SUPERSTITION MANOR WEDDING & EVENT CENTER_REDACTED.PDF

State of Arizona
Department of Liquor Licenses and Control

Created 11/10/2021 @ 03:06:46 PM
Local Governing Body Report

LICENSE

Number: 06070016 Type: 006 BAR
Name: SUPERSTITION MANOR WEDDING & EVENT CENTER
State: Pending
Issue Date: Expiration Date: 01/31/2022
Original Issue Date: 06/16/1982
Location: 1220 N SIGNAL BUTTE ROAD

MESA, AZ 85207

USA
Mailing Address:
Alt. Phone:
Email:

Currently, this license has pending applications.

AGENT

Name: SHARLEY MARIE COTTER LEAVITT
Gender:
Correspondence Address:

Phone:
Alt. Phone:
Email:
OWNER
Name: SUPERSTITION MANOR INC
Contact Name: SHARLEY MARIE COTTER LEAVITT
Type: CORPORATION
AZ CC File Number: 17646820 State of Incorporation: AZ
Incorporation Date: 05/29/2012

Correspondence Address:

USA

Phone:

Alt. Phone:
Ofticers / Stockholders
Name: Title: % Interest:

Page | of 3

SHARLEY MARIE COTTER LEAVITT President 51.00
TAYLOR NATHAN DON COTTER Director 24.50
CHARLES BLAINE COTTER Vice-President 24.50
BRITTANY ERIN LAWRENCE Secretary

CHAD GARY FISHER CREDITOR

BRITTANY ERIN BURNS

SUPERSTITION MANOR INC -
Name: BRITTANY ERIN BURNS
Gender; Female
Correspondence Address:

Phone:
Alt. Phone:
Email:
SUPERSTITION MANOR INC - CREDITOR
Name: CHAD GARY FISHER
Gender: Male

Correspondence Address:

Phone:
Alt. Phone:
Email:
SUPERSTITION MANOR INC - President
Name: SHARLEY MARIE COTTER LEAVITT
Gender: Female

Correspondence Address:

USA
Alt. Phone:
SUPERSTITION MANOR INC - Vice-President
Name: CHARLES BLAINE COTTER
Gender: Male

Correspondence Address:

Phone:
Alt. Phone:
Email:

SUPERSTITION MANOR INC - Director

Name: TAYLOR NATHAN DON COTTER
Gender: Male
Correspondence Address: Po
Phone:
Alt. Phone:
Email:
SUPERSTITION MANOR INC - Secretary
Name: BRITTANY ERIN LAWRENCE
Gender:

Correspondence Address:

Phone:
Alt. Phone:
Email:
APPLICATION INFORMATION
Application Number: 168778
Application Type: Acquisition oF ConeVagans le
Created Date: 11/10/2021
QUESTIONS & ANSWERS
006 Bar
4) Does the Business location address have a strect 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 BOARD OF SUPERVISORS

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 (ac
A.R.S.§ 4-202, 4-210 donc
Type or Print with Black Ink Pe Macy

Ihe fees allowed by R19-1-102 will be charged for alll dishonored checks. oS- ot }

ATTENTION 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. 446
Liquor License#: 06070016 / | (th E EL

1, Check the
Appropriate
Box __y, [¥] controlling Person [Agent [rremises Manager
(complete all questions except #12)
> Name: LEAVITT SHARLEY MARIE COTTER piri pcre
First (NOT a public record)
3. Social Security . = Driver k= State: ARIZONA
4. Place of bith; MESA ARIZONA UNITED STATES j,,;g,), 0508" weight 135 eyes: BLUE joj, BLONDE

City State COUNTRY (not county)
5. Name of current/most recent spouse: LEAVITT BENJAMIN SCOTT Birth onl
Last First Middie (NOT a public recor

6. Are you a bona fide resident of Arizona es[ No if yes, what is your date of residency: APRIL 2015

SUPERSTITION MANOR WEDDING & EVENT CENTER 480 286 , 7806

8, Business Name: Business Phone: 7 / ~~ /

1220 N SIGNAL BUTTE ROAD MESA ARIZONA MARICOPA 85207

Street (do not use PO Box) City” State County Zip

9. Business Location Address:

10. List your employment or type of business during the past five (5) years. If unemployed, retired, or student, list residence address.

