102-Alcohol Beverage License Application.pdfDepartment of Alcoholic Beverage Control State of California
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE(S)
ABC 211 (6/99)
TO:Department of Alcoholic Beverage Control File Number: 503668
100 PASEO DE SAN ANTONIO Receipt Number: 2018891
ROOM 119 Geographical Code: 4303
SAN JOSE, CA 95113 Copies Mailed Date: September 21, 2010
(408) 277-1200 Issued Date:
DISTRICT SERVING LOCATION: SAN JOSE
First Owner: SEASONED SKILLET LLC
Name of Business: GUMBAS
Location of Business:
County:
Is Premise inside city limits?
Mailing Address:
(If different from
premises address)
Type of license(s): 41
Transferor's license/name: 459907 / 3CHIVES LLC
License Tvpe Transactigpjype
NA STATE FINGERPRINTS
NA FEDERAL FINGERPRINTS
NA ISSUE TEMPORARY PERMIT
41 - On -Sale Beer And Wine PERSON -TO -PERSON TRANSFER
41 - On -Sale Beer And Wine ANNUAL FEE
Census Tract 5077.01
Dropping Partner: Yes.
Fee Tvne
Master
Dun
Date
Fee
NA
N
2
09/21/10
$79.00
NA
N
2
09/21/10
$48.00
NA
y
0
09/21/10
$100.00
NA
Y
0
09/21/10
$150.00
NA
y
0
09/21/10
$350.00
Total $726.00
Have you ever been convicted of a felony? No
Have you ever violated any provisions of the Alcoholic Beverage Control Act, of 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 promises 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 2l,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 belialf; (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 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)
.SEASONED SKILLET LLC See 211 Signature Page
State of California
APPLICATION SIGNATURE SHEET ("SIGN ON'�
* This form is to be used as the signature page for
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.
[] sole owner
[]Partnership
El married couple
(:1 Domestic Partner
Department of Alcoholic Beverage Control
IJ Partnership -Ltd
[] corporation
FE] Limited Liability Company
[]Other
-i.—FFLE—NUMBER (if any) 3. LICENSE TYPE A. TRANSACTION TYPE
Original [00 Person to Person Transfer
Exchange []Premise to Premise Transfer
459907 41
1-1 Other
first, middle)
Seasoned Skillet LLC
-6. —APPLICANTS MAILING ADDRESS (Street address/P.O. box, city, state, zip code)
21678 Stevens Creek Blvd. Cupertino CA 95014
---------------
............ . — - ------
7.PREmI§_ESADbRESS _(Street address, city, zip code)
21678 Stevens Creek Blvd. Cupertino CA 95014
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
license(s) for which this application is made; (4) that the transfer
rust, mirraie)
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.
PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only)
CORPORATION
10. PRINTED NAME (Last,
TITIL—E
President Vice President []Chairman . . .1 .. - o 1. f - the Board DATE PRINTNAME (Cast. first, middle) ISIGNATURE
Secretary [—I Asst. Secretary F] Chief Financial officer F]Asst. Treasurer
LIMITED LIABILITY COMPANY
11. The limited liability company is member -run SlYes ONO (if no, complete Item #12 below)
12. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle)
Sewnarain, Kemraj, Premdutt
3. MEMBER'S PRINTED NAME (Last, first, middle) SIGNATOI���, DATE SIGP
Sewnarain, Kemraj, Premdutt X i 9/2/10
Sewnarain, Saloshini X 9/2/10
ABC-21 1-SIG (2/09) "SIGN ON"
State ofCalifornia
On before me,Here Insert I
personally appeared
Name(s) of Signer(
who proved tomeVnthe basis of satisfactory evidence to
be the person(s) whose name(s)4are subscribed to the
within instrument and acknowledged to me that
he/sha/thoyexeou\ed the same in*dM�theirauthorized
oapocity(ies), and that by hi&fhen/their signature(s) on the
instrument the person(u), or the entity upon behalf of
which the person(s) acted, executed the instrument.
| certify under PENALTY OF PERJURY under the laws
of the State ofCalifornia that the foregoing paragraph io
true and correct.
WITNESS myhand and official seal.
e6�JA�
n=.m°*���x�. - 0 Signature mNotary Public
OPTIONAL
Though the information below isnot required uylaw, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document
Description of Attached Document
Title orType of Document:
Document Date: Number cdPages:
Signer(s) Other Than Named Above:
Claimed by Signer(s)
Signm/uName: S87IMA(&OA, id
O Individual
FVCorpoogo Officer --TiUo(o):'
O Pahner—OUmihed UG*neod
O Attorney in Fact
7 Trustee
F1 Guardian or Conservator
0 Other:
Signer Is Representing:
Signer's Name:
D Individual
OCorpomteOffiomr--Thle(s):—
OPakner—OUmited El General
0A8orney in Fact
OTrustee
OGuardian urConservator
Signer |sRepresenting:
_________
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