DEPARTMENT OF LIQUOR CONTROL, COUNTY OF MAUI 2145 KAOHU STREET, ROOM 105, WAILUKU, MAUI, HAWAII APPLICATION FOR RENEWAL OF LIQUOR LICENSE Page 1 of 1 DLC-029 [rev 03/17] 1. LICENSEE: 2. TRADE NAME: 3. CLASS OF LICENSE: Manufacturer Restaurant Wholesale Retail Dispenser Club Tour or Cruise Hotel Brewpub Condo Hotel Winery Small Craft 4. KIND OF LICENSE: General Beer & Wine Beer Wine Alcohol Other 5. NATURE OF LICENSE: Individual Partner Corp LLC LLP 6. INDIVIDUAL Name(s) / Residence Address / Mailing Address / Non - Business Phone No. 7. Officers & Directors / P osition / Residence Address / Mailing Address / Non - Business Phone No. Stockholders owning 25% or more of the outstanding capital stock: Name(s) / % Stock Owned / Residence Address / Mailing Address / Non - Business Phone No. 8. Organizers / Members / Managers / Agents / Partners / Position / Residence Address / Mailing Address / Non - Business Phone No. 9. PREMISES ADDRESS: 10. MAILING ADDRESS: PREMISES PHONE: I hereby c ertify that the persons listed herein above are not minors nor have they been convicted of a felony and not pardoned; that th is application has been examined by me and is true, correct, and complete. RESTAURANT LICENSEES: I also certify that 30% of gros s revenues is derived from the sale of food. Print Name and Position Signature of Licensee Date ANNUAL LIQUOR LICENSE FEES: Mfg Beer $600 Restaurant Gen $600 Wholesale Alcohol $200 Disp Beer/Wine $300 Brewpub $1,000 Mfg Wine $600 Restaurant Be er/Wine $300 Retail Gen $560 Disp Beer $150 Condo Hotel $1 , 200 Mfg Wine (fruits in state) $300 Restaurant Beer $150 Retail Beer/Wine $260 Club $320 Winery $1 , 000 Mfg Other Liquor $640 Wholesale Gen $2,400 Retail Alcohol $200 Tour or Cruise $300 Small Cra ft $1,000 Mfg Alcohol $200 Wholesale Beer/Wine $1,800 Disp Gen $600 Hotel $1,200 FOR DEPARTMENT USE O NLY LICENSE NO: ANNUAL LICENSE FEE: American LegalNet, Inc. www.FormsWorkFlow.com