FROM TO EMPLOYERS NAME OR NAME OF BUSINESS
Month/Year Month/Year DESCRIBE POSITION OR BUSINESS a .
09/2021 | current OWNER/OFFICER

10/2015 | CURRENT | PHOTOGRAPHER/OWNER

{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)

FROM TO
Month/Year Month/Year RESIDENTIAL Street Address

{ATTACH ADDITIONAL SHEET IF NECESSARY)

12, As a Controlling Person or Agent, will you be physically present and operating the licensed premises? EWes[¥No
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 Ces[_No
years?

14, Have you been cited, arrested, indicted, convicted, or summoned into court for violation of ANY criminal Lles[¥No

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 Llves[¥No
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? Ltves[7No

17, Have you had a liquor application or license rejected, denied, revoked or suspended in or outside of Arizona LVes[¥No
within the last five years? A.R.S.§4-202(D}

Les[ZNo

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.

SHARLEY MARIE COTTER LEAVITT

| (Print Full Name) 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: Sn LA A I _ State of Ls He 'Z0n Hf County of VM AK opr

The A nen was acknowledged before me this

N sy buble, A ESPARZA
1 t P
My Commission Expires O18" lntiteos Comte 72, of 270 KR POR

. D@tenmission # 650148 Month Year
My Gommission Expires
September 10, 2022

- “Signature of Notary

The Licensee has authorized the person named on this questionnaire 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, 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 I, Il, and IV. Applicants who are not U.S. citizens or nationals 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 certificate) if the name on your evidence is not the same as your current
legal name.

SECTION | - APPLICANT INFORMATION |

SHARLEY MARIE COTTER LEAVITT

INDIVIDUAL OWNER/AGENT NAME (Print or type)

SECTION Il — CITIZENSHIP OR NATIONAL STATUS DECLARATION |

Are you a citizen or national of the United States? [V]ves [Jno

It Yes, indicate place of birth:

cinWMESA ARIZONA UNITED STATES

State (or equivalent) Country or Territory.

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

ARIZONA DRIVER'S LICENSE

2) Name of document:
Go to Section lV.

If you answered No, you must complete Section Ill and IV.

9117/2018 Page | of 3
Individuals requiring ADA accommodations please call (602)542-9027

SECTION Ill — ALIEN STATUS DECLARATION Te |

To be completed by applicants who are not citizens or nationals of the United States. Please indicate alien status by
checking the appropriate box. Atlach 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 (c)(1),-1641(b) and (c})
[] 1, An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA)
C] 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.
C] 4. Analien paroled into the United States for at least ane year under Section 212(d)(5) of the INA.
] 5. An alien whose deportation is being withheld under Section 243(h) of the INA.
C] 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.

_]. 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))

L_] 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)
C] 11. Anonimmigrant whose visa for entry is related to employment in the United States, or

C] 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 Islands, Republic of Palau and the Federate States of Micronesia, 48 U.S.C. § 1901 efseq,):

hs. A foreign national not physically present in the United States.

Otherwise Lawfully Present

LC] 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 ~~

All applicants must complete this section.
| declare under penalty of perjury under the laws of the state of Arizona that the answers and evidence | have given are
true and correct to the best of my knowledge.

SHARLEY MARIE COTTER LEAVITT

Individual Owner/Agent Printed Name
Lo (olla lay
Individuedl OwneryAgentSignéture Today's Date

EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATUS

You musi 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.

A driver license issued by a state that verifies lawful presence in the United States.

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 foreign passport with a United States visa.

An I-94 form with a photograph.

