Redacted Appliaction Job #398370- Shake Shack.pdf

City of Buckeye — Regular Council Meeting (2026-06-16)

Extracted text (via ocr_local) 30845 characters

Received in the Buckeye City Clerk's office May 26, 2026 at 3:51 p.m. by LCA
State of Arizona
Department of Liquor Licenses and Control

Created 05/18/2026 @ 03:38:56 PM
Local Governing Body Report

LICENSE

Number: Type: 012 RESTAURANT
Name: SHAKE SHACK #1618
State: Pending
Issue Date: Expiration Date:
Original Issue Date:
Location: 1503 N VERRADO WAY

#101

BUCKEYE, AZ 85326

USA
Mailing Address:
Alt. Phone:
Email Pe

AGENT

Name: ANDREA DAHLMAN LEWKOWITZ
Gender: Female

Correspondence Address:

PHOENIX, AZ 85004

USA

Alt. Phone:
Email Pe

OWNER
Name: SHAKE SHACK ARIZONA LLC
Contact Name: ANDREA DAHLMAN LEWKOWITZ
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: R20278666 State of Incorporation: DE
Incorporation Date: 08/19/2015

Correspondence Address:

PHOENIX, AZ. 85004
USA ( () Yh y Dor -

4\a\2e4

Phone:
Alt. Phone:
Email:

Officers / Stockholders

Page | of 5

Name: Title: % Interest:
SHAKE SHACK ENTERPRISES LLC Member 100.00

SSE HOLDINGS LLC - Stockholder,Member

Name: SHAKE SHACK INC

Contact Name: ANDREA LEWKOWITZ

Type: CORPORATION

AZ CC File Number: State of Incorporation:

Incorporation Date:
Correspondence Address:

PHOENIX, AZ 85004

USA

Alt. Phone:
Email: Ss

SHAKE SHACK ARIZONA LLC - Member
Name: SHAKE SHACK ENTERPRISES LLC
Contact Name: ANDREA LEWKOWITZ
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: State of Incorporation:

Incorporation Date:

Correspondence Address: a
PHOENIX, AZ 85004

USA

Alt. Phone:
Email es

SHAKE SHACK ENTERPRISES LLC - Member
Name: SSE HOLDINGS LLC
Contact Name: ANDREA LEWKOWITZ
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: State of Incorporation:

Incorporation Date:
Correspondence Address:

PHOENIX, AZ 85004

USA
Phone: as
Alt. Phone:
Email: es

Page 2 of S

SHAKE SHACK INC - COO
SSE HOLDINGS LLC - COO
SHAKE SHACK ENTERPRISES LLC - COO
Name: STEPHANIE ANN SENTELL

Gender: Female
Correspondence Address:

PHOENIX, AZ 85004

USA
Alt. Phone:
Email: eS
SHAKE SHACK INC - CEO
SSE HOLDINGS LLC - CEO
SHAKE SHACK ENTERPRISES LLC - CEO
Name: ROBERT MAURICE LYNCH
Gender: Male
Correspondence Address:
PHOENIX, AZ 85004
USA
Alt. Phone:
Email: rs
MANAGERS
Name: MOLLY MACDOUGAL COOPER
Gender: Female

Correspondence Address:

PHOENIX, AZ 85004

USA
Alt. Phone:
Email es

KREKEKEKEKKRERERERR EKER ERE KERR EKER EERERERREREERKREREREREREREE

Name: MICHAEL RAY BEALS
Gender: Male
Correspondence Address:

