HomeMy WebLinkAbout- - Form 221 Attachment 1 - 5/1/2012Department of Alcoholic Beverage Control
DAILY LICENSE APPLICATIOWAUTHORIZATION - Non Transferable
Instructions: ConFlete all items. Submit to local ABC District Office with required fee (Cashier's Check or
Money Order) payable to ABC Once license is issuer/, fee cannot be refunded For a listing of ABC District
Offices please visit htip:/fwww.abe ca gov/distmap.hhw
Pursuant to the authority granted by the organization named below, the undersigned hereby applies for the
license(s) described below.
1. ORGANIZATION'S NAME
State of California
Edmund G. Brown Jr., Governor
LICENSE NUMBER GEO CODE
RECEIPT NUMBER
FEE
$
Yes [-] No I ❑ Yes [-] No
2. LICENSE TYPE (Check appropriate license type AND organization type)
a. F-] Daily General ($25.00) (Includes beer, wine and distilled spirits)
[� Political Party/Affiliate Supporting Candidate for [-]Fraternal Organization in Existence Over Five Years
Public Office or Ballot Measure with Regular Membership
Organization Formed for Specific Charitable or Civic Purpose F-] Religious Organization
Other: Vessel per Section 24045.10 B&P ($50.00)
NUMBER OF DISPENSING POINTS
b. Special Daily Beer ($25.00) Special Daily Beer & Wine ($50.00) Special Daily Wine ($25.00)
Charitable Fraternal [Social Political Other:
11 Civic FIReligious H Cultural ❑ Amateur Sports Organization NUMBER OF DISPENSING POINTS
c. []Special Temporary License ($100.00) (Different privileges depending on statute)
Television Station per Section 24045.2 or 24045.9 B&P [-] Person conducting Estate Wine Sale per Section 24045.8 B&P
Nonprofit Corporation per Sections 24045.4 and 24045.6 B&P 7 Women's Educational and Charitable Organization per
Section 24045.3 B&P
Other Special Temporary Licenses, per Section
License number
3. EVENT TYPE
Dinner
Sports Event
4. TOTAL # OF DAYS
Dance Wedding
Concert [] Birthday
ESTIMATED ATTENDANCE
Amount $
Lunch [:] Picnic [:] Barbeque []Social Gathering [ Festival
Mixer [:]Carnival [_] Dinner Dance []Other:
HOURS OF ALCOHOLIC BEVERAGE SALES, SERVICE AND/OR CONSUMPTION
From To
7. EVENT DATE(S) 8. EVENT IS OPEN TO THE PUBLIC
Yes []No
9. EVENT LOCATION (Give facility name, if any, street number and name, and city)
10. LOCATION IS WITHIN THE CITY LIMITS 11. TYPE OF ENTERTAINMENT 12. SECURITY GUARDS
Yes []No []Yes []No If yes, how many?
13. AUTHORIZED REPRESENTATIVE'S NAME 114. REPRESENTATIVE'S TELEPHONE NUMBER
15. REPRESENTATIVE'S ADDRESS
16. ORGANIZATION'S MAILING ADDRESS (If different from #15 above)
17. AUTHORIZED REPRESENTATIVE'S SIGNATURE
PROPERTY OWNER APPROVAL BY (Name), REQUIRED IPHONE NUMBER
LAW ENFORCEMENT APPROVAL BY (Name), IF APPLICABLE PHONE NUMBER
DISTRICT OFFICE APPROVAL BY (Name)
PROPERTY OWNER SIGNATURE
LAW ENFORCEMENT SIGNATURE
EMPLOYEE SIGNATURE
8. DATE SIGNED
DATE SIGNED
ISSUANCE DATE
The above-named organization is hereby licensed, pursuant to the California Business and Professions Code Division 9 and California Code of Regulations,
to engage in the temporary sale of alcoholic beverages for consumption at the above named location for the period authorized above. This license does not
include off -sale ("to -go") privileges.
This license may be revoked summarily by the Department if, in the opinion of the Department and/or the local law enforcement agency, it is
necessary to protect the safety, welfare, health, peace and morals of the people of the State.
ABC -221 (rev. 01-11)