BUCKEYE RANCH RV RESORT_REDACTED.PDF

State of Arizona

Department of Liquor Licenses and Control

Created 12/27/2024 @ 11:30:04 AM
Local Governing Body Report

LICENSE

Number: Type: 010 BEER AND WINE
STORE
Name: BUCKEYE RANCH RV RESORT
State: Pending
Issue Date: Expiration Date:
Original Issue Date:
Location: 105 N 339TH AVENUE
TONOPAH, AZ 85354
USA
Mailing Address:
Alt. Phone:
Email: Se
AGENT
Name: ANDREA DAHLMAN LEWKOWITZ
Gender: Female
Correspondence Address:
Phone:
Alt. Phone:
OWNER

Name: PREV AGAVE QOZB, LLC
Contact Name: ANDREA DAHLMAN LEWKOWITZ
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: 23391308 State of Incorporation: MN

Incorporation Date:
Correspondence Address:

Phone:
Alt. Phone:
Email:

Officers / Stockholders

06/27/2022

2

Page I of 4

Name: Title: % Interest:

PREV AGAVE QOF LLC Member 100.00

PREV AGAVE QOF LLC - Member
Name: IRVIN ROBERT KESSLER
Gender: Male
Correspondence Address:

Phone:
Alt. Phone:
Email:
PREV AGAVE QOZB, LLC - Member
Name: PREV AGAVE QOF LLC
Contact Name: ANDREADAHLMAN LEWKIWITZ
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: State of Incorporation: AZ

Incorporation Date:
Correspondence Address:

Phone:
Alt. Phone:
Email:
MANAGERS
Name: IRVIN ROBERT KESSLER
Gender: Male

Correspondence Address:

Phone:
Alt. Phone:
Email:

EHR I HRI MH ea RE RRR RAR EER RRR EAR ER RRR ARERR ES

Name: MICHAEL SAUL HARRISON
Gender: Male
Correspondence Address:

Phone:
Alt. Phone:
Email:

Page 2 of 4

APPLICATION INFORMATION

Application Number: 310630

Application Type: New Application
Created Date: 09/23/2024
QUESTIONS & ANSWERS
010 Beer and Wine Store
1) Are you applying for an Interim Permit (INP)?
No
2) Provide name, address, and distance of nearest school.
(If less than one (1) mile note footage)
Winter Wells Elementary School | 1.65 Miles
35220 W Buckeye Rd, Tonopah, AZ 85354
3) Are you one of the following? Please indicate below.
Property Tenant
Subtenant
Property Owner
Property Purchaser
Property Management Company
PROPERTY OWNER
4) Is there a penalty if lease is not fulfilled?
No
5) Is the Business located within the incorporated limits of the city or town of which it is located?
No
Ifno, in what City, Town, County or Tribal/Indian Community is this business located?
MARICOPA COUNTY
6) What is the total money borrowed for the business not including the lease?
Please list each amount owed to lenders/individuals.
7) Are there walk-up or drive-through windows on _ premises ;
No
8) Does the establishment have a patio?
No
9) Is your licensed premises now closed due to construction, renovation or redesign or rebuild?
Yes
If yes, what is your estimated completion date?
MAY 2025
DOCUMENTS
DOCUMENT TYPE FILE NAME UPLOADED DATE
ALIEN STATUS BR_AGT ADL (Cin).pdf 11/07/2024
QUESTIONNAIRE BR_AGT ADL (Q).pdf 11/07/2024
MISCELLANEOUS BR_CP Jaffe + LP (Affidavit).pdf 11/07/2024
QUESTIONNAIRE BR_CP Kessler (Q+Supple+FP).pdf 11/07/2024
DIAGRAM/FLOOR PLAN BR_Diagram.pdf 11/07/2024
QUESTIONNAIRE BR_Mgr Harrison (Q+FP+T).pdf 11/07/2024

Page 3 of 4

ORGANIZATIONAL DOCUMENTS PREV Agave QOZB, LLC_Ownership 11/07/2024
Chart.pdf

Page 4 of 4

7/21/2022

rut 1 4S Liqr, Dept anid

APPLICANT/CONTROLLING

PERSON AFFIDAVIT

Arizona Dept. of Liquor Licenses and Control
800 W. Washington St. 5'" Floor Phoenix, AZ 85007
(602) 542-5141

Type or Print with Black Ink
BE COMPLETED BY THE ORGANIZATION'S PRESIDENT. IF THIS IS A CLUB, PARTNERSHIP,
OR OTHER TYPE OF ORGANIZATION, A SIGNATURE OF EQUAL LEVEL IS REQUIRED.

