102-Application for ABC License.pdfDepartment of Alcoholic Beverage Control State of California
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSES)
ABC 211 (6/99)
TO:Department of Alcoholic Beverage Control
100 PASEO DE SAN ANTONIO
ROOM 119
SAN JOSE, CA 95113
(408) 277-1200
File Number: 505143
Receipt Number: 2025126
Geographical Code:
Copies Mailed Date:
Issued Date:
4303
October 19, 2010
DISTRICT SERVING LOCATION: SAN JOSE
First Owner: WHOLE FOODS MARKET CALIFORNIA INC
Name of Business:
Location of Business:
County:
Is Premise inside city limits?
Mailing Address:
(If different from
premises address)
Type of license(s): 21
WHOLE FOODS MARKET
20955 STEVENS CREEK BLVD
CUPERTINO, CA 95014-2107
SANTA CLARA
Yes
5980 HORTON ST
STE 200
EMERYVILLE, CA 94608-2057
Transferor's license/name: 4736 / P W SUPERMARKETS INC
License Type
21 - Off -Sale General
21 - Off -Sale General
21 - Off -Sale General
Transaction Type
Census Tract 5078.06
Dropping Partner: Yes No
Fee Type Master Dun
ANNUAL FEE NA
PREMISE TO PREMISE TRANSFER NA
PERSON -TO -PERSON TRANSFER NA
Y
Y
Y
Date Fee :,
10/19/10 $582.00
10/19/10 $100.00
0 10/19/10 $1,250.00
Total $1,932.00
Have you ever been convicted of a felony? No
Have you ever violated any provisions of the Alcoholic Beverage Control Act, or regulations of the
Department pertaining to the Act? Yes
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 premises 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: October 19, 2010
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 any 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 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; (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)
.WHOLE FOODS MARKET CALIFORNIA INC See 211 Signature Page
State of California
APPLICATION SIGNATURE SHEET
"SIGN ON")
• This form is to be used as the signature page for 1. OWNERSHIP
applications not signed in the District Office.
• Read instructions on reverse before completing.
• All signatures must be notarized in accordance with
laws of the State where signed.
one)
❑ Sole Owner
❑ Partnership
❑ Husband & Wife
❑ Partnership -Ltd
Department of Alcoholic Beverage Control
I
® Corporation
❑ Limited Liability Company
Other
2. FILE NUMBER (If any) 3. LICENSE TYPE 4. TRANSACTION TYPE
❑ Original ® Person to Person Transfer
4736 21 ❑ Exchange Premise to Premise Transfer
❑ Other
6. APPLICANT(S) NAME (Last, first, middle)
Whole Foods Market California, Inc.
6. APPLICANT'S MAILING ADDRESS (Street address/P.O. box, city, state, zip code)
5980 Horton St. Ste 200, Emeryville, CA 94608
7. PREMISES ADDRESS (Street address, city, zip code)
20955 Stevens Creek Blvd., Cupertino, CA 95014 _
APPLICANT'S CERTIFICATION
Under penalty of perjury, each person whose signature appears payment of a loan or to fulfill an agreement entered into more than
below, certifies and says: (1) He/She is an applicant, or one of ninety (90) days preceding the day on which the transfer
the applicants, or application is filed with the Department, (b) to gain or establish a
corporation, named ithe foregoing ap lication, duly authorized preference to or for any creditor or transferor, or c) to defraud or
to make this application on its behalf; (p2) that he/she has read injure any creditor or transferor, (5) that the transfer application
the foregoing and knows the contents thereof and that each of the may be withdrawn by either the applicant or the licensee with no
above statements therein made are true; (3) that no person other resulting liability to the Department,
than the appplicant or appplicants has any direct or indirect interest I understand that if I fail to qualify for the license or withdraw this
in the a plicant or applicant's business to be conducted under the application there will be 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 $100,
application or proposed transfer is not made to (a) satisfy the
SOLE OWNER
8, PRINTED NAME (Last, first, middle) �SIGNATURE DATE SIGNED
A
PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of _general partners only)
9. PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
CORPORATION
I0. PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
Lannon, David A.
TITLE
r/t ®President ❑Vice President ❑ Chairman of the Board
U ; PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
/f Percival, Albert E.
