102-Application for Alcoholic Beverage License.pdfDepartment of Alcoholic Beverage Control State of California
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE(S)
ABC 211 (6199)
TO. -Department of Alcoholic Beverage Control
100 PASEO DE SAN ANTONIO
ROOM 119
SAN JOSE, CA 95113
(408) 277-1200
DISTRICT SERVING LOCATION: SAN eIOSE,
First Owner:
Name of Business:
Location of Business:
County:
is Premise inside city limits?
Mailing Address:
(If different from
premises address)
File Number: 511240
Receipt Number: 2057577
Geographical Code: 4303
Copies Mailed Date: May 27, 2011
Issued Date:
1XI113 MITAN11112116141
ru WA WN FA W1W
10050 S DE ANZA BLVD
CUPERTINO, CA 95014-2128
SANTA CLARA
Census Tract 5080.01
222 KE ARNY ST STE 200
C/O LEGAL IliPT KIMPTON HOTEL AND
RESTAURANT GRP
SAN FRANCISCO, CA 94108-4537
Type of license(s): 47,58,66,68 \ /I
Transferor's license/name: 454498 / RP SCS CUPERTINO HOTEL Dropping Partner: Yes No X�
LLC
Lic2pM13M
Transaction
FeLType
Master Du p
Date
Fee
47 - On -Sale General Eating
PERSON -TO -PERSON TRANSFER
P40
y
0
05/31/11
$1,250.00
47 - On -Sale General Eating
ANNUAL FEE
P40
y
0
05/31/11
$876.00
58 - Caterer Permit
DUPLICATE/SECONDARY
NA
N
1
05/31/11
$131.00
58 - Caterer Permit
PERSON -TO -PERSON TRANSFER
NA
N
1
05/31/11
$0.00
66 - Controlled Access Cabin
DUPLICATE/SECONDARY I
NA
N
1
05/31/11
$577.00
66 - Controlled Access Cabin
PERSON -TO -PERSON TRANSFER
NA
N
1
05/31/11
$0.00
68 - Portable Bar
PERSON -TO -PERSON TRANSFER
P40
N
3
05/31/11
$300.00
68 - Portable Bar
DUPLICATE/SECONDARY
P40
N
3
05/31/11
$1,881.00
NA
ISSUE TEMPORARY PERMIT
NA
N
5
05/31/11
$500.00
Total $5,515.00
Have you ever been convicted of a felony? No
Have you over 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 ofthe provisions of the Alcoholic
Beverage Control Act.
STATE OF CALIFORNIA County of SANTA CLARA Date: May 27, 2011
Under penalty, of perjury, each person whose signature appears below, certifies and says: (1) He is all applicant, or one of the applicants, or an executive officer
of the applicant corporation, named in the foregoing application, duly al.1010riZed 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 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 Narne(s) Applicant Signature(s)
See 211 Signature Page
KIMPTON HOTEL & RE, STAURANT GROUP LLC
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.
11111"IFI-1:1
Kimpton Hotel & Restaurant Group, LLC
TYPE
-6, -APPLICANT'S MAILING ADDRESS (Street address/P.O. box, city, state, zip code)
222 Kearny Street, Suite 200, San Francisco, CA 94103
7. PREMISES ADDRESS (Street address, city, zip code)
10050 S. De Anza 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 tnic; (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
0995��
CORPORATION
10. PRINTED NAME (Lost, first,
President [:]Vice President E]Chairman of the Board
JINTED NAME (Last, first, middle)
Department of Alcoholic Beverage Control
0Sale Owner 1:1 Partnership -Ltd
OPartnership 0 Corporation
FlMarried Couple FolLimited Liability Company
DDomestic Partner F-1Other
TRANSACTION TYPE
L]Original ]Person to Person Transfer
E-1 Exchange OPremise to Premise Transfer
11Other
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.
E]Secretary L]Asst. Secretary []Chief Financial Officer ElAsst. Treasurer
Wnxnlm���
DATE
I L 61UNtU
11. The limited liability company is member -run r ]yes EN] No (If no, complete Itern;912 below)
12. NAME OF DE5IGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, fddl
Kinipton Group Holding LLC
13. MEMBER-5PRINTED NAME (Last, first, middle) SG BE DATE SIGNED
Depatie, Michael ____
MEMBER's PRINTED NAME (Last, first, mjddWF GNATURE DATE SIGNED
X
"
ABC-21 1 -SIG (2/09) SIGN ON"
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State ofCalifornia
County of �
On before me,
personally appeared
who proved tomennthe basis ofsatisfactory evidence to
be the person(s) whose name(s) is/are subscribed tothe
within instrument and acknowledged to me that
he/she/they executed the same in himMec/theirauthorizud
napocity(ieo)' and that by his/her/their signature(s) on the
instrument the pemon(o), or the entity upon behalf of
which the person(s) eobad, executed the instrument,
| certify under PENALTY OF PERJURY under the |uwo
of the State of California that the foregoing paragraph is
true and correct.
WITNESS my hand andofficial seal.
r�ommo��mx�. - - Signature mNotary Public
OPTIONAL _
Though the information below is not required by law, it may prove valuable mpersons relying onthe document
and could prevent fraudulent removal and reattachment o/this form manother document,
Title or Type of Document:
Document Date:
Signer(s) OtherThan Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
O Individual
O Corporate Officer --TK|n(s):
O PaMnm—OUmitedOGenera
OAttorney inFact
O Trustee Top of thumb here
O Guardian orConservator
O [xhnc
Signer hRepresenting: _..........
_
Number ofPages:
Signer'sName:
O|ndividmal
OCorporate Officer —Tide(e:__
OPurtner--OLimhad OGenens|
OAttorney in Fact
UTruni*e
El Guardian or Conservator
Signer Is Representing
0 2007 National Notary Association - 9350 Do Solo Ave., P.O. Box 2402 Chatswortl i, CA 91313-2402 - www.NationilNotary.org Itern 115907 Reorder: Call IbIl-Fror, I -BDO-876-6827