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07. ABC Long's DrugsOFFICE OF THE CITY MANAGER CITY HALL 10300 TORRE AVENU E • CUPERTINO, CA 950143255 TELEPHONE: {408) ?77-3212 • FAX: (408) 777-3366 SUMNCARY AGENDA ITEM NUMBER ~ SUBJECT AND ISSUE Application for Alcoholic Beverage License. BACKGROUND AGENDA DATE June 2, 2009 1. Name of Business: Longs Drug Store 9894 Location: 10455 Soutli De Anza Boulevard Type of Business: Market/Pha~macy Type of License: Off-Sale General (21} Reason for Application: Person to Pearson Transfer & Annual Fee RECOMMENDATION There are no use permit restrictions or zoning restrictions which would prohibit this use and staff has no objection to the issuance of the license. Prepared by: ~„~,~'. ~~' ' ao, City Planner t~'~ G:planning/misc/abc Longs Drugs Submitted by: ~~ David W. Knapp, City Manager 7-1 `Department of Alcoholic Beverage Control ~ State of California APPLICATIOl~ FOB ALCOHOLIC BEVERAGE LICENSE(S) A13C 21l (6199) TO: Department of Alcoholic Beverage Control File Number: 477779 100 Paseo de San Antonio Receipt Number: 1709980 Rm. 119 Geographical Code: 4303 San Jose, CA 95113 Copies Mailed Date: April ~f, 2009 (408)277-1200 Issued Date: DISTRICT SERVING LOCATION: Sg,~l TOSE First Owner: Name of Business: Location of Business County: Is premise inside city limits? Mailing Address: (If different from premises address) Type of license(s): 21 GARFIELD BEACH CVS LLC LONGS DRUG STORE 9894 10455 5 DEANZA BLVD CUPERTINO, CA 95014 SANTA CLARA Census Tract 5077.01 ONE CVS DR WOONSOCKET, RI 02895-6146 Transferor's license/name: 204524 / LONG5 DRUG STi Dropping Partner: Yes No 1;~icense Type Transaction Tvne ee T e Master pip Date ee 21 OFF-SALE GENERAL PERSON TO PERSON TRANSF NA Y 0 0 4 / 16 / 0 9 $1,274.00 21 OFF-SALE GENERAL ANNUAL FEE NA Y 0 04/ 16/09 $563.00 Total $1;837.00 Have .you ever been convicted of a felony? N o Have you ever violated any provisions of the Alcoholic Beverage Control Act, or regulations of the Department pertaining to the Act? No Explain any "Yes" answer to the above questions on an attachment which shall be deemed part _of this application. Applicant agrees (a) that any manager employed in an on-sale licensed premise will have all the qualifications of a licensee, and {b) that he will not violate or cause or permit to be violated any of the provisions of the Alcoholic Beverage Control Act. STATE OF CALIFORNIA County of. SANTA CLARA Date: April 17, 2009 Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He is an applicant, or one of the applicants, or an executive officer of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2) that he has read the foregoing and knows the contents thereof and that each of the above statements therein made are true; (3) that no person other than the applicant or applicants has nny direct or indirect iuterest in the applicant or applicant's business to be conducted under the license(s) for which this application is made; (4) that the- transfer application or proposed transfer is not made to satisfy the payment of a loan or to fulfill an agreement entered into more than ninety (90) days preceding the day on which the transfer application is filed with the Department or to gain or establish a preference to or for any creditor or transferor or to defraud or injure any creditor of transferor; (57 that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. Applicant Name(s) Applicant