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DLLC USE ONLY
Job #:
SPECIAL EVENT LICENSE —
APPLICATION FEE $25.00 PER DAY
CSR:
Arizona Department of Liquor Licenses and Control ~
800 W. Washington St. 5" Floor Phoenix, AZ 85007 Hoense#
(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.
1. Applicant: Salem Edward John, Jr
(Must be an Officer/Member of the Non Profit Entity) Last First Middle
2. Applicant's mailing adcress:
Street City State Zip
3. Applicants home/cell phone! Applicant's business phone:
4. Applicant's email address: PO
July 3rd Event in the Park
5. Special Event Name:
. Anthem Rotary Foundation
6. Name of Non-Profit Organization, Candidate or Political Party/Gov.:
7. Non-Profit/IRS Tax Exempt Number: 47-0930766 / 26-00640058
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 Parkway, 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**
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DAY I: 07/03/2024 Wednesday 2:00 PM 10:00 PM
DAY 2:
DAY 3: Y WV ie J
DAY 4: RECEIVE b
DAY 5: MAY 01 2024
DAY 6: erm ARiCoRa @
DAY7: billed SUPERVISORS
DAY 8:
DAY 9:
DAY10:
2/6/2023 Page 1 of 3
Individuals requiring ADA accommodations please call (602)542-2999
SECTION 2 What type of security and conirol 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 contro! barriers, If applicable.)
4 Number of Security Personnel [Fencing Clbarriers
4 Number of Police
Maricopa County Sheriff's Deputies will be at both entrances to the park
Must explain security measures:
event. Security personnell will be patrolling the area of the event.
SECTION 3 What is the purpose of this event?
[4]On-site consumption loff-site (auction/wine/disiilled spirits pull) Cleoth
Howis this special event going to conduct all dispensing, serving, and selling of spirituous liquors?
Check one of the following boxes. (R-19-318)
A) [2] Special Event being held on an unlicensed premises will require approval and signature by the Local Governing
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 License Number Phene (Include Area Code)
(Place license in non-use - Special Event Licensee selling all alcohol without retailer involvement
Must attach letter from the location suspending license for duration of special event
C]bispense and serve all spirituous liquors under retailer's license - Business operates normally, minimum of 25% of gross
revenue from alcohol sales is donated to licensee
[lbispense and serve alll 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 fetter 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.)
(lof sale only - Wine/Distilled Spirits Pull, Live or Silent Auctions — Retailer wil still be permitted to conduct all normal 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 [41 No If yes, attach letter of explanation.
2. How many special event days have been issued to this organization during the calendar year? 4
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 alcohol on behalf of the licensee. If no special event contractor is listed, the licensee is
responsible for the sales and service of alcohol. }
(Yes 1 No if yes, please provide the Name of the Special Event 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?
(Licensees who hold a series 6, 7, 11, or 12 license are automatically qualified to be the special event contractor)
(Yes [4] 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.
2/6/2023 Page 2 of 3
Indiviciiale racniiring ANA ArcArmndatinns nlance cell LANIN65AI.990090
Name: Anthem Rotary Foundation Percentage: 100%
Address: | |
City
Street State Zip
Name: Percentage: |
Address: |
Street City State Zip
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, baricades, 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) Edward John Salem Jr , 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
LOCAL GOVERNING BODY
Date Received:
L recommend (CIAPPROVAL [1 DISAPPROVAL
(Government Official)
On behalf of
(City, Town, County)
The local governing body (city, town or municipality where the fair/festival will take 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 fo be submitted. Additional licensing fees may also be required before approval may be granted.
AZDLLC USE ONLY
CIAPPROVAL EI DISAPPROVAL BY:
2/6/2023 Page 3 of 3
Indivichiale racniiringa ADA aArecAmmaAdationne nlancea call (ANN6A9.99090
SECTION 12 License premises diagram. The licensed premises for your special event is the area in which you are avihorized
to sell, dispense or serve alcoholic beverages under the provisions of your license, The following space is to be used to
prepare a diagram of your special event licensed premises. Please show dimensions, serving areas, fencing, barricades, or
other control measures and security position.
Location: Park Stadium Softball Field. N T
etoile depicts perimeter fencing 6 high (standard softball field).
- Blue area depicts entry/exit points — to be guarded by Maricopa County Sheriff’s
Office deputies and private security guards,
’ Star represents serving locations.
“SWE frrol
t
3/1/2016 Page 3 of 4
Individuals requiring ADA a¢commodations call (602)542-9027.
Edward John Salem Jr
Anthem Rotary Foundation
3655 W Anthem Way #109 PMB 107
Anthem, AZ 85086
April 24,2024
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 Application, | am including the following
information:
For our upcoming “July 3 Event in the Park, special event, 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
if you have any questions.
Please contact me at
Thank you. Sincerely,
r=
ward John Salem Jr.