ANTHEM ROTARY FOUNDATION_REDACTED.PDF

CSR:
Amount:
4 ; DLLC USE ONLY
i Job #:
SPECIAL EVENT LICENSE
—
APPLICATION FEE $25.00 PER DAY
CSR:
: _ : _
Arizona Department of Liquor Licenses and Control
Meense: - -
800 W. Washington St. 5" Floor Phoenix, AZ 85007
. (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.
2alem Edward John, Jr
1. Applicant;
(Must be an Officer/Member of the Non Profit Entity) Last First Middle
2. Applicant’s mailing address:
Street City State Zip
623-900-1001
3. Applicants home/cell phone: Applicant's business phone;
An
4. Applicants emai acre:
Anthem Days
5. Special Event Name:
Anthem Rotary Foundation
6. Name of Non-Profit Organization, Candidate or Political Party/Gov.:
47-0930766 / 26-00640058
7. Non-Profit/IRS Tax Exempt Number:
109477921
8. Arizona Corporation Commission File #: If out of State please specify:
(Attach letter of good standing)
Anthem Community Park
9, Event Location Name:
41703 N Gavilan Peak Pkwy, Phoenix, AZ 85086
10. Event Address:
Dates and Hours of Event - Days must be consecutive and may not exceed 10 consecutive days.
**SEPARATE APPLICATION FOR EACH “NON-CONSECUTIVE” DAY**
Days Date Day of Week Pade pe Paka nee 9
M
03/16/2024 Saturday 9:00 AM 7:00 PM
DAY 1:
03/17/2024 Sunday 9:00 AM 7:00 PM
DAY 2:
DAY 3:
DAY 4:
DAY 5:
DAY 6:
RECEIVED
DAY 7:
|
DAY 8: JAN 19.2024
DAY 9: MARICOPA COUNTY
~~ GLERK BOARM OF STIPER\ISORS
DAY 10:
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Indivict inte racutiring ADA ArcaAmrmndctiane mlanca call LANINGAI-9999

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.)
6 Number of Police 19 Number of Security Personnel [Fencing (Barriers
There is a fence around the area that is patrolled by security personnel and Sheriffs.
Must explain security measures:
SECTION 3 What is the purpose of this event?
[“JOn-site consumption (lof-site (auction/wine/distilled spirits pull) Cleoth
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)
B) ([] Will this event be held on a currenily licensed premises and within the already approved and licensed area?
(Must attach a letter 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 alcohol without retailer involvement
Must aitach 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
{“lDispense 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
(_Isplit 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 alcoho! that is dispensed by the licensed retailer.)
loft 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?
(Cl Yes [#] No If yes, attach letter of explanation.
2
2. How many special event days have been issued fo this organization during the calendar year?
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. }
(1 Yes [¥] No 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 [4] 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.
Atiach additional sheet if necessary.
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Indivichiede racking ADA rieearmmoaricitinns clanca eal (ANII5A9.90090

Anthem Rotary Foundation 100%
Name: Percentage;
3655 W Anthem Way #109 / PMB 107, Anthem AZ 85086
Address:
Street Clty State Zip
Name: Percentage:
Address:
Street City State Zip
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 governing body before submitting
to ihe Department of Liquor Licenses and Control. Please contact fhe local governing board for additional information.
APPLICANT SIGNATURE
Declaration:
Edward John Salem Jr declare under penalty of perjury that | am
I, (Print Name) ,
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 nd co WK
Z b>
Led ‘an
Signature
LOCAL GOVERNING BODY
Date Received:
recommend EIAPPROVAL [I DISAPPROVAL
I,
(Government Official)
On behalf of
(City, Town, County)
The local governing body (city, town or municipality where the fair/festival will take place) may require additional
applications to be completed and submitted. Please check with local government as to how far in advance they require
these applications to be submilted. Additional licensing fees may also be required before approval may be granted.
AZDLLC USE ONLY
CIAPPROVAL LC] DISAPPROVAL BY:
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Edward John Salem Jr
Anthem Rotary Foundation
January 17, 2024
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 “Autumn Fest in Anthem 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 ie you have any questions.
Thank you. Sincerely,
7 a a)
ward John Salem Jr.

SPECIAL EVENT LICENSED PREMISES DIAGRAM
(This diagram must be completed with this
application)
Special NOTE: Event Diagram: (Show dimensions, serving areas, and label type of enclosure and
Show nearest cross Streats, highway, or road if location doesn't have security positions)
an address,
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tire, Walk paths
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INDICATES THE FENCED AREA WHERE ROTARY SPECIAL EVENT
WILL BE HELD,
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