Organization: PREV AGAVE Q0OZB, LLC
Affidavit of: IRVIN ROBERT KESSLER

Position/Title: MANAGER/MEMBER

State of: MN AZ Corp./L.L.C. #: 23391308

County of: MARTIN State Incorporated: MN

L (Print Full Name) !RVIN ROBERT KESSLER Declares:

1. To obtain a liquor license to operate in Arizona, I have completed and delivered to the Arizona Dept. of Liquor
Licenses and Control, the required questionnaire and fingerprint card. { have also submitted the required questionnaires
and fingerprint cards of all officers, directors, regional managers, managing members, partners, ctc., who are involved in
the management of the policies involving spirituous liquor in the State of Arizona; and all stockholders who own ten
percent (10%) or more of the corporation or limited liability company have also been completed and submitted.

Name and title of such individuals are as follows (or list attached):
1) IRVIN ROBERT KESSLER | MANAGER/MEMBER
2)
3)
4)

2. In addition to those submitting questionnaires and fingerprint cards, list other officers, limited liability members,
and/or board members of this organization who are not submitting such information to the Arizona Department of
Liquor Licenses and Control. None of these individuals are involved in the direction of the management of policies of
this organization involving spirituous liquor in the State of Arizona.

e of birth, are as follows (or list attached):

1) PHILLIP JAFFE | MEMBER |
2) CLARENCE VINCENT LP | MEMBER |
3)
4)

individuals listed under item #2 have at any time been convicted of a
d to that member.

3. Finally, on information and belief, none of the i
felony, had a liquor license revoked, or violated any provisions of a liquor license issue

Se

laration:
|, (Print Name) !RVIN ROBERT KESSLER , declare under penalty of perjury that | am

this application, and to the best of my
orrect and complete.

authorized to submit this application. | have read the contents
knowledge believe all statements made on this application to bg tru

Signature

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

PREV AGAVE QOZB, LLC
Ownership Chart | 8/30/2024

Phillip Jaffe
Member (12.14%) No one
**Filed via CP Affidavit** owns/controls

P| —_

Clarence LP

Irvin Kessler Member (12.14%)
Member (24.29%) **Filed via CP Affidavit**

|

PREV Agave QOF, LLC
Member (100%)

PREV AGAVE QOZB, LLC |—| Irvin Kessler, Mgr LC
Applicant

ry
ied

ject

4 3 Lig

AUT

ca

Entrance/exit

Liquor storage

| gy —-O

Buckeye Ranch RV Resort
105 N. 339" Avenue
Tonopah, AZ 85354

2,342 SF

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.

DLLC USE ONLY ;
Fea ar, Be RAE L
. J .

Job #: a \aleS6

Date Acedpes V A he

CSR: KAT
Questionnaire
Ve

Au OY

Arizona Dept. of Liquor Licenses and Control ‘
https://www.azliquor.gov
(602) 542-5141

Personal Information

ok

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: 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.

A.R.S. §4-101(22) ond
ARS. §4-202(C)

. License Number:
. Business Name (doing business as

. Business Address:

4/18/2023

SECTION - 1 INDIVIDUAL INFORMATION

EO AGENT CIcoNTROLLING PERSON [1 maNaAGER
. Name:__LEWKOWITZ ANDREA DAHLMAN
Last First Middle

. Social Security CO Birth Date: |
‘@ public record) (NOT a public record)

. Driver's License ;

State Issued: AZ

(NOT a public record)

. Are you a resident of Arizona? Blyes CINo Date of residency: _04 / 01 /_ 1961

‘Home Address: a
. Daytime phone #: : = Alternative phone 7

SECTION 2 - LICENSED BUSINESS INFORMATION

SERIES 10 | PENDING

); BUCKEYE RANCH RV RESORT

105 N. 339th AVENUE, TONOPAH, AZ 85354

Page 1 of2
Individuals requiring ADA accommodations please call (602)542-2999

SECTION 3 ~ DAY TO DAY OPERATION OF BUSINESS... i. sect sit

iF

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? LClAgent Lcontrolling Person [Manager

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

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 &
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?

