EVERY KID COUNTS, INC._REDACTED.PDF

FOR DLLC USE ONLY
Received Date:
Arizona Department of Liquor Licenses and Control
Job #:
800 W Washington 5th Floor
Phoenix, AZ 85007-2934 CSR:
www.azliquor.gov
(602) 542-5141 License #:
APPLICATION FOR SPECIAL EVENT LICENSE
Fees: $25.00 per day for 1-10 days (consecutive) Cash Checks or Money Orders Only
A service fee of $25.00 will be charged for all dishonored checks (A.R.S § 44-6852)
IMPORTANT INFORMATION: This document must be fully completed or it will be returned.
The Department of Liquor Licenses and Control must receive this application ten (10) business 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.
Perelka Robert John
1. Applicant:
Last
2. Applicant's mailing address
cily n
3. Applicant's home/cell ph Applicant's business phone: ( 48'sk4463-1697 ) p
4. Applicant's email address
Every Kid Counts, Inc
SECTION 2 Name of Organization, Candidate or Political Party/Gov.:
86-0758876
SECTION 3 Non-Profit/IRS Tax Exempt Number
Scarizona Scaregrounds
SECTION 4 Event Location:
1901 N Alma School Road Mesa AZ 85201
Event Address:
SECTIONS Dates and Hours of Event. Days must be consecutive but may not exceed 10 consecutive days.
See A.R.S. § 4-244(15) and (17) for legal hours of service.
PLEASE FILL OUT A SEPARATE APPLICATION FOR EACH "NON -CONSECUTIVE" DAY
Event Start License End
Date Day of Week
Time AM/PM Time AM/PM
10-03-19 Thursday 7pm 11pm
DAY]:
10-04-19 Friday 7pm Midnight
DAY 2:
10-05-19 Saturday 7pm Midnight
DAY 3:
10-06-19 Sunday 7pm 11pm
DAY 4:
DAY 5:
DAY 6:
DAY 7:
DAY 8:
DAY 9:
DAY10:
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Individuals requiring ADA accommodations call (602)542-2999

SECTION 6 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.)
1
Number of Police 6 Number of Security Personnel •Fencing 12 Barriers
Chain link fence and barricade enclosing the event.
Explanation:
Security will be at the entrance and exit along with other roaming security. Wristbands fro 21 and older.
SECTION 7 Will this event be held on a currently licensed premise and within the already approved premises? Oyes 12 No
(If yes, Local Governing Body Signature not required)
Name of Business License Number Phone (Include Area Code)
SECTION 8 How is this special event going to conduct all dispensing, serving, and selling of spirituous liquors? Please read R-19-
318 for explanation and check one of the following boxes.
CIPlace license in non-use
ElDispense and serve all spirituous liquors under retailer's license
Dispense and serve all spirituous liquors under special event
EISplit premise between special event and retail location
(IF USING RETAIL UCENSE, PLEASE SUBMIT A LETTER OF AGREEMENT FROM THE AGENT/OWNER OF THE LICENSED PREMISES TO SUSPEND OR RUN
CONCURRENT WITH THE PERMANENT LICENSE DURING THE EVENT. IF THE SPECIAL EVENT IS ONLY USING A PORTION OF THE PREMISES,
AGENT/OWNER WILL NEED TO SUSPEND THAT PORTION OF THE PREMISES.)
SECTION 9 What is the purpose of this event?
On-site consumption Doff-site (auction/wine/distilled spirits pull) ElBoth
SECTION 10
1. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
OYes No (If yes, attach explanation.)
1
2. How many special event days have been issued to this organization during the calendar year? ____
(The number cannot exceed 10 days per year.)
3. Is the Organization using the services of a Licensed Contractor?
Efres t2 No If yes, please provide the following: Name of Licensed Contractor:
4. Is the organization using the services of a series 6, 7, 11, or 12 licensee to manage the sale or service of alcohol?
EIYes 12 No If yes, please provide the following: Name of Licensee License #:
5. List all people and organizations who will receive the proceeds. Account for 100% of the proceeds. The organization
applying must receive 25% of the gross revenues of the special event liquor sales. Attach an additional page if necessary.
Every Kid Counts Inc 25%
Name Percentage:
8220 E Appaloost Trail Scottsdale AZ 85258
Address
Scarizona Scaregrounds 75%
Name Percentage:
1901 N Alma School Road Mesa AZ 85201
Address
Sheet City State Vp
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Individuals requiring ADA accommodations call (602)542-2999

Please read A.R.S. § 4-203.02 Special event license; rules and R19-1-205 Requirements for a Special Event License.
Note: ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY.
NO ALCOHOLIC BEVERAGES SHALL LEAVE A SPECIAL EVENT UNLESS THEY ARE IN AUCTION WINE OR DISTILLED SPIRITS PULL
SEALED CONTAINERS OR THE SPECIAL EVENT LICENSE IS STACKED WITH WINE /CRAFT DISTILLERY FESTIVAL LICENSE.
SECTION 11 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.
ATTACH DIAGRAM
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 government before submission to the
Department of Liquor Licenses and Control. Please contact the local governing board for additional application requirements and
submission deadlines. Additional licensing fees may also be required before approval may be granted. For more information, please
contact your local jurisdiction.
I, (Print Full Name) 'erdicA, hereby swear under penalty of perjury and in compliance with
A.R.S. § 4-210(A)(2) and (3) that I have read and understand the foregoing and verthat-te intakmotin and statements
that I have made herein are true and correct to the best of my knowledge.
Applicant Signatue
LOCAL GOVERNING BOARD
Date Received:
1, recommend DAPPROVAL CI DISAPPROVAL
(Government Official) (Title)
On behalf of
(City. Town, County) Signature Date Phone
DLLC USE ONLY
CIAPPROVAL CIDISAPPROVAL BY: DATE: / /
A.R.S. § 41-1030. Invalidity of rules not made according to this chapter prohibited agency action . prohibited acts by state
employees; enforcement; notice
B. An agency shall not base a licensing decision In whole or in part on a licensing requirement or condition that is not specifically
authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a
licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or
condition.
D. THIS SECTION MAY BE ENFORCED IN A PRIVATE CIVIL ACTION AND RELIEF MAY BE AWARDED AGAINST THE STATE. THE COURT MAY
AWARD REASONABLE ATTORNEY FEES, DAMAGES AND ALL FEES ASSOCIATED WITH THE LICENSE APPLICATION TO A PARTY THAT PREVAILS IN AN
ACTION AGAINST THE STATE FOR A VIOLATION OF THIS SECTION.
E. A STATE EMPLOYEE MAY NOT INTENTIONALLY OR KNOWINGLY VIOLATE THIS SECTION. A VIOLATION OF THIS SECTION IS CAUSE FOR
DISCIPLINARY ACTION OR DISMISSAL PURSUANT TO THE AGENCY'S ADOPTED PERSONNEL POLICY.
F. THIS SECTION DOES NOT ABROGATE THE IMMUNITY PROVIDED BY SECTION 12-820.01 OR 12-820.
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Individuals requiring ADA accommodations call (602)542-2999

1.1•047-.• 1 4-0.7
PARKING LOT ALL CARS
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Orange is fencing
around alcohol area.
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locked office Bar/. and vendors and food
;rucks
,
d Perlmiter Fencin g 6
foot cahlnlink.
Fencing fBaracade
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