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9387 characters
CSR:
Amount:
DLLC USE ONLY
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.
Voss Jessica L
1, Appticant:
(Must be an Officer/Member of the No i i i Middle
An
No _Applesars rt te
602-935-1059
w . Applicants home/cell phone} Applicant's business phone:
4. Applicant's email address:
Amadio Ranch Farm to Table Valentine's Couples Dinner
5. Special Event Name:
6. Name of Non-Profit Organization, Candidate or Political Party/Gov.: EmpoweRanch
82-2485216
7. Non-Profit/IRS Tax Exempt Number:
21518051
8. Arizona Corporation Commission File #: If out of State please specify:
(Attach letter of good standing)
AMadio Ranch Heritage Farm
9. Event Location Name:
4701 W Dobbins Rd, Laveen, AZ 85339
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**
2/14/2024 Wednesday 5:30pm 10pm
DAY 1:
DAY 2:
DAY 3:
DAY 4:
DAY 3:
DAY 6: RECEIVED
pay’:
FANS. 2624
DAY 8: SOFA
COUNTY
GLERK BOARD OF SUPERVISORS
DAY 9:
DAY10:
2/6/2023 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 police/security personnel and type of fencing or control barriers, if applicable.)
0 Number of Police 2 Number of Security Personnel ¥lFencing [Barriers
Event tickets are paid for and reserved in advance. ID is confirmed at check-in.
Must explain security measures:
The event is only for 21+. Only serving glass of wine with dinner. We will have at least two security personnel and staff are trained in proactive risk management procedures
SECTION 3 What is the purpose of this event?
[V]On-site consumption [_loff-site (auction/wine/distilled spirits pull) [Both
How is this soecial event going to conduct all dispensing, serving, and selling of spirituous liquors?
Check one of the following boxes. {R-19-318)
A) J] Special Event being held on an unlicensed premises will require approval and signature by the Local Governing
Body on page 38. (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 attach letter from the location suspending license for duration of special event
[Dispense and serve alll spirituous liquors under retailer's license — Business operates normally, minimum of 25% of gross
revenue from alcohol sales is donated fo licensee
CDispense 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 musi be separated from any alcohol
used during the special event. Must attach letter from the location suspending license for duration of special event
CIsplit 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.)
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?
(_] Yes YI No If yes, attach letter of explanation.
0
2. How many special event days have been issued to 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 alcoho! on behalf of the licensee. If no special event contractor is listed, the licensee is
responsible for the sales and service of alcohol. }
CL Yes [Y] 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 [Y] 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.
2/6/2023 Page 2 of 3
Individuals requiring ADA accommodations please call (602)542-2999
Amadio Ranch Heritage Farm /9
Name: Percentage:
4701 W Dobbins Rd, Laveen, AZ 85339
Address:
Street City State Zip
Name: EmpoweRanch Percentage: 26
3104 E Camelback Rd. Box 760 Phoenix, AZ 85016
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.
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 governing 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) Jessica L Voss 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, correct and complete.
Queacoa L. Vow
¢
Signature
LOCAL GOVERNING BODY
Date Received:
l, recommend LIAPPROVAL [] DISAPPROVAL
(Government Official) (Title)
On behalf of
(City, Town, County) Signature
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 submitted. Additional licensing fees may also be required before approval may be granted.
AZDLLC USE ONLY
LIAPPROVAL CJ DISAPPROVAL BY:
2/6/2023 Page 3 of 3
Individuals requiring ADA accommodations please call (602)542-2999
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