REDACTED- STUNNER NIGHT RUN- ONE LOVE ARIZONA RESCUE, ADVOCACY & STERLIZATION.PDF

CSR:
Amount:

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
(602) 542-5141
Application MUST be submitted to the Department of Liquor 10 days prior to the event.

License #:

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.

re _

Street Cily State Zip

1. Applicant: Klose, Dana
(Must be an Officer/Member of the No}
. Applicant's mailing address:

NO

3. Applicants home/cell phone Applicant's business phone:

4. Applicant's email addres:

Stunner Night Run

5. Special Event Name:

6. Name of Non-Profit Organization, Candidate or Political Party/Gov.; One Love Arizona: Rescue, Advocacy & Sterilization

47-1365736

7, Non-Profit/IRS Tax Exempt Number:

#: 19399131 ig out of State please specify:

8. Arizona Corporation Commission File
(Attach letter of good standing)

9. Event Location Name: Usery Mountain Regional Park
3939 N. Usery Pass Road, Mesa, Arizona 85207

10. Event Address:

Dates and Hours of Event - Days must be consecutive and may not exceed 10 consecutive days.

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

Event Start License End
Baye Dale BayiciWeek Time AM/PM Time AM/PM
DAY 1: July 20, 2024 Saturday 6:00pm 2:00am
DAY 2:
DAY 3:
DAY 4: ev eX )
DAY 5: REC of
DAY 6: APR 16 a RS
[e}
DAY7: MARCO Oe SUPERVISO
DAY 8: ouenk
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 control measures will you take to prevent violations of liquor laws at this event?
(List type and number of police/security personnel and type of fencing or control barriers, if applicable.)

1

Number of Police Number of Security Personnel bZFencing Cbarriers

. . _ ID check and wristbands to those 21 years and older. Security patrol will remain at
Must explain security measures:

entrance/exit to beer garden for duration of event and will ensure no alcohol leaves the designated, fenced off area.

SECTION 3 What is the purpose of this event?

[Zlon-site consumption (1Of-site (auction/wine/distilled spirits pull) [Both

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) 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 currenily 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 Phone (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

Lbispense 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

Libispense 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

Lisplit 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 alcoho! that is dispensed by the licensed retailer.)

Loft sale only - Wine/Distilled Spirits Pull, Live or Silent Auctions — Retailer will 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?

(1 Yes MINo If yes, attach letter of explanation.
A

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 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. )

(Z] Yes CINo If yes, please provide the Name of the Special Event Contractor:Aravaipa Running, Noah Dougherty

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)

(1 Yes IWINo 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
individuals requiring ADA accommodations please call (602)542-2999

Name: One Love Arizona: Rescue, Advocacy & Sterilization _ percentage: 85

i

Street City State Zip
Name: Aravaipa Running Percentage: 39
Address: 2401 S. 24th Street Phoenix Arizona 85034
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, barricades, or other control
measures and security position.

ATTACH DIAGRAM

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

APPLICANT SIGNATURE

Declaration:

|, (Print Name) Dana Klose , 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, correct and a0 a,

Ut

Signature

LOCAL GOVERNING BODY

Date Received:

|, recommend LIAPPROVAL [1] DISAPPROVAL
(Government Official) (Title)

On behalf of

(City, Town, County) Signature

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

COAPPROVAL CT] DISAPPROVAL BY:

2/6/2023 Page 3 of 3
Individuals requiring ADA accommodations please call (602)542-2999

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