ANTHEM ROTARY FOUNDATION_REDACTED.PDF

DLLC USE ONLY
Job #:
SPECIAL EVENT LICENSE
Date Accepted:
APPLICATION FEE $25.00 PER DAY
CSR:
Arizona Department of Liquor Licenses and Control - -
800 W. Washington St. 5" Floor Phoenix, AZ 85007 license #:

(602) 542-5141
Application MUST be submitted to the Department of Liquor 10 days prior to the event.

SECTION 1 Applicant must be a member of a qualifying nonprofit organization, political party, or Government entity and
authorized by an Officer, Director, or Chairperson of the Organization.

1. Applicant; Salem Edward John, Jr
(Must be an Officer/Member of the N

10;
2. Applicant's mailing address

City State
3. Applicants home/cell phages icant's business phone: 623-900-1001

Zp

4, Applicant's email address

5. Special Evant Name: 3rd of July Event in the Park

6. Name of Non-Profit Organization, Candidate or Political Party/Gov.

. Anthem Rotary Foundation
7. Non-Profit/IRS Tax Exempt Number: 47-0930766 / 26-00640058

8. Arizona Corporation Commission File #: 109477921 If out of State please specify:

(Affach letter of good standing)
9. Event Location Name; Anthem Community Park

10. Event Address: 41703 N Gavilan Peak Parkway, Anthem, AZ 85086

Dates and Hours of Event - Days must be consecutive and may not exceed 10 consecutive days.

**SEPARATE APPLICATION FOR EACH “NON-CONSECUTIVE” DAY**

Event Start License End
Days Date Day of Week Time AM/PM Time AM/PM
DAY 1: July 3, 2023 Monday 2:00 PM 10:30 PM
DAY 2:
DAY 3:
a=e
DAY 4: m
A
DAY 5: we ww
s2 5 m
DAY 6: BQ 2 (?)
DAY?: Q> S w
ots S
DAY 8: Se 8 a
mea ;
DAY 9: 2 3
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DAY10: 3
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SECTION 2 What type of security and control measures will you take to prevent violations of liquor laws at this event?
(List type and number of police/security personnel and type of fencing or control barriers, if applicable.)

4 Number of Police 4 Number of Security Personnel [Fencing Cleariers

Must explain security measures: Maricopa County Sheriffs Deputies will be at both entrances to the park

event. Security personell will be patrolling the area of the event.

SECTION 3 What is the purpose of this event?

[4JOn-site consumption Clot-site (auction/wine/distilled spirits pull) Cboth
How is this special event going to conduct all dispensing, serving, and selling of spirituous liquors?
Check one of the following boxes. (R-19-318)

A) E:] Special Event being held on an unlicensed premises will require approval and signature by the Local Governing
Body on page 3. (If checked move to section 4)

B) Ciwill this event be held on a currently licensed premises and within the already approved and licensed area?
(Must attach a lefter from the licensed premises with an explanation of the option checked below)

Name of Business License Number Phone (Include Area Code)

[Place license in non-use - Special Event Licensee selling all alcoho! without retailer involvement
Must attach letter from the location suspending license for duration of special event

[dispense and serve all spirituous liquors under retailer's license — Business operates normally, minimum of 25% of gross
revenue from alcohol sales is donated to licensee

Lbispense and serve alll spirituous liquors under special event - The special event licensee is in charge of selling alcohol that was
purchased or donated by the special event licensee. The retailers existing alcohol inventory must be separated from any alcohol
used during the special event. Must attach letter from the location suspending license for duration of special event

(split premise between special event and retail location - Both the special event licensee and the retailer will conduct
sales of alcohol. (These sales will be done in separate areas. If alcohol is donated or purchased by the special event licensee
it must be in a separate area than the alcohol that is dispensed by the licensed retailer.)

Cloff sate only - Wine/Distilled Spirits Pull, Live or Silent Auctions — Retailer will still be permitted to conduct all normal sale and
service of alcohol.

SECTION 4
1. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
(1 Yes] No if yes, attach letter of explanation.

2. How many special event days have been issued to this organization during the calendar year? 4
3. Is the Organization using the services of a Special Event Contractor? {A licensee can ufilize the services of a special event
contractor who may purchase and sell alcohol on behalf of the licensee. If no special event contractor is listed, the licensee is

responsible for the sales and service of alcohol. }

(1 Yes [v1 No If yes, please provide the Name of the Special Event Contractor:

4. \s the organization using the services of a series 6, 7, 11, or 12 licensee to manage the sale or service of alcohol?
(Licensees who hold a series 6, 7, 11, or 12 license are automatically qualified to be the special event contractor)

(1 Yes [¥] No if yes, please provide the Name of Licensee: License #:

5. List the name of the Individual or Organization that will receive revenues, MUST EQUAL 100 PERCENT.
Attach additional sheet if necessary.

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Anthem Rotary Foundation Percentage: 100%

Name:
Address: 3655 W Anthem Way #109 PMB 107 Anthem AZ 85086
Street City State Zip
Name: Percentage:
Address:
Street City State lip

Please read A.R.S. § 4-203.02 Special event license; rules and R19-1-205 Requirements for a Special Event License.
ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY.

SECTION. 5 License premises diagram. The licensed premises for your special event is the area in which you are
authorized to sell, dispense or serve alcoholic beverages under the provisions of your license. Please attach a diagram
of your special event licensed premises. Please show dimensions, serving areas, fencing, barricades, or other control
measures and security position.

if the special event will be held at a location without a permanent liquor license or if the event will be on any portion of a location
that is not covered by the existing liquor license, this application must be approved by the local goveming body before submitting
to the Department of Liquor Licenses and Control. Please contact the local governing board for additional information.

APPLICANT SIGNATURE

Declaration:

|, (Print Name) Edward John Salem Jr , declare under penalty of perjury that | am
authorized to submit this application. | have read the contents of this application, and to the best of my knowledge
believe all statements made on this application to be true, corre

LOCAL GOVERNING BODY
Date Received:

1, recommend CMIAPPROVAL [1 DISAPPROVAL
(Government Official) (Title)

On behalf of

(City, Town, County) Signature

The local governing body (city, town or municipality where the fair/testival will take place) may require additional
applications to be completed and submilted. Please check with local government as fo how far in advance they require
these applications fo be submitted. Additional licensing fees may also be required before approval may be granted.

AZDLLC USE ONLY

DlaprrOVAL CI DISAPPROVAL BY:

2/6/2023 Page 3 of 3

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Edward John Salem Jr
Anthem Rotary Foundation
3655 W Anthem Way #109 PMB 107

Anthem, AZ 85086
March 30, 2023

Arizona Department of Liquor Licenses and Control
800 W Washington St, 5" Floor

Phoenix, AZ 85007

To whom it may concern,

With regard to section 3 of the Special Event License Application, | am including the following
information:

For our upcoming “Anthem Rotary July 3 In the Park” special event, all spirits and beverages are
supplied to the Anthem Rotary Foundation by a wholesale distributor. The company is Crescent Crown
Distributing, 1640 W Broadway Rd, Mesa, AZ 85202

Please contact me i” ie you have any questions.

Thank you. Sincerely,

Edward John Salem Jr.