PHOENIX, AZ 85004

USA
Alt. Phone:
Email: Po

Page 3 of 5

APPLICATION INFORMATION

Application Number: 398370

Application Type: New Application
Created Date: 04/23/2026
QUESTIONS & ANSWERS

012 Restaurant

1) Are you applying for an Interim Permit (INP)?
No
2) Are you one of the following? Please indicate below.
Property Tenant
Subtenant
Property Owner
Property Purchaser
Property Management Company
PROPERTY TENANT
3) _ Is there a penalty if lease is not fulfilled?
Yes
What is the penalty?
TERMINATION AND/OR OTHER MONETARY PENALTIES
4) _ Is the Business located within the incorporated limits of the city or town of which it is located?
Yes
5) What is the total money borrowed for the business not including the lease?
Please list each amount owed to lenders/individuals.
0.00
6) Are there walk-up or drive-through windows on the premises?
No
7) Does the establishment have a patio?
Yes
Is the patio contiguous or non-contiguous (within 30 feet)?
CONTIGUOUS
8) Is your licensed premises now closed due to construction, renovation or redesign or rebuild?
Yes
If yes, what is your estimated completion date?
OCTOBER 2026
9) What type of business will this license be used for?
RESTAURANT
DOCUMENTS
DOCUMENT TYPE FILE NAME UPLOADED DATE
MISCELLANEOUS 1618 AGT ADL (Ctn).pdf 04/23/2026
QUESTIONNAIRE 1618_AGT ADL (Q).pdf 04/23/2026
RECORDS REQUIRED FOR AUDIT _1618_Audit.pdf 04/23/2026
QUESTIONNAIRE 1618_CP Lynch (Q+Supple).pdf 04/23/2026
QUESTIONNAIRE 1618_CP Sentell (Q+Supple).pdf 04/23/2026
DIAGRAM/FLOOR PLAN 1618_diagram.pdf 04/23/2026

Page 4 of 5

QUESTIONNAIRE
ORGANIZATIONAL DOCUMENTS
RESTAURANT OPERATION PLAN

1618_menu.pdf

1618_MGR Beals (Q+FP+T).pdf
1618 Ownership.pdf
1618_ROP.pdf

Page 5 of 5

04/23/2026
04/23/2026
04/23/2026
04/23/2026

SHAKE SHACK #1618

1503 N. Verrado Way, #101
Buckeye, AZ 85326

3,000 SF (interior) + 711 SF (patio)

Exit —
<p OOOO] LTE (0. Res 0
| i, A EL csecs| San,

Be l(t ae horghs Bey tebe

Exit

Liquor storage

Ne 4

Kitchen

Entrance/exit

Exit

Shake Shack Arizona, LLC
Ownership Chart | 01/07/2025

Publicly-traded
NYSE: SHAK
No one owns 10% or more

Noone Shake Shack Inc.
else owns eemneiell siemiadts Robert Lynch, CEO
10% or 24 Union Square East, 5" Floor Stephanie Sentell, COO
more New York, NY 10003
SSE Holdings, LLC
Member (100%) Robert Lynch, CEO
225 Varick Street, Suite 301 Stephanie Sentell, COO

New York, NY 10014

Shake Shack Enterprises, LLC

Member (100%) Robert Lynch, CEO
Stephanie Sentell, COO

225 Varick Street, Suite 301

New York, NY 10014

Shake Shack Arizona, LLC

Applicant

Arizona Department of Liquor Licenses and Control

https://www.azliquor.gov DLLC USE ONLY

(602) 542-5141 %©*®* ZOBZ1O
RESTAURANT OPERATION PLAN} Hic $5"
RESTAURANT SERIES 12 AND ae
HOTEL/MOTEL SERIES 11 ONLY =o
1. Name of restaurant (Please print): SHAKE SHACK #1618
2. Must indicate the equipment below by Make, Model, and Capacity:
LIST ONLY THE FOLLOWING - NO ATTACHMENTS
Grill LANG GAS COUNTERTOP GRIDDLE (9K-236SC-NAT-SH)
Oven NONE
Freezer CUSTOM THERMALRITE- SHAKE SHACK WALK-IN COOLER/FREEZER COMBO
Refrigerator CUSTOM THERMALRITE- SHAKE SHACK WALK-IN COOLER/FREEZER COMBO
Sink 3 - EAGLE HAND SINKS (HSA-10-F-2X) | 1 - EAGLE HAND SINKS (HSA-10-F-LRS-2X)
Dish Washing Facilities EAGLE 3 COMPARTMENT SINK (314-18-3-30-SLF-TB) | 1 - ECOLAB DISHWASHER (EHT-V)
Food Preparation Counter
(Dimensions) EAGLE STAINLESS STEEL TOP WORK TABLE (T3030SB-BS)
Other

