ANTHEM ROTARY FOUNDATION_REDACTED.PDF

CSR:
Amount:

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

12 (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: D4ALEM EDUALO
(Must be an Officer/Member of the Non Pi

2. Applicant's mailing address:

ENE

3. Applicants home/cell phone: Applicant's business phone: 62Z2-900-/20)

4. Apptcants orc acces;
5, Special Event Name: Concer Li THe atk

6. Name of Non-Profit Organization, Candidate or Political Party/Gov: Aniretéin _(CoTAC2_ -QUNOATION
7. Non-Profit/IRS Tax Exempt Number: 47-0930 '1bb WA Zo-OO06Y 0OS8
8. Arizona Corporation Commission File #: 129477 4Z Ki out of State please specify:

= (Aftach letteyof good standing)
9. Event Location Name:_A2N 7AEM COMM nl 17 frie = 2067ZALL L5E

lo NIW.
10. Event Address: 1703 NW. 6AwL AW (EA W4 LAREN IS, MA BSOBE

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: 4-22-2023 SATiebty 10.00 Am 9! 30 (mM
DAY 2:
DAY 3: 2
in
DAY 4: a _
=
DAY 5: ae a
Fa >
. BPO=ze QO
DAY 6: (uke)
Ou 8 my
; ae a SS
DAY 7: e2Q ~ &
ses m
5 |
DAY 9: =
fo)
DAY10: a
11/7/2022

Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-2999

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 palice/security personnel and type of fencing or control baniers, if applicable.)

4 Number of Police 2 Number of Security Personnel ClFencing (Barriers
Must explain security measures: 7#/4é AEA Aouno 7té n/ Py, SOFT BALL
fitlo 12 tinct Comeleretg (elics feetur ofFictes bw Il aay
He Eitbnths AAO gxyee AS Well As aor ferttel of THE (es,

SECTION 3 What is the purpose of this event?

Mon-site consumption [loff-site (auction/wine/disfilled spirits pull) [Both

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) 4 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)

8) [) will this event be held on a curently licensed premises and within the already approved and licensed area?
(Must attach a letier from the licensed premises with an explanation of the option checked below)

Name of Business. Ucense Number Phone (Include Area Code)

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

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

(Dispense and serve all 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

Csplit 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.)

CCloft sale 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?
Dyes BENo If yes, attach letter of explanation.

2. How many special event days have been issued to this organization during the calendar year? Z

3. Is the Organization using the services of a Special Event Contractor? {A licensee can utilize 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. }

Clyes BANo If yes, please provide the Name of the Special Event Contractor:

4. ls 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)

(Yes [XtNo if yes, please provide the Name of Licensee: License #:

11/7/2022 Page 2 of 3
individuals requiring ADA accommodations please call (602)542-2999

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

Nome: _Awi+téend LoTH@ Y CUNOATION Percentage:_/C0Z
Address: eee W_AnTHEM WAyg Fie 9_ (pb 107 Axl. THEM =
Name: * " perseniugel. ‘
Address: i iy se i

Please read A.R.S. § 4-203.02 Special event license; rules and R19-1-205 Requirements for a Spe vent 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 he 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 governing body before submitting
to the Department of Liquor Licenses and Control. Please contact the local governing board for additional information.

APPLICANT SIGNATURE

Declaration:

1, (Print Name) Z0uWslo Tt SAleErw Zl... 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, Ee complete.

lll) ela

Signature

Date Received:

L, recommend CIJAPPROVAL [1 DISAPPROVAL

(Government Official)

On behalf of

(City, Town, County)

AZDLLC USE ONLY

CIAPPROVAL CI DISAPPROVAL BY:

11/7/2022 Page 3 of 3
Individuals requiring ADA accommodations please call (602)542-2999

2

' YeSresents ge

butles and private 5

Ghats

WS? Baas
eo nigh

show dimensions, ing,

agi

{standard satesai| field),

~ 10 be guarded by Maricopa County Sherif’. |
curity guards,
Tying locations,

i
|
i
|
i
:
i
I
|
{
i
i
an
YA

individuals requiring ADA

f

fh Cayley
Page dat4 f J oe
uccommodailons cal (402}542-9027,

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

Anthem, AZ 85086
January 26, 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 “Concert 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 ' you have any questions.

Thank you. Sincerely,

Edward John Salem Jr.