit does not render and application complete or compliant with approval criteria. If actual recorded costs exceed the initial deposit, agree to pay additional monthly billings to the City to reimburse the City for the processing of my application at the hourly rates hereinafter stated. $ NA deposit for hours of Community Development Department staff time. Additional time above the deposit amount will be billed at $325.00 per hour. $ NA deposit for hours of Engineering Department staff time. Additional time above the deposit amount will be billed at $325.00 per hour. City of Aspen: Jessica Garrow, AICP Community Development Director City Use: Fees Due: $ Received $ Case # Signature: PRINT Name: Enrique Bienkowski Title: Owner LAND USE APPLICATION Project Name and Address: 400 E Hopkins Ave, Aspen, CO 81611, temporary food stand Parcel ID # (REQUIRED) 27370733009 APPLICANT: Name: Enrique Bienkowski Address: 104 Williams Way, Aspen, CO 81611 Phone #: 970.948.3437 email: ebienkowskiahotmail.com v REPRESENTIVATIVE: Name: Enrique Bienkowski (same as above) and Misheel Chuluun Address: Misheel: 410 Paepcke Drive Unit 101, Aspen CO 81611 Phone#: Misheel: 970.300.2515 email: misheel.chuluun@gmail.com Description: Existing and Proposed Conditions Renewal requested for a shave ice stand that has existed for over 18 years. Review: Administrative or Board Review Required Land Use Review(s): Growth Management Quota System (GMQS) required fields: Net Leasable square footage Lodge Pillows Free Market dwelling units Affordable Housing dwelling units Essential Public Facility square footage Have you included the following? FEES DUE: $ [� Pre -Application Conference Summary 0 Signed Fee Agreement 0 HOA Compliance form 0 All items listed in checklist on PreApplication Conference Summary Authorized Representatives) Our names are Enrique Bienkowski and Misheel Chuluun. We will be opening the shaved ice stand in front of Radio Board Shop called The Snowy Pineapple at 400 E. Hopkins Ave. Aspen Colorado, 81611. All mail will be sent to OscarRose LLC at PO Box 536 Aspen CO, 81612. Enrique's telephone number is 970.948.2427 and Misheel's is 970.300.2515. We are the representatives and will be acting on behalf of OscarRose LLC. Print name: Enrique B Signature: ✓�--- Date: Print name: Mi Signature: Date: 7 �C 'ILA" �1, NO � Street Address and Legal Description of Parcel 400 E. Hopkins Ave. Aspen CO, 81611 Legal Description- Lot K, Block 87 Parcel ID Number- 273707330009 Homeowner Association Compliance Policy All land use applications within the City of Aspen are required to include a Homeowner Association Compliance Form_ (this form) certifying the scope of work included in the land use application complies with all applicable covenants and homeowner association policies. The certification must be sign„ ed by the property owner or Attorney representing the property owner. Property Name: Enrique Bienkowski Owner ("I"): Email: ebienkowski@hotmail.com Phone No.: 970.948.3437 Address of 400 E Hopkins Ave Property' Aspen, CO 81611 (subject of application) I certify as follows: (pick one) ® This property is not subject to a homeowners association or other form of private covenant. ❑ This property is subject to a homeowners association or private covenant and the improvements proposed in this land use application do not require approval by the homeowners association or covenant beneficiary. ❑ This property is subject to a homeowners association or private covenant and the improvements proposed in this land use application have been approved by the homeowners association or covenant beneficiary. I understand this policy and I understand the City of Aspen does not interpret, enforce, or manage the applicability, meaning or effect of private covenants or homeowner association rules or bylaws. I understand that this document is a public document. Owner signature: Owner printed name: NM Attorney signature: CW 1,66 �date: 4/16/2019 Attorney printed name: Enrique Bienkowski date: Summary of Intent and Written Description Enrique Bienkowski 104 Williams Way Aspen Co, 81611 970-948-3437 ebienkowski@hotmail.com The Snowy Pineapple 400 East Hopkins Ave. Aspen CO, 81611 26.470.060.8 Temporary outdoor vending development for shave ice stand at 400 East Hopkins Ave. a. The shave ice stand at 400 East Hopkins will operate from June 1, 2019 until October 1, 2019. b. Operation hours for the shave ice stand will be 10:OOAM to 8:00 PM seven days a week. c. The counter area of the shave ice stand is (18) square feet. d. The shave ice stand at 400 East Hopkins Ave. is in association with Radio Board Shop Aspen and has the approval from the owner of the property, and the adjacent renters. e. The shave ice stand has obtained approval from the Environmental Health Department as of 06-08-09 C.J. The shave ice stand will have a waste disposal container that is emptied daily and stored inside 400 East Hopkins Ave. at night and when the stand is not in operation. f. The shave ice stand at 400 East Hopkins Ave. is a temporary vending application. g. The shave ice stand at 400 East Hopkins Ave. shall abide by all public health and safety codes, fire codes, sign/ lighting codes and sales tax license regulations. H. Foods being offered at The Snowy Pineapple a. Shave Ice b. Canned soda c. Bottled water d. Iced Coffee ol Z 0 le .2 o fie Signage The sign being used is the chalkboard on the front of the cart (see picture). The chalkboard is less than 20 sq. ft. w o cu 'rW4W - V J Current Renter Approval. I (print name)711^a. 61-1- �� '( allow the Snowy Pineapple (shave ice stand) to temporally use the space outside Radio Board Shop at 400 East Hopkins Ave. Aspen. Co. 81611. G rDatel l Signature C ICOLORADO Department of Public License to Operate: Retail Food Establishment I Health & Environment License must be posted at the following location, in a conspicuous place: This certifies that licensee shown hereon is 400 E Hopkins Ave Aspen, CO 81611 Issue date: 2/21/19 License Valid until: 12/31/19 Snowy Pineapple PO Box 536 ASPEN, CO 81612 Issued By: Aspen Environmental Health Department authorized and licensed to engage in business in accordance with the provisions of the laws and regulations of the Colorado Department of Public Health & Environment. Any alterations to this license will automatically make it null and void. Sales Tax ID: License Type: Limited Current Renter Approval. (print name) �^� � �� -� ��'. (� m:C--�, allow the Snowy Pineapple (shave ice stand) to temporally use the space outside Radio Board Shop at 400 East Hopkins Ave. Aspen. Co. 81611. Signature_ �& Date 7- C Owner Approval I (print name) Z7. 1141Z Zap allow The Snowy Pineapple (shave ice stand) to temporarily use the space outside of Radio Board Shop at 400 E. Hopkins Ave Aspen CO, 81611, which is on private property and has 6 foot egress from building entrance/exits per city requirements. The shave ice stand will operate from June 1st, 2019 until October 1st, 2019. The hours of operation are 10 am to seven days a week, serving shave ice, bottled water, and ice offee. Signature: Date: 4 • / 8 - l9 Adjacent Business Approval. - _- t I (print name) a ki,,, _ �;�.� 0 give permission to The Snowy Pineapple (shave ice stand) to temporally use the space adjacent to La Creperie du Village and Peter Lik Gallery. The stand will be in front of RadioBoard shop at 400 E. Hopkins. Aspen.Co.81611 Print Name: J Signatu Print Name: Date Date Date Signature Date