3. Attach a copy of your FULL menu with pricing INCLUDING NON-ALCOHOLIC BEVERAGES

4. What percentage of your public premises is used primarily for restaurant dining?

Do not include kitchen, bar, hi-top tables, or game area.) 65 %

5. Does your restaurant have a bar area that is distinct and separate from the dining area? Cves b=4} No

If yes, what percentage of the public floor space does this area cover?) %

6. List the seating capacity for:

a) Restaurant dining area of your premises: [ 93 ]
(DO NOT INCLUDE PATIO SEATING)
b) Bararea [ +O ]
TOTAL [= 93 ]
5/5/2025 Page 1 of 2

Individuals requiring ADA accommodations please call (602)542-2999

7. What type of dinnerware is primarily used in your restaurant? reusable Rbisposable [Roth

8. Does your restaurant contain any games, televisions, or any other entertainment? Klves Lno
If ves, specify what types and how many (examples: 4-TV’s, 2-Pool Tables, 1-Video Game, etc.)

2-3 TVs

9. Do you have live entertainment or dancing? Dyes Kno
Ifyes, what type and how often (example: DJ-2 x a week, Karaoke-2 x a month, Live Band-1 x a month, etc.)

10. List number of employees for each position:

Position How many
**50 Team Members cross-trained

Cooks as Cooks, Servers, Bussers, Expo, Cashiers
Bartenders See above
Hostesses See above
Managers 2
Servers See above
Other ( )
Other ( )
Other ( )

5/5/2025 Page 2 of 2
individuals requiting ADA accommodations please call (602)542-2999

Arizona Department of Liquor Licenses and Control

https://www.azliquor.gov DLLC USE ONLY

(602) 542-5141 bk 498410

Date Cee
RECORDS REQUIRED FOR AUDIT ta a
RESTAURANT/HOTEL/MOTEL license #

In the event of an audit, you will be asked to provide to the Department any documents necessary to determine
Compliance with A.R.S. §4-205.02(G). Such documents requested may include however, are not limited to:

1.Name of restaurant (Please print): SHAKE SHACK #1618

2. All invoices and receipts for the purchase of food and spirituous liquor for the licensed premises.

3. A list of al/ food and liquor vendors

4. The restaurant menu used during the audit period

5. A price list for alcoholic beverages during the audit period

6. Mark-up figures on food and alcoholic products during the audit period

7.A recent, accurate inventory of food and liquor (taken within two weeks of the Audit Interview Appointment)
8. Monthly Inventory Figures - beginning and ending figures for food and liquor

9. Chart of accounts (copy)
10. Financial Statements-Income Statements-Balance Sheets

11. General Ledger
A. Sales Journals/Monthly Sales Schedules
1) Daily sales Reports (to include the name of each waitress/waiter, bartender, etc. with sales for that day)
2) Daily Cash Register Tapes - Journal Tapes and Z-tapes
3) Dated Guest Checks
4) Coupons/Specials/Discounts
5) Any other evidence to support income from food and liquor sales
B. Cash Receipts/Disbursement Journals
1) Daily Bank Deposit Slips
2) Bank Statements and canceled checks

12. Tax Records

A. Transaction Privilege Sales, Use and Severance Tax Return (copies)
B. Income Tax Return - city, state and federal (copies)

C. Any supporting books, records, schedules or documents used in preparation of tax returns

5/5/2025 Page 1 of 2 LIC-APPREQ-AUDITRCDS-00)
Individuals requiting ADA accommodations please call (602)542-2999

13. Payroll Records

A. Copies of all reports required by the State and Federal Government
B. Employee Log (A.R.S. §4-119)
C. Employee time cards (actual document used to sign in and out each workday)

D. Payroll records for all employees showing hours worked each week and hourly wages

14. Off-site Catering Records (must be complete and separate from restaurant records)

A. All documents that support the income derived from the sale of food off the license premises.

B. All documents which support purchases made for food to be sold off the licensed premises.

C. All coupons/specials/discounts

The sophistication of record keeping varies from establishment to establishment. Regardless of each licensee's accounting
methods, the amount of gross revenue derived from the sale of food and liquor must be substantially documented.

REVOCATION OF YOUR LIQUOR LICENSE MAY OCCUR IF YOU FAIL TO COMPLY WITH
A.R.S. §4-210(A)7 AND A.R.S. §4-205.02(G).