SNS AF

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 govemment, 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 requiring ADA accommodations please call (602)542-9027

Arizona Department of Liquor Licenses and Conirol
800 W Washington 5th Floor
Phoenix, AZ 85007-2934
www.azliquor.gov
(602) 542-5141

QUESTIONNAIRE
A.RS.§4-202, 4-210

Type or Print with Black Ink Peands a

The fees allowed by R19-1-102 will be charged for all dishonored checks. “os qm - O

ATTENTION 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.
06070016 J It 4TT
Liquor License#: O

1, Check the

Appropriate

Box __y, Controlling Person LJagent LPremises Manager
(complete all questions except #12)

> Name: COTTER CHARLES BLAINE — |
First (NOT a public record)
3. Social Security ,| Driver a State: ARIZONA

4. Place of birth: LONG BEACH CALIFORNIA UNITED STATES Height: 06'02 Weight: 190 JAZEL Hair: GRAY

City State COUNTRY (not county)
5. Name of current/most recent spouse: COTTER JEANNE Birth
Last First Middle {NOT a public recor
6. Are you a bona fide resident of Arizona? ‘es| No if yes, what is your date of residency: SEPTEMBER 2019
7. Daytime telephone number: ae ' E-mail ~~, i i

SUPERSTITION MANOR WEDDING & EVENT CENTER 480 286 , 7806

Business Phone:

1220 N SIGNAL BUTTE ROAD MESA ARIZONA MARICOPA 85207

Street (do not use PO Box) Clty State ‘County Zip

8. Business Name:

9. Business Location Address:

10. List your employment or type of business during the past five (5) years. If unemployed, retired, or student, list residence address.

|_ month/Year Monihyvear DESCRIBE POSITION OR BUSINESS EMPLOYERS NAME OR NAME OF BUSINESS
09/2021 | current CEO/OWNER

07/2011 | CURRENT MANAGING MEMBER

(ATTACH ADDITIONAL SHEET IF NECESSARY)

1/11/2018 Page 1 of 2
Individuals requiting 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)

FROM TO
Month/Year Month/Year

09/2019 CURRENT
01/2017 09/2019
07/2009 01/2017

RESIDENTIAL Street Address

(ATTACH ADDITIONAL SHEET IF NECESSARY)

12. As a Controlling Person or Agent, will you be physically present and operating the licensed premises? LYes[WNo
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 [es[¥INo
years?

14, Have you been cited, arrested, indicted, convicted, or summoned into court for violation of ANY criminal Llres[¥No

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 [yes[¥INo
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? [Wes[¥No

17. Have you had a liquor application or license rejected, denied, revoked or suspended in or outside of Arizona Lres[VNo
within the last five years? A.R.S.§4-202(D)

LVes[ZNo

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
CHARLES BLAINE COTTER

| (Print Full Name) 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,

State of County ol4 AK) Cog? 1D lok cop Ca
hi

ie wee instrament was acknowledged before me this
JUANITA A ESPARZA

= 3 Notary Public, State of Arizona “ey of. ( da FOPSR 202 {

Batenmission # 650148 ez Year
My Sommission Expires
__Septamber 10, 2022

~ Signature of Notary

The Licensee has authorized the person named on this questionn4 anager for the above License.
PRINT NAME: SIGNATURE:
1/11/2018 Page 2 of 2

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

Arizona Department of Liquor Licenses and Control
800 W Washington 5" Floor
Phoenix, AZ 85007-2934
www.azliquor.gov
(602) 542-5141

QUESTIONNAIRE
A.RS.§ 4-202, 4-210

ype or Print with Black Ink 4. ag,

Pp ' ith Black | Dowd y nm
he fi I d by R19-1- harged f Il dish d checks, q = C

je fees allowe: R19-1-102 will be charged for al shonored checks. Q Sy \

ATTENTION APPLICANT: This is a legally binding document. Please type or print in black ink, An investigation of your

denial or revocation of a license or permit and could result in criminal prosecution.

background will be conducted. Incomplete applications will not be accepted. False or misleading answers may result in the |. —-

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. UTM
Liquor License#: 06070016 /| (, b tté

1. Check the
Appropriate
Box ——p Controlling Person Oo Agent O Premises Manager
(complete all questions except #12)
> Name: COTTER TAYLOR = NATHANDON gin pat

First (NOT a public record)
3. Social Security . Driver on i= State: ARIZONA

4, Place of birth: CHANDLER ARIZONA UNITED STATES Height: 06'03 Weight: 230 Eyes: BROWN Hair: BROWN
Clty State COUNTRY (not county)
5. Name of current/most recent spouse: COTTER CHELSEA LARUE Birth Date:
Last First Middle (NOT a public record)

JUNE 1985

6, Are you a bona fide resident of Arizona? [ves Cho If yes, what is your date of residency:

7. Daytime telephone number! E-mail addres:

SUPERSTITION MANOR WEDDING & EVENT CENTER

480 | 286 , 7806

(AI.