3. Has an entity in which you are or have been a controlling person had an Yes CJ] 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 C1 No &
involved fraud or misrepresentation?

a PALE

1, (Print Full Name) _ANDREA DAHLMAN LEWKOWHZ 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 I have made herein are true and correct to the best of my knowledge.
Signature, Date; _ 09/05/2024

GO

em sss

4/18/2023 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999

ALIEN STATUS
RESTAURANT/HOTEL/MOTEL

ee Arizona Dept. of Liquor Licenses and Control
e 800 W. Washington St. 5!" Floor Phoenix, AZ 85007
(602) 542-5141

Type or Print with Black Ink

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 IV. Applicants who are not U.S. citizens or natlonals
must also complete Section Ill.

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 cerificate) if the name on your evidence Is not the same
as your current legal name.

SECTION | — APPLICANT INFORMATION

ANDREA DAHLMAN LEWKOWITZ

APPLICANT NAME (Print ortype)

Are you a citizen or national of the United States? [¥]Yes (Cho - If yes, indicate place of birth:

y MANKATO state MIN country USA

Cit

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

AZ DRIVERS LICENSE

2) Nameof document:

If you answered No, you must complete Sections Ill.

Page 1 of 3

7/21/2022
Individuals requiting ADA accommodations please call (602)542-9027

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:

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

3. 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)

4. A United States certificate of birth abroad.
5. A United States passport. ***Passport must be signed***
6. A foreign passport with a United States visa.

7. An\-94 form with a photograph.

8. A United States citizenship and immigration services employment authorization document or

refugee travel document.
9. A United States certificate of naturalization.
10. A United States certificate of citizenship.
11. A tribal certificate of Indian blood.

12. 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

13.
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

7/21/2022
Individuals requiring ADA accommodations please call (602)542-9027

SECTION Ill — QUALIFIED ALIEN DECLARATION

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))

1. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA)
An alien who is granted asylum under Section 208 of the INA.

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

An alien paroled into the United States for at least one year under Section 212(d)(5) of thelNA.

An alien whose deportation is being withheld under Section 243(h) of the INA.

An alien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.

An alien who is a Cuban/Haitian entrant.

DOOOOooOooo

eS NF HF BF wW Dw

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. A citizen 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 Iskands, Republic of Palau and the Federate States of Micronesia, 48

U.S.C. § 1901 etseq.];
13. A foreign national not physically present in the United States.
14. Otherwise Lawfully Present
15. A person not described in categories 1-13 who is otherwise lawfully 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 licensure. See 8 U.S.C. §

ANDREA DAHLMAN LEWKOWITZ Os Je 09/05/2024

Signature Date

Print Name

Page 3 of 3

7/2\/2022
Individuals requiring ADA accommodations please call (602)542-9027

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.

DLLC USE ONLY

Arizona Dept. of Liquor Licenses and Control ind Tees net AT
https://www.azliquor.gov EA | ifeets ‘@ mee
(602) 542-5141 Job #: KANO O)

Personal Information
Questionnaire

SS AT

pag eget Yle {
CSR: Wer

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: 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.