A.R.S. §4-210(A) 7
The licensee fails to keep for two years and make available to the department upon reasonable request all invoices,

records, bills or other papers and documents relating to the purchase, sale and delivery of spirituous liquors and, in
the case of a restaurant or hotel-motel licensee, all invoices, records, bills or other papers and documents relating to

the purchase, sale and delivery of food.

A.R.S. §4-205.02(M)
For the purpose of this section:

Restaurant: an establishment that derives at least forty percent (40%) of its gross revenue from the sale of food

Gross revenue: the revenue derived from all sales of food and spirituous liquor on the licensed premises regardless of
whether the sales of spirituous liquor are made under a restaurant license issued pursuant to this section or under any
other license that has been issued for the premises pursuant to this article.

Declaration:

ANDREA DAHLMAN LEWKOWITZ
|, (Print Name) , declare under penalty of perjury that | am

authorized to submit this application. | have read the contents and to the best of my knowledge believe all statements

made on this application to be true, correct, and complete.

*MAKE A COPY OF THIS DOCUMENT AND KEEP IT WITH RECORDS REQUIRED BY THE STATE*

Page 2 of 2 UC-APPREQ-AUDMIRCDS-001

5/5/2025
Individuals requiring ADA accommodations please call (602)542-2999

EST. 2004 in NYC

D .
7 W 0 sHAKeS3sHAck

» f 68 F

Stand Fox Aemething Good”

= 100% all-natural Angus beef. No hormones and
no antibiotics ever. Our proprietary Shack blend is

freshly ground and served on a non-<GMO potato bun.

ShackBurger®* ca
Cheeseburger with lettuce, tomato, ShackSauce
$5.29 Single 550
$8.09 Double 855
SmokeShack® *

Cheeseburger with all-natural smoked
Nimon Ranch bacon, chopped cherry pepper,

ShackSauce
$6.84 Single 620
$9.64 Double 725
$6.99 ‘Shroom Burger 490

Crisp-ried portobello mushroom filled with
melted muenster and cheddar cheeses, topped
with lettuce, tomato, ShackSauce

Shack Stack®* 795
Cheeseburger and a ‘Shroom Burger with lettuce,
tomato, ShackSauce

$9.59

Hamburger”
Let us nowt if you would like lettuce, tomato,
pickle or onion

Single
Double
Add bacon -51.55

100% all-natural cage-free chicken. No hormones
and no antibiotics ever. Served on a non-GMO
potato bun,
Chick'n Shack

$6.29 Crispy chicken breast with lettuce, pickles,

385
620

$4.29
$6.59

@
&

buttermilk herb mayo

100% all-natural Vienna beef. No hormones
and no ens ever. Served on a non-GMO
potato bun.
$4.25 Shack-cago Dog®
Dragged through the garden with Rick's Picks
Shack relish, onion, cucumber, pickle, tomato,
sport pepper, celery salt, mustard

53.20 HotDog
Add Shack cheese sauce - 50.50

Col
360

350
70

320

sa.s9 Chicken Dog
Shake Shack chicken, apple and sage sausage

| Pozen Custard |
’ a |

Dense, rich, creamy ice cream, spun fresh all day. |

Our custard base is made from all-nctural sugar,

never from corn syrup. |

Cai

Shakes 640-930
Hand-spun vanilla, chocolate, salted caramel,
black & white, strawberry, peanut butter,
coffee Fair Shake
Make it malted -50.50
Add whipped cream -$0.50
Shake of the Week
Featured custard flavor

Floats
Root beer, purple cow, creamsicle

$5.29

60
75

$5.59

$5.29

Cups & Cones

Vanilla, chocolate, flavor of the week
Single Dip

Double Dip

Pints To Go

220-280
540

| $3.59
$4.59

| $5.99
Fl Concretes

Frozen custard blended with mixins
Single

Double

Shack Attack

Chocolate custard, fudge scuce, chocolate truffle
cookie dough and Mast Brothers Shake Shack dark
chocolate chunks, topped with chocolate sprinkles

Pratt St. Pie Oh My
Vanilla custard and slice of Dangerously Delicious
blueberry pancake pie

