ANTHEM ROTARY FOUNDATION_REDACTED.PDF

Amount:
i DLLC USE ONLY
Job #:
SPECIAL EVENT LICENSE
Date Accepted:
APPLICATION FEE $25.00 PER DAY
CSR:

Arizona Department of Liquor Licenses and Control
800 W. Washington St. 5" Floor Phoenix, AZ 85007 cents s

(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.

_ Applicant; Salem Edward John, Jr.
(Must be an Officer/Member of the Non Profit Enti Last First Middle
yer
Clty State Tip
3. Applicants home/cell vn —— Applicant's business phone: 623-900-1001
4. Applicant's email ccc

Autumn Fest Event in the Park

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:

8. Arizona Corporation Commission File #: 109477921 If out of State please specify:
(Attach letter of good standing)

9. Event Location Name: Anthem Community Park
10. Event Address: 41703 N Gavilan Peak Pkwy, Phoenix, AZ 85086

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 eau ieee
DAY 1: 10/26/2024 Saturday 10:00 AM 07:00 PM
DAY 2: 10/27/2024 Sunday 10:00 AM 07:00 PM
DAY 3:
DAY 4:
DAY 5: RECEIVED
DAY 6: AUG_05-2024
DAY 7: MARICOPA COUNTY __
DAY 8: CLERK BOARD OF SUPERVISORS
DAY 9:
DAY10:
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SECTION 2 What type of security and control measures will you take to prevent violations of liquor laws at this event?
(List ype and number of police/security personnel and type of fencing or control baniers, If applicable.)

4

4 Number of Police Number of Security Personnel [Fencing Cpariers

Must explain security measures: Maricopa County Sheriffs and Security Personnel will be on site

patrolling the event. The entire area is fenced. Consumption only within fenced area.

SECTION 3 What is the purpose of this event?

[(4lOn-site consumption [off-site (auction/wine/distilled spirits pull) Ceoth

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 Goveming
Body on page 3. (If checked move to section 4)

B) [-) will this event be held on a currently 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 Ucense Number Phone (Include Area Code)

place license in non-use - Special Event Licensee selling all alcoho! without retailer involvement
Must attach letter from the location suspending license for duration of special event

[-Ibispense and serve alll spirituous liquors under retailer's license — Business operates normally, minimum of 25% of gross
revenue from alcohol sales is donated to licensee

Cbispense 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 must be separated from any alcohol
used during the special event. Must attach letter from the location suspending license for duration of special event

[split 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.)

[oft sate only - Wine/Distilled Spirits Pull, Live or Silent Auctions — Retailer will still be permitted to conduct all nomal 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?

C1 Yes [4] No If yes, attach letter of explanation.

2. How many special event days have been issued to this organization during the calendar year? 3

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. }

(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 I 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.

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Anthem Rotary Foundation Percentage: 100%

Name:
Address: 3655 W Anthem Way, #109 / PMB 107, Phoenix, AZ 85086
Street City State Zp
Name: Percentage:
Address:
Street City State Tp

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
fo the Department of Liquor Licenses and Control. Please contact the local governing board for additional information.

APPLICANT SIGNATURE

Declaration:

1, (Print Name) LDYlD Tele SALE _TYL_, 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, 2 AW i

ic
= l Signature

LOCAL GOVERNING BODY
Date Received:

1, recommend [LIAPPROVAL [J DISAPPROVAL
(Government Official)

On behalf of

(City, Town, County)

The local governing body (city, town or municipality where the fair/festival will fake place) may require additional
applications to be completed and submitted. Please check with local government as fo 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

CIAPPROVAL EJ DISAPPROVAL BY:

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SPECIAL, EVENT LICENSED PREMISES DIAGRAM
(This diagrara rust be completed with this application)

Special Event Diagram: (Show dimensions, servin

9 areas, and label iype of enclosure and security positions)
NOTE: Shaw nearest cross streois, highway,

or road If location doesn't have an address.

. All of the darkarea 's Qrass the whiteoreas
tire Walk paths N*

INDICATES THE FENCED AREA WHERE ROTARY SPECIAL EVENT
WILL BE HELD,

wil
I

ict Luithem We

ta

(ssuih) vend jouspppo

Edward John Salem Jr
Anthem Rotary Foundation
3655 W Anthem Way #109 PMB 107

Anthem, AZ 85086
August 1, 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 Applications, | am including the following
information:

For our upcoming “Autumn Fest in Anthem special event as well as both Charity Classic events, 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

Thank you. Sincerely,

dward John Salem Jr.