ARS, §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)

. License Number:
. Business Name (doing business as

. Business Address:

4/18/2023

SECTION - 1 INDIVIDUAL INFORMATION

Clacent EIconTROLLING PERSON C manacer
Name: KESSLER IRVIN ROBERT
Last First
. Social Security A Birth Date

(NOT a public record) (NOT a public record)

. Driver’s License fF t“‘i‘iséCS State Issued: ARIZONA

(NOT a public record)

. Are you a resident of Arizona? Yes LINo Date of residency: 01 08/1955

rai ars
ome es: rr

. Daytime phone #: | e;,lUmr Alternative phone i

SECTION 2 — LICENSED BUSINESS INFORMATION

SERIES 10 | PENDING

): BUCKEYE RANCH RV RESORT

105 N. 339th AVENUE, TONOPAH, AZ 85354

Page 1 of 2
Individuals requiting 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? ClAgent Ccontrolling Person [Manager
MICHAEL HARRISON

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

SECTION 4 — BACKGROUND

If you answer “YES” to any Question 2 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 [1 No
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 [J 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 C1 No
involved fraud or misrepresentation?

a Sa =

|, (Print Full Name) IRVIN ROBERT KESSLER 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 antl statements that | have made herein are true and correct to the best of my knowledge.

Date: 09/23/2024

Signature:

pS SS SE

4/18/2023 Page 2 of 2
individuals requiring ADA accommodations please call (602)542-2999

Pa tL 19 cle, beet athe
Name Irvin Kessler

AZ Dept. of Liquor
Questionnaire Supplement

SECTION 4, Question 1 - YES

| have owned or | have been a controlling person for an entity that owns or owned the following liquor
license(s) in the past five years

State Business Name

AZ Verde Fencepost LLC
AZ CO River LLC

CA Coach RV LLC

fo

Signature

i i i se oe am. 2. DLLC USE ONLY
Arizona Dept. of Liquor Licenses and Controk=.5 it 19 utpoedet
https://www.azliquor.gov

Pei

(602) 542-5141 job Z
Date Accented:
Personal Information - tial

Questionnaire

Wha?
Qi vey
god BETS

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: 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).

. Name:

Last First
. Social Security i
OT a public record)
. Driver’s License

Controlling Person:
person directly or
indirectly possessing
control of an applicant
or licensee.

ARS. §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)

. License Number:
. Business Name (doing business as

. Business Address:

4/18/2023

SECTION - 1 INDIVIDUAL INFORMATION

Clacent, CIcoNnTROLLING PERSON MANAGER

HARRISON

MICHAEL SAUL

|
(NOT a public recor:

State Issued: ARIZONA _

(NOT a public record)

. Are you a resident of Arizona? Yes CINo Dateofresidency: 10/01 /2006

a i

. Daytime phone #: i Alternative phone _ =

SECTION 2 — LICENSED BUSINESS INFORMATION

SERIES 10 | PENDING

): BUCKEYE RANCH RV RESORT

105 N. 339th AVENUE, TONOPAH, AZ 85354

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? Clagent Ccontrolling Person [Manager
MICHAEL HARRISON

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 [1 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
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 C1 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 LC] No
involved fraud or misrepresentation?

ae = a Ts

SE a

MICHAEL SAUL HARRISON

|, (Print Full Name) 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 verify that
the information and statements that I have made herein are true and correct to the best of my knowledge.

—{—— sate 09722724

Signature:

4/18/2023 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999

transaction

Billing Information
Michael Harrison

RECEIPT

Account Information

Product ID Item Description Amount Quantity Gross
PSAPTO01 Conduct Criminal Background Checks $22.00 1 $22.00
for Pre-Employment Screening - State
& Federal Agencies
PSPSPCC1 Service Fees $0.44 1 $0.44
TOTAL $22.44
Notes:

Arizona Department of Public Safety: This is a transaction for AZDPS for A000352670

Certificate #752498

Certificate of Completion
bp, For ee
Title 4 BASIC LiquorLaw, Training
4 16 Atizo . Certificates are completed by a state-

int.

ras a result of a liquor law violation. Persons
etimes require BASIC Title 4 Training a condition of

On- and off-sale

A Certificate of Completion must be on a formipro ide
approved training provider and, when issued.
The State requires BASIC Title 4 training only as ap
required to have BASIC Title 4 training are listed ai
employment. | 5
A replacement Certificate of Completion:for- Title “4 training must be-availab
completion date. ef . ee

ing provider for two years after the training

= Michael Ss Harrison ahi i ,

Full Name (please print)

tion Date
letion date}

Training, Provider Information © ;

on. Corporation (PSCC)

