SPECIAL OLYMPICS ARIZONA_REDACTED.PDF

DLLC USE ONLY

Job #:
Arizona Department Liquor License and Control
800 W Washington St. 5' Floor Date Accepted:
Phoenix, AZ 85007-2934 SER:
azliquor.gov ,
602-542-5141 aia

SPECIAL EVENT LICENSE APPLICATION
FEE $25.00 PER DAY

A service fee of $25.00 will be charged for all dishonored checks (A.R.S § 44-6852
1-10 days consecutive days only, Cash, Checks or Money Orders Only

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.

1. Applicant; Yamie Heckerman

2. Applicant's mailing address:

City State Zip

3. Applicants home/cell phone: ne: 602.230.9135

4. Applicant's email address:

SECTION 2 Name of Non-Profit Organization, Candidate or Political Party/Gov.: Special Olympics Arizona

SECTION 3 Non-Profit/IRS Tax Exempt Number: 86-0307564
SECTION 4 Event Location: Usery Mountain Regional Park, 3939 N Usery Pass Rd, Mesa AZ 85207

SECTION 5 Dates and Hours of Event. Days must be consecutive but may not exceed 10 consecutive days.
See A.R.S. § 4-244(15) and (17) for legal hours of service.

**SEPARATE APPLICATION FOR EACH “NON-CONSECUTIVE” DAY**

Event Start License End
Time AM/PM Time AM/PM

DAY 1: 11.13.21 Saturday 7AM 12 AM

DAY 2:

Days Date Day of Week

DAY 3:

DAY 4:

DAY 5:

DAY 6:

DAY 7:

DAY 8:

DAY 9:

DAY 10:

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SECTION 6 What type of security and control measures will you take fo prevent violations of liquor laws at this event?
{List type and number of police/secutity personnel and type of fencing or control barriers, if applicable.)

Number of Police 1 Number of Security Personnel [MFencing [barriers

Explanation: ID check and wristbands to those 21 years of age and older. Security personnel

will remain at the entrance/exit of the fenced in beer garden for the duration of the event
to ensure no alcohol leaves the designated beer garden.

SECTION 7 Will this event be held on a curently licensed premises and within the already approved premises?
OyYes@I No If yes, Local Governing Body signature is not required.

Name of Business Ucense Number Phone (include Area Code)

SECTION 8 Howis this special event going to conduct all dispensing, serving, and selling of spirituous liquors? Please read
R-19-318 for explanation and check one of the following boxes.

Place license in non-use

Libispense and serve all spirituous liquors under retailer's license
Mbispense and serve alll spirituous liquors under special event
Osplit premise between special event and retail location

SECTION 9 What is the purpose of this event?

[Mlon-site consumption Lloft-site (auction/wine/distilled spirits pull) [Both

SECTION 10

1. Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years?
DYes HINo If yes, attach explanation.

1

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 Licensed Contractor?

Aravaipa Running, LLC

Yes CI No If yes, please provide the Name of the Licensed Contractor:

4, |s the organization using the services of a series 6, 7, 11, or 12 licensee to manage the sale or service of alcohol?

Des [7] No if yes, please provide the Name of Licensee: License #:

5. The applying non-profit organization must receive 25% of the gross revenues of the total liquor sales. List the names
of the individuals or organizations who will receive the rest of the proceeds, MUST EQUAL 100%.

Name: Special Olympics Arizona Percentage: 00%
Address: 2409 N Citrus Road Bldg 64 Goodyear, AZ 85395
Name: Aravaipa Running, LLC “ percentage, 80% .
Address: 2401 S 24th St Phoenix Arizona 85034

Street city State Zip
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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 11 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

Ifthe 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 government before submission
to the Department of Liquor Licenses and Control. Please contact the local governing board for additional application
requirements and submission deadlines. Additional licensing fees may also be required before approval may be granted. For
more information, please contact your local jurisdiction.

SIGNATURE

1, (Print Full Name) Jam ee the eKerman 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 | have made herein are true and correct to the best of my knowledge.

Applicant signature! AV 0 fr

GOVERNING BOARD

Date Received:

recommend CIAPPROVAL [LI DISAPPROVAL

(Government Official) (Tille)

On behalf of ,
(City. Town, County) Signature

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CIAPPROVAL C1 DISAPPROVAL BY:

A.R.S. § 41-1030. Invalidity of rules not made according to this chapter; prohibited agency action; prohibited acts by
state employees: enforcement; notice

B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically
authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a
licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement
or condition.

D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award
reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state
for a violation of this section.

E. A state employee may not inlentionally or knowingly violate this section. A violation of this section is cause for disciplinary action
or dismissal pursuant to the agency's adopted personnel policy.

F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.

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Individuals requiring ADA accommodations please call (602)542-9027