HomeMy WebLinkAboutalc appDepartment of Alcoholic Beverage Control State of California
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE(S)
AHC 21 l (6199)
TO:Department of Alcoholic Beverage Control File Number: 521531
1900 CHURN CREEK RD Receipt Number: 2110550
STE 215 Geographical Code: 0405
BEDDING, CA 96002 Copies Mailed Date: May 3, 2012
(530} 224-4830 Issued Date:
.DISTRICT SERVING LOCATION: BEDDING
First Owner: POLLAK, 3ACOB HANK
Name of Business:
Location of Business: 5742 SKYWAY
PARADISE, CA 95969
County: BUTTE
Is Premise inside city Iimits? Yes Census Tract 0022.00
Mailing Address:
{If different fi~om
premises address)
Type of license(s): 47
Transferor's licenselname: 415463 / POLLAK, HOWARII ALAN Dropping Partner: Yes No~
License Type Transaction Tvue Fee Tvne Master Dup Date Fee
47 - On-Sale General Eating ANNUAL FEE P20 Y D 05/03/12 $644.00
47 - On-Sale General Eating PERSON-TO-PERSON TRANSFER P20 Y 0 05/03/12 $1,250.00
NA FEDERAL FINGERPRINTS NA N 1 05/03/12 $24,00
NA STATE FINGERPRINTS NA N 1 05/03/12 $39.00
Total $1,957.40
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 ofthis 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 BUTTE Date: May 3, 2012
Under penalty ofperjury, each person whose signature appears below, certifies and says: {I} 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
[snows the contents [hereofand that each of the above statements therein made are Prue; (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 fu1611 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 oftransferor; (5} that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department.
Applicant Names}
POI,LAK, JACOB HANK
Applicant Signature(s)
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