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DState of California Department of Alcoholic Beverage Control APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE(S) ABC 21 l 6199 TO:Department of Alcoholic File Number: 577874 Beverage Control Receipt Number: 2405862 31 1,CHANNEL ST ROOM 168 Geographical Code: 3903 STOCKTON, CA 95202 Copies Mailed Date: January 17,2017 (209)948-7739 Issued Date: IV DISTRICT SERVING LOCATION: sTOCKTON JAN 19 2097 First Owner: S RAFFO LLC Name of Business: 133 CLUB ENVIRONWNTAL HEALTH Location of Business: 133 W YOSEMITE AVE PERro".SIRVICES MANTECA, CA 95336 County: SAN JOAQUIN —Is Premise ince city iirrilts?� Yes Census Tract-01151:08 Mailing Address: 222 W LOCKEFORD ST (If different from #2 premises address) LODI,CA 95240 Type of license(s): 48 i Transferor's license/name: 365776 I AZEVEDO,LUCY Dropping Partner: Yes_ Nom' QUADRADO License Tyke Transaction Tvae Fee Type Master Pup Date Fee 48-On-Sale General Public PERSON-TO-PERSON TRANSFER P40 Y 0 01/17/17 $1,250.00 48-On-Sale General Pub]is ANNUAL FEE P40 Y 0 01/17/17 $876.00 58-Caterer Permit PERSON-TO-PERSON TRANSFER NA N l 01/17/17 $0.00 Total $2,126.00 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? Yes 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 of the provisions of the Alcoholic Beverage Control Act. STATE OF CALIFORNIA County of SAN JOAQUIN Date: January 17,2017 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 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 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. Effective July 1,2012,Revenue and Taxation Code Section 7057,authorizes the State Board of Equalization and the Franchise Tax Board to share taxpayer information with Department of Alcoholic Beverage Control.The Department may suspend,revoke,and refuse to issue a license if the licenseeZs name appears in the 500 largest tax delinquencies list.(Business and Professions Code Section 494.5.) Applicant Name(s) Applicant Signature(s) See 211 Signature Page S RAFFO LLC Z-��1� �'?-t 7 �- {fir-�,r--rt l ��•-