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State of Arizona
Department of Liquor Licenses and Control
Created 03/24/2022 @ 02:36:21 PM
Local Governing Body Report
LICENSE
Number: 06070373 Type: 006 BAR
Name: LONGBRANCH SALOON
State: Pending
Issue Date: Expiration Date: 01/31/2023
Original Issue Date: 04/07/1978
Location: 10600 W BUCKEYE ROAD
TOLLESON, AZ 85353
USA
Mailing Address:
Phone:
Alt. Phone:
Email:
Currently, this license has pending applications.
AGENT
Name: NATASHA MITCHELLE HARRIS
Gender: a
Correspondence Address:
Phone: P|
Alt. Phone:
OWNER
Name: DAVIS & STEELE I] LLC
Contact Name: NATASHA MITCHELLE HARRIS
Type: LIMITED LIABILITY COMPANY
AZ CC File Number: L10114550 State of Incorporation: AZ
Incorporation Date: 12/11/2001
Correspondence Address: Po
USA
Phone:
Alt. Phone:
Officers / Stockholders
Page | of 3
Name: Title: % Interest:
TERRY LEON DAVIS Manager MBR 50.00
NATASHA MITCHELLE HARRIS MEMBER 50.00
DAVIS & STEELE If LLC - Manager MBR
Name: TERRY LEON DAVIS
Gender: Male
Correspondence Addre:
: |
wa
j
Phone:
Alt. Phone:
Email:
DAVIS & STEELE Il LLC - MEMBER
Name: NATASHA MITCHELLE HARRIS
Gender: Female
Correspondence Address:
|
a
|
Phone:
Alt. Phone:
Email:
MANAGERS
Name: TERRY LEON DAVIS
Gender: Male
Correspondence Address:
J
Phone:
Alt. Phone:
Email:
c
>|
APPLICATION INFORMATION
Application Number: 190258 . ,
Application Type: Acquisition of Control Agente
Created Date: 03/24/2022 , '
Chany
QUESTIONS & ANSWERS
006 Bar
4) Does the Business location address have a street address for a City or Town but is actually in the
boundaries of another City, Town or Tribal Reservation?
Yes
If Yes, what City, Town or Tribal Reservation is this Business located in?
MARICOPA COUNTY
COMPLIANCE ACTIONS
000262-20
03/07/2020 - Incident Date
04/17/2020 - Fine
04/30/2020 - Fine Payment ($500.00)
04/29/2020 - Case Closed
Violations
Statute Counts Description
4-207.01.B 1 Altered floor plan without notifying Department
4-244 32 I Allowing Alcohol to be Removed from Premises
3/7/2020 Incident date
4/17/2020 Mail In Consent issued/mailed, $500.00 Penalty fine assessed
4/24/2020 Sizned Mail In Consent received
4/29/2020 $500.00 Fine paid, Receipt #R39802
Page 3 of 3
Arizona Department of Liquor Licenses and Control
800 W Washington 5‘ Floor
Phoenix, AZ 85007-2934
www.azliquor.gov
(602) 542-5141
QUESTIONNAIRE |
A.R.S.§4-202, 4-210 Co AS
Type or Print with Black Ink
The fees allowed by R19-1-102 will be charged for all dishonored checks.
ATIENTION APPLICANT: This is a legally binding document. Please type or print in black ink. 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
Attention local governments: Social security and birth date information is confidential. This information may be given to law
enforcement agencies for background checks only
QUESTIONNAIRE IS TO BE COMPLETED BY EACH CONTROLLING PERSON, AGENT AND MANAGER BEING DISCLOSED TO THE DEPARTMENT. EACH
PERSON COMPLETING THIS FORM MUST SUBMIT A BLUE OR BLACK LINED FINGERPRINT CARD ALONG WITH A $22 FEE. FINGERPRINTS MUST BE DONE
BY A LAW ENFORCEMENT AGENCY OR BONA FIDE FINGERPRINT SERVICE. FOR AN ADDITIONAL $13 FEE, FINGERPRINTS MAY BE DONE AT THE
DEPARTMENT OF LIQUOR WHEN ACCOMPANIED BY A COMPLETED APPLICATION.
