COMPLIANCE INFO_COMPLIANCE INFO 2020

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Stato of California Department of Alcoholic Beverage Control COVID-19 TEMPORARY CATERING AUTHORIZATION APPLICATION Before completing this application,please review Form ABC-218 CV191nstr.for important information regarding the COVID-19 Temporary Catering Authorization. LICENSE NUMBER Instructions: Indicate the license number this temporary authorization will apply to in the appropriate box and then complete sections#1 and#2.Once complete,submit to the local ABC office with a non- 48-428019 refundable payment in the amount of$100.00.Acceptable forms of payment are business/personal check,cashiers check or money order.You must also submit Form ABC-253 which clearly identifies RECEIPT NUMBER(FOR ABC USEkppoNLY) where the area is in relation to the existing licensed premises.If you are entering into an agreement /7, n with another person/entity for meal service,you must also submit a copy of the agreement or contract Oi lX lY which establishes the details of this business relationship.Incomplete orinaccurate applications may TOTAL FEE result in delay or denial of the application request.If approved,a COVID-19 Temporary Catering t,P Authorization will be sent to you via the email address you provide below.If you do not have a valid QI'll4-41 email address,the authorization will be mailed to your premises. SECTION 1 (Application Details And Licensee Acknowledgment) 1.LICENSEE NAME(S)(if an individual,first name,middle name,last name.) 2.CONTACT PERSON 3.CONTACT PHONE NUMBER Todd Marvin Anderson Todd Anderson (209)482-1419 4. LICENSED PREMISES ADDRESS 5. EMAILADDRESS 18783 E.Hwy 88 Clements,CA 95227 itsinspection®hotmail.com 6. DESCRIPTION OF EXPANDED AREA(Adjacent suite,sidewalk,parking lot,slat You must also complete and submit Form ABC-253 Mich identifies where the expansion is is relation to the exiating premises. Rear patio and adjacent lot back yard 7.DESCRIPTION OF HOW THE EXPANDED AREA WILL BE DELINEATED(Theater style stanchions pad mpe,temporary tram,etc.) Permanent fencing B.WILL THE EXPANDED AREA BE SHARED WITH ANY OTHER PERSON 9.ARE YOU CONTRACTING WITH ANOTHER PERSON FOR MEAL SERVICE(if yes,you..at attach is copy of the agreemen() Oyes ✓ No W] Yes ❑No 10.DO YOU HAVE LEGAL AUTHORITY TO USE THE REQUESTED AREA 11.WHAT IS YOUR LEGAL AUTHORITY TO USE THE AREA(Valid lease,rental contract,aly permit,eta) F,/]Yes 171 No Own IN COMPLETING THIS APPLICATION FORA COVID-19 TEMPORARY CATERING AUTHORIZATION,I ACKNOWLEDGE ALL OF THE FOLLOWING: Check all of the boxes below.Failure to acknowledge all of the below may result in delay or denial of the application R/ The requested expansion and its intended operation is and must remain consistent with state and local health and safety directives.Additionally, I V have forwarded a copy of this application request to the appropriate local law enforcement agency. W1This authorization is limited to service of those alcoholic beverages authorized by the applicant license type. If approved,the authorization will be limited to service of alcoholic beverages during times in which bona fide meals are being served in the expanded area,whether by us or another persontentity under agreement with us. 17 Except as to any conditions that the Department has determined will not be enforced under other Notices of Regulatory Relief,any operating conditions in place for the existing licensed premises will apply to the temporarily expanded area. If the Department determines that operation of the temporarily expanded area is contrary to public health,safety,or welfare,new or additional operating conditions may be added to the authorization at the time of or after its issuance. / If the temporarily expanded area is being shared with other ABC licensees,we will be held jointly responsible for any violations that may occur Y within the shared area. ❑Z If approved,the authorization may be canceled by the Department for reasons including,but not limited to:1)upon termination of the temporary program granting the issuance of this authorization;2)for violations of any law,rule,ordinance,or directive pertaining to business activities conducted on the premises and expanded area;3)for negatively impacting nearby residents;4)upon objection by local law enforcement;5)if in the discretion of the Department continuance of the permit will negatively impact the public health,safety,or welfare. SECTION 2 (Licensee Declaration And Signature) I declare under penalty of perjury tha st of my knowledge these statements are true and correct. LICENSEE SIGNATURE DATE SIGNED 5/25/20 SECTION 3 (FOR ABC USE ONLY) AB6253ATTACHED MEAL PROVIDER CONTRACT REQUIRED IS MEAL PROVIDER A LICENSEE ALSO APPLICATION APPROVED ❑ Yes ❑ No ❑Yes, attached ❑No ❑ Yes ❑ No ❑ N/A ❑ Yes ❑ No APPROVAL/DENIAL BY(ABC Official Name) ABC OFFICIAL SIGNATURE DATE SIGNED ABC-218 CV19(05/20)