Salty Balty

770-910

Shack-made Lemonade
Originol or featured flavor
Small

Large

Col

30.155
95-235

$2.80
$3.55

Organic Fresh Brewed Iced Tea
Small

Large

Fifty/Fifty™

Hal lemonade, half organic iced tea
Small

large

$2.30
$2.80

$2.55 80

$3.30

Fountain Soda

Coke, Diet Coke, Coke Zero, Sprite,
Fanta Orange, Fanta Grape, Dr Pepper
Small

Large

Abita Draft Root Beer
Small
Large

Stumptown Cold Brew Coffee
Brewed with Direct Trade beans

0-180
0.270

$2.30
$2.80

180
270

$2.80
$3.55

$4.75

Honest Kids Organic Apple Juice 40

SHACK |:°° Bottled Water
1% supports the cleanup of

water sources

$1.90

$2.40

A ShackMeister® Ale

Brewed exclusively for Shake Shack by

Brooklyn Brewery Gol
55.69 Draft, 1602. 190
$7.69 Draft, 2402 285

Chocolate and vanilla custard, chocolcte truffle |
cookie dough, cheesecake blondie and sea salt

5% of sales from our Solty Bally concrete support

Wine

Moveable Feast, providing nutritious meals at no cot Shack Red or White
Pp lnces in neea Made exclusively for Shake Shack by
|
| Frog's Leap, Napa Valley, CA Cal
lace a Your Own Concrete 280320 | $7.89 White, 60z. Glass 120
ase as | $8.89 Red, 60z. Glass 125
Mix-Ins 5.320
$0.60 © Chocolate truffle cookie dough
each —* Chocolate loffee - Week
eexcvbeny purée Treats for those with four feet.
.
uae ne 53.99 Pooch-ini®

Yukon potatces. No artificial ingredients

52.99 Fries 420

53.99 Cheese Fries 560

* Salted caramel souce
© Peanut butter sauce

* Marshmallow sauce

* Dark chocolate chunks

| $7.99

ShackBurger dog biscuit, peanut butter sauce,
vanilla custord
Not intended for small dogs.

Bag O' Bones
5 ShackBurger dog biscuits by Bocce's Bakery

2, 000 calories a day is used for general nutrition on advice, but
colorie needs vary.

| food sate

Please silica your cashier if o pee in your party hos a
Peanuts, nuts ond other food allergens are present
‘ot Shake Shack, We cannot guarantee thot our products will be
free of the eight mojor allergens identified by the FDA.

*Nolice: consuming raw or undercooked meats, poultry, seafood,
or eggs may increase your risk of foodborne illness, especially
# you have certain medical conditions.

Arizona Department of Liquor Licenses and Control

https://www.azliquor.gov DLLC USE ONLY
(602) 542-5141 * 2483-10
— SS Date Accepted:
Personal Information so
Questionnaire ——-

ATTENTION APPLICANT: This is a legally binding document. An investigation of your background will be

conducted. Incompl

revocation of a license or permit and could result in criminal prosecution.

THE COMPLETED QUESTIONNAIRE NEEDS TO BE SUBMITTED TO THE DEPARTMENT ALONG WITH A $22. FEE, AND FD-258

ete applications will not be accepted. False or misleading answers may result in the denial or

FINGERPRINT CARD, THAT HAS BEEN SEALED IN AN ENVELOPE, AND SIGNED ORINITIALED BY THE FINGERPRINT TECHNICIAN, MUST

INCLUDE THE FINGERPRI
ENFORCEMENT AGENCY.

Agent: a person who
is designated by an
applicant or licensee
to receive
communications from
the department and to
file and sign
documents submitted
to the department on
behalf of the applicant
or licensee. An agent
is not a manager.

A.R.S. §4-202(A).

Controlling Person:

person directly or
indirectly possessing
control of an applicant
or licensee.

A.R.S. §4-101(10).

Manager: An
individual {not an
entity) approved by
the Department of
Liquor who has the
authority to organize,
direct, carry out,
control or to
otherwise operate the
day-to-day operations
of a liquor-licensed
business.