Liquor License#: CWO +033-3 pa
1. Check the U {le SY
Appropriate hs
Box ___+.» O Controlling Person Bd Agent O Premises Manager
(complete all questions except #12)
2. Name Pars Necashna Michneite ___ Birth Date a
Last First Middle
4. Place of birth Hollywood Ch Us & Height’ SS‘! %_ Weight \SO_ Eyes: BK Hair: Bee’
City
State COUNTRY (not county)
5. Name of current/most recent spouse: Birth Date / /
last First Middle (NOT a public record)
6. Are you a bona fide resident of Arizona? Byes ONo if yes, what is your date of residency Fen LA]
7. Daytime telephone number: | E-mail address PO
8. Business Name: LOMA yx nan Saloon Business Phone: (2a%3 9.36/ {390
9. Business Location Address: (OlOO (wo. BockKeuc BA Tolleson re S455
Street (do not use PO Box ) City State County Zip
10. List your employment or type of business during the past five (5) years. If unemployed. retired, or student, list residence address
FROM Ife} EMPLOYERS NAME OR NAME OF BUSINESS
MORINTYeRr monthhour DESCRIBE POSITION OR BUSINESS
ca los CURRENT Lead Barlendktr
(ATTACH ADDITIONAL SHEET IF NECESSARY)
1/11/2018 Page 1 of 2
Individuals requiring ADA accommodations please Call (602)542-2999
11. Provide your residence address information for the last five (5) years: A.R.S. §4<202(D)-5 -
FROM 1o
Month/Year Month/Year RESIDENTIAL Street Address
Or lao CURRENT
(ATTACH ADDITIONAL SHEET IF NECESSARY)
12. As a Controlling Person or Agent, will you be physically present and operating the licensed premises? Yes ONo
If you answered YES, then answer #13 below. If NO, skip to #14.
13. Have you attended a DLLC approved Basic & Management Liquor Law Training Course within the past 3 ves ONo
years?
14. Have you been cited, arrested, indicted, convicted, or summoned into court for violation of ANY criminal OYes HINo
law or ordinance, regardless of the disposition, even if dismissed or expunged, within the past five (5) years?
15. Are there ANY administrative law citations, compliance actions or consents, criminal arrests, indictments or OYes BNo
summonses pending against you? (Do not include civil traffic tickets.) A.R.S.§4-202,4-210
16. Has anyone EVER obtained a judgement against you the subject of which involved fraud or misrepresentation? OYes KINO
17. Have you had a liquor application or license rejected, denied, revoked or suspended in or outside of Arizona Yes KANo
within the last five years? A.R.S.§4-202(D)
, , , a . , Dyes HINo
18. Has an entity in which you are or have been a controlling person had an application or license rejected,
denied, revoked or suspended in or outside of Arizona within the last five years? A.R.S.§4-202(D)
If you answered “YES” to any Question 14 through 18 YOU MUST attach a signed statement.
Give complete details including dates, agencies involved and dispositions.
CHANGES TO QUESTIONS 14-18 MAY NOT BE ACCEPTED
NOTARY
| (rint Full Namey Wockagha Mitchelle harris hereby declare that | am the Agent/ Controlling Person /
Premises Manager filing this application. | have read this document and verify the contents and all statements are true,
correct and complete, to the best of my knowledge.
Signature: L Vatasbra Ath State of Ar LOWMAN County ot ManicoP SD _
The foregoing instrument was acknowledged before me this
id) ~
My Commission Expires on: 12. i 7 - BOBZA aI Day of Jonny BOR?
Date Day Month y) Year
RA WHEELER
> Noten bettie. State of Arizona
Marjeobe Coun Signature of Notary
ed on this questionnaire to act as manager for the above License.
PRINT NAME: SIGNATURE:
1/11/2018 Page 2 of 2
Individuals requiring ADA accommodations please Call (602)542-2999
State of Arizona ~~
Department of Liquor Licenses and Control
800 W. Washington 5" Floor
Phoenix, AZ 85007
(602) 542-5141
ARIZONA STATEMENT OF CITIZENSHIP
OR ALIEN STATUS FOR STATE PUBLIC BENEFITS
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, ar 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 thal 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 nationals must also
complete Section III.
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 certificate) if the name on your evidence is not the same as your current
legal name.
[ SECTION | - APPLICANT INFORMATION |
INDIVIDUAL OWNER/AGENT NAME (Print or type) Na tasha bear =
SECTION Il - CITIZENSHIP OR NATIONAL STATUS DECLARATION
Are you a citizen or national of the United States? Xl yes [Jno
If Yes, indicate place of birth:
City. Hollywood State (or equivalent)_ Cali Gaymnta Country or Territory, USA
if you answered Yes, 1) Attach a legible copy of a document from the attached list.
2) Nameof document: Rassonet )
Go to Section IV.
If you answered No, you must complete Section Ill and IV.