Signature(s) GARFIELD BEACH CVS LLC LONGS DRUG STORES CALIFORNIA LLC 7-2 Slate of California - Department of Alcoholic Beverage Control APPLICATION SIGNATURE SHEET ("SIGN ON") • This form is to be used as the signature page for 1. owNi=RSHIP rrPE (check are) applications not signed in the District Office. ~ ^ SOIe Owner ^ COrpOratian • Read instructions on reverse before completing. ' ^ Partnership ®Limrted Liability Company • All signatures must be nofarized in accordance with ^ Husband & Wife ^ Other laws of the State where signed. I ^ Pa)tnerslup-Ltd __ __ 2. FILE NUMBER (II arty) 5. APPLICANT(S) NAME (Lost, prsl, middle) 3. LICENSE TYPE 4. TRANSACTION TYPE 29 ~ ^ Original ®Person to Person Transfer ^ E3:change ^ Premise to Premise Transfer ^ Other Longs Drugs Stores California LLC- G~~rtieid Beach CVS LLC 6. APPLICANT'S MAILING ADDRESS (Street addresslP.O. bo74 dly, slalE, 2p code) One CVS Dr., Woonsocket RI 1)2895 7, PREM)SES ADDRESS (SUeel address, dtY. vP ~) v~~iev~ APPLICANT'S CERTIf'1CAT10N Under penalty of perjury each pperson whose signature appears payment of a loan or to fulfil] an agreement entered into more than hefow, certifies and says: (1) He/5he is an applicant, or one of ninety (90) da}_s preceding the day on which the transfer the applicants, or an executive officer of the applicant ' application is filled with the Department; (b) to ain or establish a corporation, named in the fore going application, duly authorized preference to or for any creditor or transferor, or~c} to defraud or to make this application on its~ehalf; {2) that he/she has read ot~ure any creditor or transferor; (5) that the transfer application the foregoing and knows the contents thhereof and that each of the ma',~ be withdrawn by either the applicant or the licensee with no above statements therein made are true; (3) that no person other resitting liabilityy to the Department. than the appplicant or a~plicants has any direct or indirect interest ;' understand t}1at if I fail to qualify for the license or withdraw this in the applicant or appplicant's business to be conducted under the application there will he a service charge of one-fourth of the license(s) for which this application is made; (4 that the transfer license fee paid, up to ~ IU(I. application or proposed transfer is not made to ~a) satisfy the I SOLE OWNER 8. PRINTED NAME (Last. arsl, middle) !SIGNATURE !DATE SIGNED X PARTNERSHIP/LIMITED PARTNERSHIP (Signatures o~f general partners only) 9, PARTNER'S PRINTED NAME (Lash first, mld~) SIGNATURE DATE SIGNED x PARTNER'S PF21NTE0 NAME {Las4 (rsL rcgddk) SIGNATURE DATE SIGNED X ~ PARTNER'S PRINTED NAME {Last, frcsl, mddle) _ . SIGNATURE DATE SIGNED X . ~ CORPORATION 10. PRINTED NAME (Last, 1'rs1, middle) SIGNATURE ~ i DATE SIGNED ~X I TITLE ^ President ^ Vice President ^ Chaimaan of the Board PRINTED NAME (Last, fksl, middle) SIGNATURE DATE SIGIJED I I X TITLE ^ Secretary ^ Asst Secretary- ^ Chief Financial Officer ^ Asst. Treasurer LIMITED LIABILITY COMPANY 11. The limited liability company is member-run ©YeS ^NO (If no, complete Item #12 below) 12. fdAME OF DESIGNATEO MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, flrsl, Piddle) ABC INITIALS/DATE {ABC use orU~ I Linda M. Cimbron, Asst. Secretary 13. MEMBER'S PR~d7FD NAME (Last, l'vsi, middle) Cimbron, Linda M. SIGNATU ~~,,~ /~~ ''-- ~^ ~ j DATE SIGNED xi~~~~~- /~'C ~~/~~%i~~ i ~~~ 2 ~ Z~~~ MEMBER'S PRINTED NAME (Lass, first, middle) ABC-211-SIG (2/d3) DATf SI~k,GffNED GG~~ ~~}} ryry QQ f`tU~ dd ~ LU~U "SIGN ON" 110 7-3 Slate of California LICENSE TF~i'A'NSFER REQUEST • Th)s form is to be signed by transferors only. • Read instructions before completing. • All signatures must be notarized in accordance with laws of the State where _~ned. __ _ ___~.