1
2

A.R.S. §4-101(22) and
ALR.S. §4-202(C)

9/5/2025

INT VERIFICATION FORM. MUST BE COMPLETED BY A RECOGNIZED FINGERPRINT SERVICE OR LAW

Fe Currant OF-AS-DOF]
SECTION - 1 INDIVIDUAL INFORMATION

rood
ESHMANAGER

ent

LEWKOWITZ

CIcONTROLLING PERSON

ANDREA DAHLMAN

. Name:
First Middle

Last
Social Security+ birth cate:
(NOT a public record) (NOT a public record)
. Driver's License : a =
(NOT a public record)
. Are you a resident of Arizona? [x]yes [CNo Date of residency: © /__/ 1961

Email address: _ i

- Home i

. Daytime phone #:__ i Alternative phone #: i

State Issued:

SECTION 2 — LICENSED BUSINESS INFORMATION
SERIES 12 | PENDING

. License Number:
SHAKE SHACK #1618

. Business Name (doing business as):

“Binsinase address: 1503 N. VERRADO WAY, #101, BUCKEYE, AZ 85326

Page 1 of 2 UC-GEN-QUEST-001

Individuals requiring ADA accommodations please call (602)542-2999

SECTION 3 — DAY TO DAY OPERATION OF BUSINESS

Must attach copies of Basic and Management Title 4 training certificates for person managing the day to day
operation of the licensed business.

Who is managing the day to day operations? Chagent Licontrolling Person Pimanager
MICHAEL BEALS —— “TRD

Name of persons who will be handling the day to day operations:

SECTION 4 — BACKGROUND

Hf you answer “YES” to any Question 1 through 5 YOU MUST attach a signed statement. Give complete details including
dates, agencies involved and dispositions. CHANGES TO QUESTIONS 1-5 MAY NOT BE ACCEPTED

1. Have you owned, or been a controlling person of any entities that held a liquor Yes [] No
license in Arizona, or any jurisdiction, in the past 5 years?

2. Have you been cited, arrested, indicted, convicted, or required to appear in Yes [] No [XJ
court for violation of ANY criminal law or ordinance, regardless of the
disposition, even if dismissed or expunged, within the past 5 years?

3. Has an entity in which you are or have been a controlling person had an Yes [[] No
application or license rejected, denied, revoked, or suspended in or outside of
Arizona within the last 5 years? A.R.S.§4-202(D

4. Have you had ANY administrative law citations, compliance actions, or Yes [-] No
consents, in any jurisdiction in the past 5 years? (Do not include civil traffic
tickets)

A.R.S.§4-202,4-210
*Administrative Law Violations are any civil penalties, fines, suspension,
or revocations of your liquor license.

5. Has anyone EVER obtained a judgement against you the subject of which Yes [] No
involved fraud or misrepresentation?

SIGNATURE

1, (Print Full Name) ANDREA DAHLMAN LEWKOWITZ hereby swear under penalty of perjury and in
compliance with A.R.S. § 4-240(A)(2) and (3) that | have read and understand the foregoing and verify that
the wer statements that | have made herein are true and correct to the best of my knowledge.

Signature: Date: 4/13/2026

Page 2 of 2 LIC-GEN-QUEST-001

5/5/2025
Individuals requiring ADA accommodations please call (602/542-2999

Arizona Department of Liquor Licenses and Control

https://www.azliquor.gov - DLLC USE ONLY
(602) 542-5141 Job & 348370
eet ack Zo
ALIEN STATUS i oe
License #:

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. §
1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-
exempt "qualified aliens” (and sometimes only particular categories of qualified aliens), nonimmigrant, and certain
aliens paroled into the United States are eligible to receive state, or local public benefits. With certain exceptions, a
professional license and commercial license issued by a State agency is a State public benefit.

Arizona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must submit documentation
to the license agency that satisfactorily demonstrates the applicant’s presence in the United States is authorized under
federal law.

Directions: All applicants must complete Sections |, Il, and 1V. Applicants who are not U.S. citizens or nationals
must also complete Section III.

Submit this completed form and a copy of one or more document(s) from the attached "Evidence of U.S. Citizenship,
U.S. National Status, or Alien Status" with your application for license or renewal. If the document you submit does

not contain a photograph, you must also provide a government issued document that contains your photograph. You

must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence is not the same
as your current legal name.