1220 N SIGNAL BUTTE ROAD MESA ARIZONA MARICOPA 85207

Street (do nof use PO Box) City State ‘County Zip

8, Business Name: Business Phone:

9. Business Location Address:

10, List your employment or type of business during the past five (5) years.-If unemployed. retired, or student, list residence address.

FROM. TO EMPLOYERS NAME OR NAME OF BUSINESS
Month/Year Month/Year DESCRIBE POSITION OR BUSINESS
| 09/2021 | current WEDDDING

02/2008 | CURRENT | WEDDING VENDOR/PHOTOGRAPHY

(ATTACH ADDITIONAL SHEET IF NECESSARY)

1/31/2018 Page 1 of 2
Individuals requiring ADA accommodaiions please call (602)542-2999

11. Provide your residence address information for the last five (5) years: A.R.S. §4-202/D)

FROM TO
Month/Year Month/Year RESIDENTIAL Street Address

02/2021 CURRENT
10/2017 02/2021

(ATTACH ADDITIONAL SHEET IF NECESSARY)

12. As a Controlling Person or Agent, will you be physically present and operating the licensed premises? ClYes[7No
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 Lves[-No
years?

14, Have you been cited, arrested, indicted, convicted, or summoned into court for violation of ANY criminal [es[VNo

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 Cles(VNo
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? Lves[¥No

17. Have you had a liquor application or license rejected, denied, revoked or suspended in or outside of Arizona [Ves[7No
within the last five years? A.R.S.§4-202(D)

Les[¥No

18. Has an entity in which you are or have been a conirolling 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
TAYLOR NATHAN DON COTTER

| (Print Full Name) _ 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.

sonatune LA] State of [fhizne County of Mp ieoper
hn. A. The er. instrument was acknowledged before me this
JUANITA A ESPARZA ’)
My Co! ission Expires Notary Public, State of Arizong' / grt Day of TOBE POPS

unty
Balance # 650148 D Month Year
My Gommission Expires

September 10, 2022

The Licensee has authorized the person named on this questi manager for the above License.
PRINT NAME: SIGNATURE:
1/11/2018 Page 2 of 2

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

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.8 4-202, 4-210
Type or Print with Black Ink Pend Wid
The fees allowed by R19-1-102 will be charged for all dishonored checks. Los wae

ATTENTION 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.

ZY
Liquor License#: 06070016 AVR RAD

1, Check the

Appropriate

Box —> Controlling Person | Agent Premises Manager
(complete all questions except #12)

> Name: LAWRENCE BRITTANY _ERIN — iC
Last First (NOT a public record)
3. Social Security CC Driver — | State: ARIZONA

4,Place ot bith; MESA ARIZONA UNITED STATES jieigh}, 05°08" weignt, 185 eyes: BLUE join, BLONDE

City State COUNTRY (not county)
5. Name of current/most recent spouse: LAWRENCE DILLON JOHN Birth — i

Last First Middle {NOT a public record)

6. Are you a bona fide ~~ - yes, what is yo! i _ JULY 1994
7, Daytime telephone numb: E-mail tis
SUPERSTITION MANOR WEDDING & EVENT CENTER 480 , 286 7806

Business Phone: _""— / ~~ /-

1220 N SIGNAL BUTTE ROAD MESA ARIZONA MARICOPA 85207

Street (do not use PO Box } City State ~ “County Zp

8. Business Name:

9. Business Location Address:

10, List your employment or type of business during the past five (5) years. If unemployed, retired, or student, list residence address.

