09. ABC WalgreensCITY OF
`~
CUPERTIN4
City Hall
10300 Torre Avenue
Cupertino, CA 95014
(408) 777-3212
Fax: (408) 777-3366
OFFICE OF THE CITY MANAGER
AGENDA ITEM NUMBER ~I
SUBJECT AND ISSUE
Application for Alcoholic Beverage License.
BACKGROUND
1. Name of Business:
Location:
Type of Business:
Type of License:
Reason for Application:
RECOMMENDATIO
SUMMARY
AGENDA DATE "~~1 ~ ~ ~, ~ ~~ D
Walgreens
20011 Bollinger Road
Market
Off Sale Beer & Wine {20}
Original & Annual Fees
There are no use permit restrictions or zoning restrictions which would prohibit this use
and staff has no objection to the issuance of i:he license. License Type 20 authorizes tlne
sale of beer and wine for consumption off tlne premises where sold.
Prepared by:
~~ ' ~ hao, City Planner
G: plrtnni.~tg/~utsc/nbcWal~ eer~s
Submitted by:
David W. Knapp, City Manager
9-1
Department of Alcoholic Beverage Control
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSES}
ABC 211 {6/99)
State of California
TO: Department of Alcoholic Beverage Control
100 Paseo de San Antonio
Rm. 119
San Jose, CA 951 ] 3
(408)277-1200
DISTRICT SERVING LOCATION: SAN TOSE
First Owner: WALGREENCO
Nalne of Business: WALGREENS
Location of Business:
County:
Is premise inside city limits?
Mailing Address:
(If different from
premises address)
Type of licenses}: 20
Transferor's license/name:
File Number: 485034
Receipt Number: 1743354
Geographical Code: 4303
Copies Mailed Date: December 7, 2009
Issued Date:
20011 BOLLINGER RD
CUPERTINO, CA 95014-4532
SANTA CLARA
Yes
104 WILMOT RD
MS 1447
DEERFIELD, IL b0015
Census Tract 5080.01
Dropping Partner: Yes
License Tvne Transaction Type Fee Tvoe Master P~i42 ate
20 OFF-S ALE B EER ANC ORIGINAL FEES NA Y 0 12 / 0 7 / 0 4
20 OFF-SALE BEER AM ANNUAL FEE NA Y 0 1 2/ 0 7/ 0 9
Nq~~
Fee
$100A0•
$254.00
Total
$354.00
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? N e
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 wilt have ail 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: December 7, 2009
Under penalty of perjury, each person whose signature appears below, certifies and says: (L) 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 olhef
than the applicant or applicants leas arty direct or indirect interest 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 [o 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, (5} 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)
WALGREEN CO See 211 fiignature Page
9-2
State of California
APPLICATION SIGNATURE SHEET ("SIGN ON")
Department of Alcoholic Beverage Control
• This form is to be used as the signature page for
applications not signed in the District Office. Sole +Jwner
• Read instructions on reverse before completing. Partnership
• All signatures must be notarized in accordance ^ Married Couple
with laws of the State where signed.
I] Domestic Partner
2. FILE NUMBER (If any) 3. LICENSE TYPE. 4. TRANSACTION TYPE
~Origir~al
Exchange
N/A 20
5. APPLICANT{SI NAME (Last, (first, middle) ~ - ~ ~ ~ R'- w
Walgreen Co.
6. APPLICANT'S MAILING ADDRESS (Slreel addresslP,O. hox, city, stale, zip code) ~~
104 Wilmot Raad, M.S. #1447, Deerfield,lL 60015
7. PREMISES ADDRESS (Slreel address, city, zip code)
20011 13oilinger RD., Cupertino, CA 95074-4532
APPLICANT S CER77FlCATlON
Under penalty of perjury, each person whose signature appears payment of a loan or to fillfill an agreement entered into more than
below, certifies and says: (1) He/She is an applican#, or one of ninety (90} days preceding the day on which the transfer
the applicants, or an executive officer of the applicant application is filed with the Department, (b} to gain or establish a
corporation, named in the foregoing application, duly authorized preference to or for any creditor or transferor, or (c) to defraud or
to make this application on its behalf; (2) that he/she has read the injure any creditor or transferor, (5) that #ITe transfer application
foregoing and knows the contents thereof and that each of the ntay be withdrawn by either the applicant or the licensee with no
above statements therein made are true; (3) that uo person other resulting liability to the Depar4nent.
than the applicant or applicants has any direct or indirect interest 1 understand that if T fail to qualify for the license or withdraw
in the applicant or applicant's business to be conducted under the tlTis application there will be a service charge ofone-fourth of the
license(s) for which this application is made; (4) tha! the transfer license fee paid, up to $100.
30LE OWNER
PARTNERSHIPIt_IMITED PARTNERSHIP (Signatures of general partners only)
CORPORATION
70. PRINTED NAME {Las4 rest, middle) SIG RE DATE SIG~NIEDT (~
Green, Dana 1, X~~~~r ~. /I//rl' ~.~,~~l~ o t~ 1 ~ ~ ~ ~ ll~
President aVice Presiden# ~Chalrman of the Board
rran i to nruee l~as4 arse, nsaae) SIG RE DATE 61GNE pp
Kellen, Margarita E. X ~~~ O ~~ ~ 9 ~ ~ O a
. t
Secretary Asst. Secretary Chief Financial Officer Asst, Treasur r
LIMITED LIABILITY COMPANY
11. The limited liability company is mem]>er-run ~~Yes ~No {tf no, complete Item #12 below}
12. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, flrsl, middle)
'13. MEMBER'S PRINTED NAME (Lest, first, middle) - - SIGNATURE - ~ DAT£ SIGNED
X ~4~5'/°`°+tLS""E11'an'`~`'A'a. .~;s~~?R
MEMBERS PRINTED NAME {Last, first, middle) SIGNATURE 1-r ~ 4~• SIGNED '~~
X JEFtNNE il1~ ~I LER
ABG211-SIG (6108} "SIGN ON" ~OtBnr P]!bliC, Sta.Y~ Of IIIi17015 ~; 9 - 3
lUly Commission Expires March 19, 2072 r
Partnership-Ltd
~/ Corporation
Limited Liability Company
Other _.__
Person to Person Transfer
Premise to Premise Transfer
~Olher
.. _ ... l ,