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102-Application for Alcoholic Beverage License.pdf
Department of Alcoholic Beverage Control State of California APPLICATION FOR ALCOHOLIC BEVERAGE LICENSES) ABC 211 (6/99) TO: Department of Alcoholic Beverage Control File Number: 503495 100 PASEO DE SAN ANTONIO Receipt Number: 2018263 ROOM 119 Geographical Code: 4303 SAN JOSE, CA 95113 Copies Mailed Date: September 16, 2010 (408) 277-1200 Issued Date: DISTRICT SERVING LOCATION: SAN JOSE First Owner:. ONE EYED SPIRITS INC - Name of Business: ONE EYED SPIRITS Location of Business: County: Is Premise inside city limits? Mailing Address: (If different from premises address) Type of license(s): 12,18 Transferor's license/name: 19200 STEVENS CREED BLVD STR20® CUPERTINO, CA 95014-2530 SANTA CLARA Yes Census Tract 5080.02 Dropping Partner: Yes No License Type Transaction Type Fee Type Master Dun Date Fee 18- Distilled Spirits Wholesi ORIGINAL FEES NA Y 0 09/16/10 $100.00 18 - Distilled Spirits Wholesi ANNUAL FEE NA Y 0 09/16/10 $514.00 12 - Distilled Spirits Importer DUPLICATE/SECONDARY NA N 1 09/16/10 $74.00 NA STATE FINGERPRINTS NA Y 0 09/16/10 $78.00 NA FEDERAL FINGERPRINTS NA N 3 09/16/10 $48.00 Total $814.00 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? 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 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: September 16, 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) .ONE EYED SPIRITS INC See 211 Signature Page State of California APPLICATION SIGNATURE SHEET ("SIGN ON") Department of Alcoholic Beverage Control • This form is to be used as the signature page for Sole owner Partnership -Ltd applications not signed in the District Office. El • Read instructions on reverse before completing. Partnership Corporation • All signatures must be notarized in accordance Married CoupleLimited Liability Company with laws of the State where signed. Domestic Partner FlOther 2. FILE NUMBER (If any) 3. LICENSETYPE 4. IRANSAcnUN fYrt Original Person to Person Transfer Exchange Premise to Premise Transfer 12/18 nOther -5. APPLICANT(S) NAME.(Last, first, middle) One Eyed Spirits, Inc. 6. APPLICANT'S MAILING ADDRESS (Street address/P.O. box, city, state, zip code) 19200 Stevens Creek Blvd., Suite 200, Cupertino, CA 95014 7. PREMISES ADDRESS (St real address, city, zip code) 19200 Stevens Creek Blvd., Suite 200, Cupertino, CA 95014 APPLICANTS CERTIFICATION Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He/Slie 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/she 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 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, (b) to gain or establish a preference to or for any creditor or transferor, or (c ) to defraud or injure any creditor or transferor; (5) that the transfer application may be withdrawn by either the applicant or the licensee -with no resulting liability to the Department. I understand that if I fail to qualify for the license or withdraw this application there will be a service charge of one-fourth of the license fee paid, up to $100, 8. PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED . PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only) 9. PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE W PARTNER'S PRINTED NAME (Last, first, middle) SIGNATURE X PARTNERS PRINTED NAME (Last, first, middle) SIGNATURE DATE SIGNED X %CORPORATION j 10. PRINTED NAME (Last, first, middle), Harvela, Juh1a t-� r E ) n o M TITLE \ \ l 1 r President ❑Vice President Chairman of the Board PRINTED NAME (Last, first, middle) r.h KI Secretary F]Asst, Secretary Chief Financial Officer Ass,, TwasureT LIMITED LIABILITY COMPANY 11. The limited liability company is member -run Yes 12. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle)a , NAME (Last, first, middle) middle) X 00 ri ABC-211-SIG (2/09) "SIGN ON" STATE OF CALIFORNIA COUNTY OF Cer'ICC�C On _before me,l rio ' J Notary Public, personally appeared who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under Penalty of Perjury under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. ATTENTION NOTARY The information requested below is OPTIONAL, It could, however, prevent fraudulent removal and reattachment of this certificate to any unauthorized document. THIS CERTIFICATE Title of Type of Document A -z1l S t _ MUST BE ATTACHED ONLY TO THE DOCUMENT DESCRIBED AT RIGHT Number of pages 01 t Date of Document Z2 - � -- l c Signer(s) other than named above MA(E - Wolcotts Forms, our resellers and agents make no representations or warranty, express or implied, as to the fitness of this form for any specific use or purpose. If you have any question, it is always best to consult a qualified attorney before using this or any legal document, © 2007 Wolcotts Forms, Inc. Signer #1 name: ner #1 CAPACITY CLAIMED BY SIGNER(S) ❑ INDIVIDUAL(S) ❑ CORPORATE OFFICER(S) ❑ PARTNERS ❑ ATTORNEY IN FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER SIGNER IS REPRESENTING: (Name of Person(s) or Entity(ies)) Signer #2 name: g ^ l Thumbprint signer#2 CAPACITY CLAIMED BY SIGNER(S) ❑ INDIVIDUAL(S) ❑ CORPORATE OFFICER(S) ❑ PARTNERS ❑ ATTORNEY IN FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER SIGNER IS REPRESENTING: (Name of Person(s) or Entity(ies)) �67uu5�632i7ll. State of California APPLICATION SIGNATURE SHEET ("S/ ON") Department of Alcoholic Beverage Control • This form is to be used as the signature page for Sole Owner Partnership -Ltd applications not signed in the District Office. • Read instructions on reverse before completing. Partnership no Corporation • All signatures must be notarized in accordance Married Couple n Limited Liability Company with laws of the State where signed. Domestic Partner D Other 2. FILE NUMBER (if any) 3. LICENSE TYPE 4. 1 nAMAU I1UN 1 rrt *Original Person to Person Transfer ❑Exchange Premise to Premise Transfer 12/1 8 POther 5. APPLICANT(S) NAME (Last, first, middle) One Eyed Spirits, Inc. 6. APPLICANT'S MAILING ADDRESS (Street address/P.O, box, city, state, zip codej 19200 Stevens Creek Blvd., Suite 200, Cupertino, CA 95014 7. PREMISES ADDRESS (Street address, city, zip code) 19200 Stevens Creek Blvd., Suite 200, Cupertino, CA 95014 APPLICANT'S CERTIFICATION Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He/She 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/she 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 licenses) for which this application is made; (4) that the transfer 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, (b) to gain or establish a preference to or for any creditor or transferor, or (c ) to defraud or injure any creditor or transferor; (5) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. I understand that if I fail to qualify for the license or withdraw this application there will be a service charge of one-fourth of the license fee paid, up to $100. SOLE OWNER a. 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 F9[III_A 7 D Fes+ CORPORATION 1e. PRINTED NAME (Last, first, middle} SIGNATURE DATE SIGNED Harvela, Jussi X TITLE President vice President Chairman of the Board PRINTED NAME (Last, first, middle) SIGN URE DATE SIGNED 1Witter III, Dean Xcc,K _ rsL 9/7/2010 �TITLE 1111111111ISecretary 11Asst, Secretary Chief Financial Officer E]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-211-SIG (2/09) "SIGN ON" r' r ...:z�.!�v: �.-�a�.�a�a!�a!-�a,�..;�.''�S!c�t.; �L.�a..sit/�rc�',:;,�3.y�S:�N:�.',c�i����,,..,5!.�.�.a�.'S!��. • v/�S�vsaS.�t,=ate.-�.`..,L!�5�.-�aS�.T.\.ca. '��,yaL!aa9 State of California County of 1�< 'i k, aC,t 5 (,3 On 7 ( t t 10 before me, Date Here Insert Name and Title 611the Officer personally appeared who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized KAREN BODISHBAUGH capacity(ies), and that by his/her/their signature(s) on the Comm.# 1837685 U1 NOTARY POeUGCMIFORMMA Einstrument the person(s), or the entity upon behalf of crlr i COMM.CMME OF sut 25, 2 1 which the person(s) acted, executed the instrument. My tAM, EXP. FE®. 25, 2013 p ( ) I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my ha and official sea/l. Signature &,& 6l' Place Notary Seal Above Signature of Notary PubIrc OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Title or Type of Document: Document Date: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: ❑ Individual ❑ Corporate Officer — Title(s): _ ❑ Partner — ❑ Limited ❑ General ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: RIGHTTHUMBPRINT OF SIGNER Number of Pages: Signer's Name: ❑ Individual ❑ Corporate Officer — Title(s): _ ❑ Partner — ❑ Limited ❑ General ❑ Attorney in Fact ❑ Trustee ❑Guardian or Conservator ❑ Other: Signer Is Representing: RIGHTTHUMBPRINT OF SIGNER •! f ✓.'"u✓4i✓'.+. ✓ '✓:�:� v:�:`✓•'�6v6�✓:�:'ri'�4�'✓,:�✓..�6�✓SL.L..�.v'd_'✓.'.'=%G�4�t/.4�✓.G'� ,y .=�..d:�%: ✓4�.✓,:v✓G� 'v:iU.L'.v✓.'u 'i v:�:'✓ I/ /.. •• •1 ,1 •/ 01/ i