SECTION !— APPLICANT INFORMATION

APPLICANT NAME (Print ortype) ANDREA DAHLMAN LEWKOWITZ

SECTION Il - CITIZENSHIP OR NATIONAL STATUS

Are you a citizen or national of the United States? Yes oO No - If yes, indicate place of birth:

City___ MANKATO State MN country _USA

If you answered Yes, 1) Attach a legible copy of a document from the list below.

2) Nameof document: ___AZ DRIVER LICENSE

If you answered No, you must complete Sections Ill.

5/5/2025 Page 1 of 3 LIC-GEN-ALIENSTAT-001
Individuals requiring ADA accommodations please call (602)542-2999

EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATUS

You must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence is not
the same as your current legal name.

Evidence showing authorized presence in the United State includes the following:

10.

ll.

12.

13.

5/5/2025

An Arizona driver license issued after 1996 or an Arizona non-operating identificationcard.
A driver license issued by a state that verifies lawful presence in the United States.

A birth certificate or delayed birth certificate showing birth in one of the 50 states, the District of Columbia,
Puerto Rico (on or after Jan. 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American
Samoa, or the Northern Mariana Islands (on or after November 4, 1986, Northern Mariana Islands local time)

A United States certificate of birth abroad.

A United States passport. ***Passport must be signed***
A foreign passport with a United States visa.

An 1-94 form with a photograph.

A United States citizenship and immigration services employment authorization document or refugee

travel document.

A United States certificate of naturalization.

A United States certificate of citizenship.

A tribal certificate of Indian blood.

A tribal or bureau of Indian affairs affidavit of birth.

Any other license that is issued by the federal government, any other state government, an agency of this state

or a political subdivision of this state that requires proof of citizenship or lawful alien status before issuing the

license.

Page 2 of 3 LIC-GEN-ALIENSTAT-001
Individuals requiring ADA accommodations please call (602)542-2999

Applicants who are not citizens or nationals of the United States. Please indicate alien status by checking the
appropriate box. Attach a legible copy of a document from the attached list or other document as evidence

of your status.

Name of document provided

Qualified Alien Status (8 U.S.C.§§ 1621(a)(1),-1641(b) and (c))
C1.an alien lawfully admitted for permanent residence under the Immigration and Nationality Act(INA)

C2.an alien who is granted asylum under Section 208 of the INA.

D3. refugee admitted to the United States under Section 207 of the INA.

(4 Analien paroled into the United States for at least one year under Section 212(d)(5) of theINA.
[1s.An alien whose deportation is being withheld under Section 243(h) of the INA.

C16.analien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.
(17.an alien who is a Cuban/Haitian entrant.

Oo 8.An alien who has, or whose child or child's parent is a “battered alien" or an alien subject to extreme
cruelty in the United States

Nonimmigrant Status (8 U.S.C. § 1621(a)(2))

9. Anonimmigrant under the Immigration and Nationality Act [8 U.S.C § 1101 et seq.] Non-immigrants are
persons who have temporary status for a specific purpose. See 8 U.S.C § 1101(a)(15).

Alien Paroled into the United States for Less Than One Year (8 U.S.C. § 1621(a)(3))
10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA

Other Persons (8 U.S.C § 1621(c)(2)(A) and (C)
11. A nonimmigrant whose visa for entry is related to employment in the United States, or
12. Acitizen of a freely associated state, if section 141 of the applicable compact of free association approved
in Public Law 99-239 or 99-658 (or a successor provision) is in effect [Freely Associated States include the

Republic of the Marshall Islands, Republic of Palau and the Federate States of Micronesia.
48 US.C. § 1901 etseq.];

13. A foreign national not physically present in the United States.
14. Otherwise Lawfully Present

15. Aperson not described in categories 1-13 who is otherwise lawfilly present in the United States.

PLEASE NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons

who fall into this category ineligible for, S.C. §
ANDREA DAHLMAN LEWKOWTIZ 4/13/2026
Print Name Date
5/5/2025 LIC-GEN-AUIENSTAT-001

Individuals requiring ADA accommodations please call (602)542-2999

Arizona Department of Liquor Licenses and Control

https://www..azliquor.gov DLLC USE ONLY
(602) 542-5141 lob 248370
Date Accepted:
Personal Information bes be
Questionnaire —

ATTENTION APPLICANT: This is a legally binding document. An investigation of your background will be

conducted. Incomplete applications will not be accepted. False or misleading answers may result in the denial or
revocation of a license or permit and could result in criminal prosecution.

