ABC - Double Tree CampbellDepartment of Alcoholic Beverage Control State of California
APPLICATION FOR ALCOHOLIC BEVERLAGE LICENSE(S)
ABC 211 (6;99)
TO: Department of Alcoholic Beverage Control File Number: 643275
100 PASEO DE SAN ANTONIO Receipt Number: 2756250
ROOM 119 Geographical Code: 4302
SAN .10SF. CA 95113 Copies Mailed Date: October 13, 2022
(108) 277-1200 Issued Date:
DISTRICT SERVING LOCATION: SAN JOSE
First Owner: 1995 SOUTH BASCOM F&B LLC
Name of Business: DOUBLE TREE CAMBOELL
Location of Business: 1995 S BASCOM AVE
CANIPBELL, CA 95008
County: SANTA CLA.RA
Is Premises inside city limits? Yes Census Tract: 5026.04
Mailinc, Address:(Vdifferent 1145 GUGENIA. M.. STL 200
from CARPINTI' RIA, CA 93013-2169
premises address)
Type of license(s):
Transferor's license/name:
47 Dropping Partner: Yes__ No
603840 / FREMONT HOTEL OPERATING COMPANY LLC
License Type
47 - On -Sale General Eating Place
Transaction Type
PER
Master
Y
Secondary LT And Count
License Tv- e
Transaction Description
Fee Code
Drip Date
Fee
Application Fee
SIATE FINGERPRINTS
NA
I 10, 13 22
$39.00
Application Fee
PERSON FO PERSON TRF
NA
0 10. 13 _
S 1 .3r15.Q11
Application Fee
FEDERAL FINOERPRIN'IS
`A.
1 10,13
47 - On -Sale General Eatine Plac(
ANNUAL FEE
P.tll
0 l0; 13 22
S 1.290.00
Total
S2.658.00
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
STATE OF CALIFORNIA County of SAN-TA CLARA Date: October 13, 2022
Applicant Name(s)
1995 SOUTH BASCOM F&B LLC ` it it,
State of California
APPLICATION SIGNATURE SHEET ("SIGN ON")
Department of Alcoholic Beverage Control
• Read instructions on reverse before completing.
• All signatures must be witnessed by an ABC ❑Sole Owner nPartnership-Ltd
employee or notarized in accordance with laws Partnership (Corporation
of the State where signed.
Married Couple uLimited Liability Company
Domestic Partner Other
�jOriginal aPerson to Person Transfer
47 CExchange Premise to Premise Transfer
Other
1995 South Bascom F&B, LLC
6. APPLICANTS MAILING ADDRESS (Street address/P.O. box, city, state, zip code)
1145 Eugenia Place #200 Carpinteria, CA 93013
7. PREMISES ADDRESS (Street address, city, zip code)
1995 S. Bascom Ave., Campbell, CA 95008
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 license(s) for which
this application is made; (4) that the transfer application or proposed
SOLE OWNER
transfer is not made to (a) 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, (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, the application fee shall be non-refundable as specified in
Section 23320 B&P.
UAI t blUNtU
PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only)
CORPORATION
UPresident Vice President OChairman of the Board
uSecretary LJAsst. Secretary DChief Financial Officer ElAsst. Treasurer
LIMITED LIABILITY COMPANY
11. The limited liability company is member -run IL �No (If no, complete Item #12 below)
12. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle)
Todd Moreau, Christoper Hahs, Managers
13. MEMSER'S PRINTED NAME (Last, first, middle)
Moreau, Todd X
MEMBER'S PRINTED NAME (Last, first, middle) SIG
Hahs, Christopher —
IX�
IRE _ _ DATE SIGNEq
DATE SIGNEp
i (!
ABC-211-SIG (rev. 07/19) "SIGN ON"
Notary Acknowledgement
"A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document."
State of zi -✓✓ , County of
On - Via_, ; > _before me, !< �:' , Notary Public,
personally appeared. ' , who proved to me on the basis of
satisfactory evidence to be the person(s)'whose name() is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/he#tfteir authorized capacity(ies�, and
that by his/her/their- signatures on the instrument the person), or the entity upon behalf of which
their 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 anal official seal. NOTARY IMPRESSION HERE
V , ;� - *my
RANAT KURIAKOSE
I'r � Notary Puhlic -California
Orange County T
NOTARY SIGNATURE Commission
Comm. Expires Aug 2, 2026
Notary Acknowledgement
"A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document."
State of , County of
On
before me,
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 signatures on the instrument the person(s), or the entity upon behalf of which
their 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. NOTARY IMPRESSION HERE
NOTARY SIGNATURE