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. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle) ABC INITIALS/DATE (ABC use only)
13. MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
A
ABC-211-SIG (2J03) �.� X "SIGN ON"
State of California
County of
(insert name and title ofthe
personally appeared \
who proved tonecmthe basis of satisfactory evidence tobmthe persoDKwhose is/am
subscribed tothe within instrument and acknowledged tornethat hehaheAhey, executed the same in
his/hedffre�authorized capacityf�&), and that by hisAie#tNe4 signature(&) on the instrument the
peroonfef or the entity upon behalf of which the person*acted, executed the instrument.
| certify under PENALTY PERJURY under the laws ofthe State ofCalifornia that the foregoing
WITNESS my1iand anO official seal. COMM. #1720344 m
Notary Puwic� LA
VMycorrmExPAw26,MA1
Cupertino
State of California Department of Alcoholic Beverage Control
APPLICATION SIGNATURE SHEET ("SIGN ON")
• This form is to be used as the signature page for 1. OWNERSHIP TYPE (Check one)
applications not signed in the District Office. F-1 Sole Owner Z Corporation
• Read instructions on reverse before completing. El Partnership 0 Limited Liability Company
• All signatures must be notarized in accordance with F-1 Husband & Wife El Other
laws of the State where signed. ❑ Partnership -Ltd
2. FILE NUMBER (if any) 3, LICENSE TYPE 4. TRANSACTION TYPE
El Original X Person to Person Transfer
4736 21 E] Exchange 0 Premise to Promise Transfer
El Other
5. APPLICANT(S) NAME (Last, first, middle)
Whole Foods Market California, Inc.
6. APPLICANT'S MAILING ADDRESS (Street address/P.O. box, chy, state, zip code)
5980 Horton St. Ste 200, Emeryville, CA 94608
7. PREMISES ADDRESS (Street address, city, zip code)
20955 Stevens Creek Blvd., Cupertino, CA 95014
APPLICANT'S CERTIFICATION
Under penalty of perjury, each erson whose signature appears payment of loan or to fulfill an agreement entered into more than
below, certifies and says: (1) HeIghe is an applicant, 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 ain or establish a
corporation, named in the foregoing a -ication, duly authorized preference I to or for any creditor or transferor, or V) to defraud or
to make this application on its behalf; that he/she has read injure any creditor or transferor; (5) that the transfer application
the foregoing and knows the contents thereof and that each of the may be withdrawn by either the applicant or the licensee with no
above statements therein made are true; (3) that no person other resulting liability to the Department.
than the applicant or aglicants has any direct or indirect interest I Understand that if I fail to qualify for the license or withdraw this
in the stI t i ican or applicant's business to be conducted under the application there will be a service charge of one-fourth of the
licenseethis is application is made; (4) that the transfer license fee paid, Lip to $ 100.
application or proposed transfer is not made to (a) satisfy the
SOLE OWNER
B. PRINTED NAME (Last, first. middle) SIGNATURE DATE SIGNED
� X
PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only)
9. PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
CORPORATION
10. PRINTED NAME (Lost, first, middle) SIGNATURE DATE SIGNED
Lannon, David A. X
TITLE
Z President E]Vice President ❑ Chairman of the Board
PRINTED NAME (Last, first, middle) SIGNATURE DATE SIG
Percival, Albert E. X .3
TITLE
Secretary E] Asst, Secretary E] Chief Financial Officer E] Asst, Treasurer
LIMITED LIABILITY COMPANY
11. The limited liability company is member -run El Yes E]No (if no, complete Item #12 below)
12. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle) ABC INITIALS/DATE (ABC use only)
13. MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
MEMBER'S PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED
X
ABC-21 1 -SIG (2103) "SIGN ON"
STATE OF TEXAS }
) SS:
COUNTY OF TRAVIS }
On this the 23rd day of September, 2010, ALBERT Ea PERCIVAL personally
appeared before me, a Notary Public in and for the State and County aforesaid, known to
be the person described in and who executed the aforesaid documents, and who
acknowledged to me that he/she executed the same freely and voluntarily and for the uses
and purposes therein mentioned.
WITNESS my hand and official seal, the day and year first above written.
RYAN BISSETT _ -
"�:"= Notary Public, State of Texas
4},y My Commission Expires otary Public
'- March 18, 2012