FROM TO EMPLOYERS NAME OR NAME OF BUSINESS
Month/Year Month/Year DESCRIBE POSITION OR BUSINESS
11/2011 | cuprent BUSINESS MANAGER
(ATTACH ADDITIONAL SHEET IF NECESSARY)
1/11/2018 Page | of 2

individuals requiring ADA accornmodations please call (602)542-2999

11. Provide your residence address information for the last five (5) years: A.R.S. §4-202(D)

FROM TO
Month/Year Month/Year

09/2021 CURRENT
11/2011 09/2021

{ATTACH ADDITIONAL SHEET IF NECESSARY)

12. As a Controlling Person or Agent, will you be physically present and operating the licensed premises? [VlYes[_No
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 [VlYes[_No
years?

14. Have you been cited, arrested, indicted, convicted, or summoned into court for violation of ANY criminal es[VNo

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 Lles[¥No
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? Cves[¥No

17. Have you had a liquor application or license rejected, denied, revoked or suspended in or outside of Arizona Lles[7VNo
within the last five years? A.R.S.§4-202(D)

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
| (Print Full Name) BRITTANY ERIN BURNS hereby declare that | am the Agent/ Conirolling 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: ee Ie testo. biz PAF County of WL Coy

é. JUANITA A ESPARZA 2 The foregoing instrument was acknowledged before me this

Notary Public, State of Arizon
issi ‘ Maricope County , TA @: DBR
My Commission Expires ony Commission #550148 Af “Day of C Zt ¢ ) NZ) /

Batay Commission Expires 6 Month Year

September 10, 2022 i

Y Signature of Notary

The Licensee has authorized the person named on this questionnd Ny 62x as manager for the above License.

XJ
paint ame, SHARLEY MARIE COTTER LEAVITT s.cnvature: 0 _

1/11/2018 Page 2 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) nL EES os

Monthyvear Month/Year RESIDENTIAL Street Address
CURRENT
(ATTACH ADDITIONAL SHEET IF NECESSARY)
12, As a Controlling Person or Agent, will you be physically present and operating the licensed premises? [yes[-No

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 [Yes[_No
years?
14. Have you been cited, arested, indicted, convicted, or summoned into court for violation of ANY criminal (es[_No

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 Cyes[“No
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? [Yes_No

17. Have you had a liquor application or license rejected, denied, revoked or suspended in or outside of Arizona [es[_No
within the last five years? A.R.S.§4-202(D)

Lres[_No

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
| (Print Full Name) BRITTANY ERIN LAWRENCE 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: State of County of
The foregoing instrument was acknowledged before me this

My Commission Expires on: Day of ,
Date Day Month Year

Signature of Notary
numero - |

The Licensee has authorized the person named 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

Arizona Department Liquor License and Control DLLC USE ONLY
800 W Washington St. 5! Floor Job #:
Phoenix, AZ 85007-2934
azliquor.gov

Date Accepted:

602-542-5141 CSR:
BUSINESS INFORMATION / NAME CHANGE
(No Fee Required)
Type or Print with Black Ink
1, License Number: 06070016
2. Agent / Individual Name: LAWRENCE BRITTANY ERIN
Last First Middle

3. Business Name (DBA):

{Exacily as it appears on the license)

For all changes that apply to you, please check applicable boxes and complete:

New Business Name:

| New Business Location Address: NOTE: THIS IS NOT A LOCATION TRANSFER, THIS IS A LOCAL GOVERNMENT
OR U.S. POSTAL AUTHORIZED ADDRESS CHANGE, DOCUMENTATION MUST BE ATTACHED,

Street City State Zip

| New Mailing Address:
Street City State Zip

Other (olease explain): LAST NAME HAS CHANGED FROM BURNS TO LAWRENCE
DUE TO MARRAIGE. SEE ATTACHED COPY OF MARRIAGE LICENSE

(Attach additional sheet in necessary)

I, (Print Full Name) BRITTANY ERIN LAWRENCE 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 1
have made herein are true and correct to the best of my knowledge.

<
Applicant Signature: ey

6/23/2020 Page 1 of 1
Individuals requiring ADA accommodations please call (602)542-2999