9/17/2018 Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-9027
SECTION Ill - ALIEN STATUS DECLARATIONS ©
To be completed by 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))
CL] 1. Analien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA)
CE] 2. Analien who is granted asylum under Section 208 of the INA.
C 3. Arefugee admitted to the United States under Section 207 of the INA.
| 4. Analien paroled into the United States for al least one year under Section 212(d)(5) of the INA.
[fat 5. An alien whose deportation is being withheld under Section 243(h) of the INA.
| 6. Analien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.
C 7. Analien who is a Cuban/Haitian entrant.
Cs. 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))
CI 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))
CE] 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)
C] 11. Anonimmigrant whose visa for entry is related to employment in the United States, or
LJ 12. A citizen of a freely associated stale, 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 Islands, Republic of Palau and the Federate States of Micronesia, 48 U.S.C. § 1901 efseq.}:
Ch. A foreign national not physically present in the United States
Otherwise Lawfully Present
CJ 14, 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. § 1621(a).
9/17/2018 Page 2 of 3
Individuals requiring ADA accommodations please Call (602)542-9027
| —_ SECTION IV- DECLARATION’ |
lL
All applicants must complete this section.
| declare under penaity of perjury uncer the laws of the state of Arizona that the answers and evidence | have given are
true and correct to the best of my knowledge
WNatusha tharris
Individual Owner/Agent Printed Name
Individual Owner/Agent Signature Today's Date
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 identification card
2. Adriver license issued by a state that verifies lawful presence in the United States.
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 January 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)
A United States certificate of birth abroad.
A United States passport. ***Passport must be signed***
a no Ss
A foreign passport with a United States visa.
7. Ant-94 form with a photograph
8. A United States citizenship and immigration services employment authorization document or refugee travel
document.
9. AUnited 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
13. Any other license that is issued by the federal government, any other state government, an agency of this
state or a political subdivision of this state that requires proof of citizenship or lawful alien status before issuing
the license.
9/17/2018 Page 3 of 3
Individuals requiting ADA accommodations please Call (602)542-9027
Certificate of Completion “A alle
For Bone and off-sale
Title 4 BASIC Liquor Law Training
A Certificate of Completion must be on a form providediby the Arizona: Deparlmént of Liguor. Certificates are completed by a state-
approved training provider and, when issued, the Certificate is signed. by ihe, course’ Participant.
The State requires BASIC Title 4 training only as a prerequisite for MANAGEMENT Tile 4 training or as a result of a liquor law violation. Persons
required fo have BASIC Title 4 training are istey! a the base’of. «Wt Cortiiore, Hees, Sometimes require BASIC Title 4 Training a condition of
employment.
Areplacement Certificate of Comptelians co Title 4 fing pest 8 SMO through the gine provider for two years after the training
completion date. .
% Student Information
A Wace ss
Ful Name (please A
- . Signature z 4
i if SP vere ee AZ ZL
Training Completion ey - Cettificate Expiration Date
; £ i eid ° o} fees = flhreéyears from completion date)
training Provider Information
ABC - Arizona Bnsitiess Council for Alcohol Education
Company Name
8155 North 24th Avenue, Suite A; Phoenix, Arizona 85021
Mailing Address
(602) 285-1396
Daytime Contact Phone Number
|, Jesus Altamirano _ 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).
ZI WAS
Instructor Signature Day Mo Yeor
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-stale 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 to a location) and the agent change form (which assigns a new agent to active liquor
licenses) are not complete until valid Certificates of Completion for all required persons have been submitted to the Department of Liquor.
ABCA-112 REV. 11/16
Certificate of Completion
For oe
Title 4 MANAGEMENT Liquor Law Training
Liguer. Certificates are completed by a state-
A Certificate of Completion must be ona ie i Re by the ‘Asizond aay 3
completion date.
siddent information q
Wetatinn “Dearne =
s Cou cit De Education
GoriRahy Baro’
ABC - Arizona Bus i
8155 North 24th venue Suited; Phoenix, Arizona 85021
Genie ‘Address
(602) 285-1396
Daytime Contact Phone Number
, Jesus Altamirano , 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 Ti Loz Provider named in this section as provided by A.A.C. R19-1-103(E) and (F).
— 23/\\/jq
insirutor Signature Day Mo Year
Persons required io 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 aclively 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) ore 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 to a location) and the agent change form {which assigns a new agent to active liquor
licenses) are not complete until valid Certificates of Completion for all required persons have been submitted to the Department of Liquor.
ABCA-121 REV. 06/18