KIWANIS CLUB OF NEW RIVER REDACTED.PDF

DLLC USE ONLY
Job #:

SPECIAL EVENT LICENSE

Date ‘Accepted:
APPLICATION FEE $25.00 PER DAY

CSR:

_ Arizona Department of Liquor Licenses and Control _ 7 -
800 W. Washington St. 5"" Floor Phoenix, AZ 85007 conse #:

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

- SECTION 1 plicant must be a member ofa qualifying nonprofit organization, polilical party, or Govemment entity and
_ authorizes y an Officer, Director, or Chairperson of the Organization.

1. Applicant Patty Faber
(Must be an Officer/Member of the No) Middle
Gilly ‘State
3. Applicants home/cell iii Applicant's business phone; 9234695959

4. Applicant's email address
5, Special Event Name: NeW River Kiwanis Lobsterfest

6. Name of Non-Profit Organization, Candidate or Political Party/Gov.: Kiwanis Club of New River

7. Non-Profit/IRS Tax Exempt Number: 86-0599283

8. Arizona Corporation Commission File #: 2051862 If out of State please specify:
(Attach letter of good standing)
9. Event Location Name; New River Kiwanis Park

10. Event Address: 48606 N 17th Avenue, New River, AZ 85087

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

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

SECTION 2. Whal type of security and control measures will you take fo prevent violations of liquor laws at this event?
coe (List ype and number of pollce/securlly personnel and type of fencing or control banters, if applicable.)

2

Number of Police Number of Security Personnel [Fencing [eleaniers

Must explain security measures: {tis a fenced in area with security posted at the entrance/exit areas

SECTION 3 Whatis the pu ose of this event?

: Clon-site consumption Clof-site (auction/wine/dlistilled spirits pull) [lpoth
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) [1 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 Phone (include Area Code)

piace license in non-use - Special Event Licensee selling all alcohol without retaller Involvement
Must attach letter from the location suspending Ilcense for duration of special event

[dispense 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 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

Csplit 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.)

Clot 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?
(yes [21 No If yes, attach letter of explanation.

2. How many special event days have been issued fo this organization during the calendar year? none

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. : : / — /

Kiwanis Club of New River Percentage: 100

Name:
Address: 48606 N 17th Ave New River, AZ 85087 ee
Street : chy . State Zp
Name: Percentage:
Address:
Sireet Cliy 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.

{f the speclal 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:

L (Print Name) Patty Faber , 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 tue, comet and cqgmplete

: 0 Signature

LOCAL GOVERNING BODY
Date Received:

I, recommend CIAPPROVAL [1 DISAPPROVAL
(Government Official) (Mile)

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

TIAPPROVAL Cl DISAPPROVAL BY:

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