THE COMPLETED QUESTIONNAIRE NEEDS TO BE SUBMITTED TO THE DEPARTMENT ALONG WITH A $22. FEE, AND FD-258
FINGERPRINT CARD, THAT HAS BEEN SEALED IN AN ENVELOPE, AND SIGNED OR INITIALED BY THE FINGERPRINT TECHNICIAN, MUST
INCLUDE THE FINGERPRINT VERIFICATION FORM. MUST BE COMPLETED BY A RECOGNIZED FINGERPRINT SERVICE OR LAW

ENFORCEMENT AGENCY.

Agent: 2 person who
is designated by an
applicant or licensee
to receive
communications from
the department and to
file and sign
documents submitted
to the department on
behalf of the applicant
or licensee. An agent
is nota manager.

A.R.S. §4-202(A).

Controlling Person:

person directly or
indirectly possessing
control of an applicant
or licensee.

| A.R.S. §4-101(10).

Manager: An

individual (not an
entity) approved by
the Department of
Liquor who has the
authority to organize,
direct, carry out,
control or to
| otherwise operate the
day-to-day operations
of a liquor-licensed
business.

A.R.S. §4-101(22) and

A.R.S. §4-202(C)

5/5/2025

Fe Curren O|-j0-207)

EP: 1/2025
SECTION - 1 INDIVIDUAL INFORMATION
Cacent WIconTROLLING PERSON LJ MANAGER
1. Name:__SENTELL STEPHANIE ANN
Last First Middle
2. Social Security mz Birth Date:

(NOT a public record)

d; GA

(NOT a public record)

3. Driver’s License #: State Issue

(NOT a public record)
5. Are you a resident of Arizona? [Yes [¥No Date of residency: / /

6. Email address: Sr
7.Home Address: ee

8. Daytime phone rr _ =a Alternative phone #: ci =

SECTION 2 — LICENSED BUSINESS INFORMATION

SERIES 12 | PENDING
SHAKE SHACK #1618

1. License Number:

2. Business Name (doing business as):

. _ 1503 N. VERRADO WAY, #101, BUCKEYE, AZ 85326
3. Business Address:

Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-2999

SECTION 3 — DAY TO DAY OPERATION OF BUSINESS

Must attach copies of Basic and Management Title 4 training certificates for person managing the day to day
operation of the licensed business.

Who is managing the day to day operations? CTagent Controlling Person (VJManager
MICHAEL-BEALS=
TeD

Name of persons who will be handling the day to day operations:

SECTION 4 — BACKGROUND

If you answer “YES” to any Question 1 through 5 YOU MUST attach a signed statement. Give complete details including
dates, agencies involved and dispositions. CHANGES TO QUESTIONS 1-5 MAY NOT BE ACCEPTED

1. Have you owned, or been a controlling person of any entities that held a liquor Yes No [J
license in Arizona, or any jurisdiction, in the past 5 years?

2. Have you been cited, arrested, indicted, convicted, or required to appear in Yes [] No
court for violation of ANY criminal law or ordinance, regardless of the
disposition, even if dismissed or expunged, within the past 5 years?

4. Have you had ANY administrative law citations, compliance actions, or Yes [[] No
consents, in any jurisdiction in the past 5 years? (Do not include civil traffic
tickets)
A.R.S.§4-202,4-210
*Administrative Law Violations are any civil penalties, fines, suspension,
or revocations of your liquor license.

5. Has anyone EVER obtained a judgement against you the subject of which Yes [_] No
involved fraud or misrepresentation?

SIGNATURE

I, (Print Full Name) STEPHANIE ANN SENTELL hereby swear under penalty of perjury and in

compliance with A.R.S. § 4-210(A)(2) and (3) that | have read and understand the foregoing and verify that
the information and statements that | have made herein are true and correct to the best of my knowledge.

Signature: Hiphanee we Ont! Date: Lf [ js] ZozS_

5/5/2025 Page 2 of 2
Individuals requiring ADA accommodaiions please call (602)542-2999