~_~ 4. LICENSEE'S NAME (Tiam~wlSalferl Longs Drug Stores California Inc. 6. EXISTINC9 PROMISES ADDRESS y~-~ieu~ Department of Alcoholic Beverage Control SIG_N__O_F_F_J_ ___ __________ ___ 17. DISTRICT UFFICE ..._ ~ 2 LICENSE NUMBER ~ Santa Ana 373109 J. TRANSACTION TYPE ^ Exchange O Prcn~ise to Premise Transfer Qx Person to Person Transfer ^ Other-. 5. APPLICANT'S NAME rkanskuew/BuYerl ~ Longs Drugs Stores California LLC Garfetd (3cach CVS LLC 7. LICENSEE'S MAILING ADDRESS {AanslerrrlSeBer) o ut,GYace a rn.~r1c ivu,~cn 141 N CIVIC DR, WALNUT CREEK, CA 94596 ~ 925-290-6891 ------- 1 hereby request surrender of my license under Section ~24045.5(bJ of the A8C Act so tha(a Temporary Permit maybe issued to the _ Transferee. _ ---- 5. SIGNATURE OF TRANSFERURISELLERFQR TEMPORARY PERMIT(adyartsi~gakseroq~ ~ DATE SIGNED iD ENEWAL DUE DATE I it. SURRENDER DATE -12 TEMP. EFFECTIVE DHTE ~ 13. 7EIdP, EXPIRATION DHT£ TRANSFEROR'S CERTIF1CA710N Under penalty of perJury, each person whose signature appears below, certifies and says: (t) He is the licensee named iu the foregoins~ transfer application, duly authorized to make this transfer appbcaUOn; (2} that hr hereby makes application to surrender all interest in tie license(s) described above and to transfer same to the applicant and/or location indicated at the uppper portion of this form, if such transfer is approved by the Director; (3) that the transfer application or proposed transfer is not made to satisf}~ the payment of a loan or to fulfill an agreemet7t entered Into more than ninety days preceding the da}~ on which the transfer application is filed with the Department or to main or establish a preference to or for any creditor of transferor or to defraud or injure any creditor of transferor; (4) that the transfer application map be withdrawn by either the applicant or the licensee with no resulting liability to the Department. _ SOLE OWNER _ 14. SOLE OWNER'S PRINTED NAAAE (Last rrst, middle) ~ SIfiNATUtiE 1~ DNTE SIGNED X i pARTNERSHIPlLIMITED PARTNERSHIP (sfgnafut'es of genera! partners only) 15. PARTNER'S PRINTED NAME (Cast, first, middle) !SIGNATURE ~ iX OATE SIGNED PARTNER'S PRINTED NAME (Last, rlraC middle) ;SIGNATURE PATE SIGNF~ I 3,3X I PARTNER'S PRINTED NAME (LeN, first, middle) ~ SIGNATURE DATE SIGNED IX i _ (-npona e•rlnnt ~ - (Las1, rrsl, coddle) SIGNATURE ~ DATE SIGNED Lankowsky, Zenon P. i X ~; ~ I ~QU ~ ~ ~~~$ ®President ^ Vice President ^ Chairnzan of the Board CORPORATE OFFICER'S PRINTED NAME (Last, first, mkMle) ~ SIGNATURE DATE SIGNED Moffatt, Thomas ;X ~ ~~~~ ~ ~ ~~~~ TITLE _® Secretary ^ Assistant Secretary O Chief Finaneia Officer ^ Assistant Treasurer LIMITED LIABILITY COMPANY 77 The limited liability company is member-run ~ Ye5 ^ NO (Ii no, complete Item #18 below) 19. NAME OF DESIGIJATED LLC MANAGER, MANAGIIJG MEMBER OR DESIGNATED OFFICER (Cost, rus+, middle) ABC INITIALSJDATE (ABC useunlT9 15. LLC MEMBER'S PRIIJTED NAME tLasl, rnsl, kdddle) ~ ~ SIGNATURE ~ OATE SIGNkU ' V I ~ ^ i LLC MEMBEF75 PRINTED NAME (Last rlrs4 mMdla) - j SIGNATURE ~ ~ DATE SIGNED - ;X i ASG211-A (9101) "S1G OFF" ~ 7-4110