102-Application for Alcoholic Beverage License.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: 503842
100 PASEO DE SAN ANTONIO Receipt Number: 2035862
ROOM 119 Geographical Code: 4303
SAN JOSE, CA 95113 Copies Mailed Date: January 11, 2011
(408) 277-1200 Issued Date:
FBI R] I M 9 M 1114311110 00
First Owner: THRIFTY PAYLESS INC
Name of Business: RITE AID 5967
Location of Business: HOMESTEAD RD & DE ANZA BLVD 2.0,580
SC
CUPERTINO, CA 95014
County:
Is Premise inside city limits?
Mailing Address:
(If different from
premises address)
Type of license(s): 21
Transferor's license/name:
SANTA CLARA
........ ....
STE 300
_S_4Xa.11fENTO, CA
Census Tract
Dropping Partner: Yes No
License Type Transaction Type_
Fee Type Master Du2 Date Fee
21 - Off -Sale General ANNUAL FEE NA y 0 01/11/11 $582.00
Total $582.00
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 all 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 23, 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 appl icant's, bus iness 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 all 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)
THRIFTY PAYLESS INC —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.
T FILE NUMBER (if any) 13. LICENSE TYPE
one)
L-] Sole Owner
El Partnership
E] Husband & Wife
[J Partnership -Ltd
Department of Alcoholic Beverage Control
M Corporation
E] Limited Liability Company
E_J Other
4. TRANSACTION FYPL
2 Original E] Person to Person Transfer
EJ Exchange El Premise to Premise Transfer
[:]Other
5. Apf3f, jCA4T_(S) NAME (Last, first, middle)
Thrifty Payless Inc (CAA Rite Aid #5967)
6. APPLICANTS MAILING ADDRESS (Street address/P.O. box, city, state, zip code)
2600 Capitol Avenue Suite 300 Sacramento CA 95816-5930
7. PREMISES ADDRESS (Street address, city, zip code)
Homestead Road and DeAnza Boulevard 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
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 or establish a
the applicants, or an executive officer of applicant
gain
named in the forming BID lication, duty authorized
a F corpor' 'ion to make this application on its behalf; �) that he/she has read
preference to or for any creditor or transferor, or (c) to defraud or
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
than the applicant or applicants has any direct or indirect interest
business to be under the
resultingliability 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
in the ap I or applicant's conducted
liccnse(s�lo,anI. 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 (Las , us -_ SIGNATURE I DATE SIGNED
PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only)
9. P 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 (Last, first, middle) S175
;E DATE SIGNED
Michael A. Podgurski Ix _V
TITLE
[] President IN Vice President E] Chairman of the B&rd
PRINTED NAME (Last, first, middle) SIGNATURE g DATE SIGNED
X Michael C. Yount
TITLE E] Secretary N Asst. Secretary E] Chief Financial Officer 1HAsst. Treasurer
LIMITED LIABILITY COMPANY
M
1 1� �TtOF D�J�ilitycAoGmp�anyls member -run El Yes El No (if no, complete Item #12 below)
ME DESIGNATED
MAN OFFICER (Last, first, middle)
12. NAME OF DESIGNATED MANAG ING MEMBER OR DESIGNATEDI ABC INITIALS/DATE (ABC use only)
13, MEMBER's PRINTED NAME (Last, first, middle)
MEMBER'S PRINTED NAME (Last, first, middle)
ABO-211-SIG (2/03)
X
SIGNATURE
X
"SIGN ON"
DATE SIGNED
L)
Commonwealth of Pennsylvania, County of Cumberland
on-(114L)00-4a before me, Deborah A. Hurley, personally appeared
Michael A. Podgurski, personally known to me to be the person whose name is
subscribed to the within instrument and acknowledged to me that he executed the same in
his authorized capacity, and that by his signature on the instrument, the person, or the
entity upon behalf of which the person acted, executed the instrument.
WITNESS my hand and official seal.
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
DEBORAH A. HURLEY, Notary Public
East Pennsboro, Twp., Cumberland County
My Commission Expires October 7, 2011
iiii'lull,it�IVA�t&,Tff""TN�Irti2timin"f
Commonwealth of Pennsylvania, County of Cumberland
-2011 before me, Deborah A. Hurley, personally appeared
Michael C. Yo6nt, personally known to me to be the person whose name is subscribed to
the within instrument and acknowledged to me that be executed the same in his
authorized capacity, and that by his signature on the instrument, the person, or the entity
upon behalf of which the person acted, executed the instrument.
WITNESS my hand and official seal.
11101, I'll, MUMARM141
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
DEBORAH A. HURLEY, Notary Public
East Pennsboro Twp., Cumberland Comfy
My Commission Expires October 7, 2011