Professional Server Ce

Company Name’

P.O. Box 192, Madison, ‘South Dakota 57042

Mailing Address

1- (800) 247-7737

Daytime Contact Phone Number

l, Robert Graham _ certify that the above named individual did successfully complete

Instructor Name (please print)
Title 4 BASIC Training in accordance with A.R.S. §4-112(G)(2) and Arizona Administrative Code (A.A.C.)R19-1-103

using training course content and materials approved by the Arizona Department of Liquor Licenses and Control.
| understand that misuse of this Certificate of Completion can result in the revocation of State-approval for the Title

4 Training Provider named in this section as provided by A.A.C. R19-1-103(E) and (F).

Pobet VGrb— 24 /_09_/__2024

Instructor Signature Day Mo Year

Persons required fo complete BASIC & MANAGEMENT Title 4 training: 1) owner(s} actively involved in the daily business operations of a liquor-
licensed business of a series listed below

2) licensees, agents and managers actively involved in the daily business
operations of a liquor-licensed business of a series listed below

In-state Microbrewery (series 3) Government (series 5) Bar (series 6) Beer & Wine Bar (series 7)
Conveyance (series 8) Liquor Store (series 9) Private Club (series 14) Hotel/Motel w/restaurant (series 11)
Restaurant (series 12) In-state Farm Winery (series 13) Beer & Wine Store (series 10)

Liquor license applications {initial and renewal) are not complete until valid Certificates of Completion for all required persons have been
submitted to the Department of Liquor.

The questionnaire (which designates a manager f
licenses) are not complete until valid Certificates of

‘0 a location} and the agent change form (which assigns a new agent to active liquor
f Completion for all required persons have been submitted to the Department of Liquor.

July 11, 2013

Certificate #752969

Certificate of Completion
I pe. For et
NT Liquor

Title 4 MANAGEME

A Certificate of Completion must be on a formipr x th
approved training provider and, when issued, the
Basic Title 4 training is a prerequisite for MANAGEM h
at the Department of Liquor and satisfactory comple: ¢
to issuing a Certificate of Completion for MANAGEMENT Title 4 tra
A replacement Certificate of Completion-for Title 4 trai
completion date. Pe 2 5

3letion for BASIC Title 4 training must be on file
Course must be verified by the training provider prior

ining: provider fortwo years after the training

09-26-2024
Training'C mpl :

P.O. Box 192, Madison, South Dakota 57042

Mailing Address

4- (800) 247-7737

Daytime Contact Phone Number

L, Robert Graham certify that the above named individual did successfully complete
Instructor Name (please print)

Title 4 MANAGEMENT Training in accordance with A.R.S. §4-112(G) (2) and Arizona Administrative Code

(A.A.C.)R19-1-103 using training course content and materials approved by the Arizona Department of Liquor

Licenses and Control. | understand that misuse of this Certificate of Completion can result in the revocation of

State-approval for the Title 4 Training Provider named in this section as provided by A.A.C. R19-1-103(E) and (F).

Lobet VGrb— 26 /_09 /___2024

Instructor Signature Day Mo Year

Persons required to complete BASIC & MANAGEMENT Title 4 training: 1) owner(s) actively involved in the daily business operations of a liquor-
licensed business of a series listed below
2) licensees, agents and managers actively involved in the daily business
operations of a liquor-licensed business of a series listed below

In-state Microbrewery (series 3) Government (series 5) Bar (series 6) Beer & Wine Bar (series 7)
Conveyance (series 8) Liquor Store (series 9) Private Club (series 14) Hotel/Motel w/restaurant (series 11)
Restaurant (series 12) In-state Farm Winery (series 13) Beer & Wine Store {series 10)

Liquor license applications (initial and renewal) are not complete until valid Certificates of Completion for all required persons have been
submitted to the Department of Liquor.

The questionnaire (which designates a manager fo a location) and the agent change form (which assigns a new agent fo active liquor
licenses) are not complete until valid Certificates of Completion for all required persons have been submitted to the Department of Liquor.

July 11, 2013