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Town of Wickenburg
Commercial Facade Grant Application
Organization Name: ‘Youn Caceer - Cyde Gree,
Aatress: pao.) Moca Daca A Vievins Be
(CA-Gi0-037L__
Phone:
Contact Name and Titte: “Do hal Gosgy ~ = Ovfna ‘A
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Scope of Work:
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Funding Amount Requested: Bory wears
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Authorized Agency: Representative
Google Maps 159 W Wickenburg Way
Map data ©2025, Map data ©2025 Google 20 ft
TOWN OF WICKENBURG BUSINESS LICENSE APPLICATION
nbarg 155 N. Tegner St., Suite A - Wickenburg, AZ 85390 - (928) 684-5451 - Fax (602) 506-1580
Towra of SWHe Pam Black pblack@wickenburgaz.qov x1569 -Amy Brown abrown@wickenburgaz gov x1517
* Indicates REQUIRED Information License #
This application must be approved before you can lawfully engage in business in the Town of
Wickenburg. A license is necessary for each business location. All businesses must comply with all
ordinances/regulations and requirements affecting public peace, health and safety. Application fee is
non-refundable and license issued is non-transferable. A new license is required if ownership changes.
* SECTION A- BUSINESS INFORMATION *
1. Legal Business Name * Kon Cass éer- Q\ ycle Ga “cer
2. Physical Location of Business* (Street Address, City, State, Zip) (Cannot be a PO Box or mailbox store address)
(WoaS W Mosnliaht Mesa RA Wickentorsy Az 85290
3. Business Phone Number bo Qo C246
4. Mailing Address (Address, City, State, Zip)
[Beas yd Mocrlopr Moca RA [oievetoos Az. $5970
5. Email Address * Ga Syr Datknet ;
6. Company Website Address 7. Number of Employees at Wickenburg location
8.N and Title of Point of Contact for Business *
a
19. Point of Contact net Number * lo .
O22 41D O29?
10. Start Date of Business/Activity in Wickenburg *
11. Corporate Name
12. Corporate Address (Street Address, City, State, Zip)
13. Corporate Phone Number
14. Type of Ownership * a Limited Liability Company (LLC) 5 Corporation
a Sole Proprietor PP Parinership o Other
15. Enter Certificate / License Number(s) AND provide copies of the following items (if applicable to your business type)
Arizona Transaction Privilege Tax (Sales Tax)* | o Copy License # A094 TS
County Health Certificate(s) * a Copy | License #
Liquor License — State of Arizona * a Copy License #
PLEASE INCLUDE A COPY OF YOUR TRANSACTION PRIVILEGE TAX (TPT) LICENSE. Ail businesses that
are required to collect sales tax must have an Arizona TPT number issued by the AZ Dept. of Revenue.
TOWN OF WICKENBURG BUSINESS LICENSE APPLICATION
* SECTION B — NATURE OF BUSINESS OR GOODS SOLD *
(Please specify the nature of the business, type of goods sold or specific project) *
Commerega) Rontel Pruldings
* SECTION C - BUSINESS CATEGORY (Check ail that apply) *
"a Bank / Mortgage / Investment | a Contractor / Builder __ :
o Door to Door Sales (Complete Section 1) a Home-Based Operations (Complete Section F)
a Hotel / Motel uo Insurance Services
a Manufacturer a Medical Services
a Mobile Vendors (Complete Section G) _ a Non-Profit (Business License is not required)
o Ranch o Reaitor
Rental & Leasing (Complete Section H) _c Restaurant / Bar / Coffee —T
oRetail a Roping & Rodeo = —=
0 Service o Services and Retail oe
a Shuttle / Taxi | 0 Utilities
La Wholesale _ = i Other Sst
* SECTION D — TYPE OF LICENSE *
a New Business License (No Liquor) — January — December - $50
o New Business License (Liquor Sales) — January — December - $100
o Seasonal Business - October — April - $50
o Door-to-Door Sales — Not more than 7 consecutive days per month for door-to-door - $25 per day
Special Event Business - $25 for up to four-day event, $10 for one-day event (Contact Event Coordinator)
SECTION E — CHANGE IN BUSINESS LICENSE
o Change in Business Address - Complete Section A with new address
o Change in Business Name — Complete Section A with new name
Former Name of Business (If Different)
o Business Acquisition - Date Acquired
Former Name of Business (If Different)
o Added Business Activity at Same Location - Compiete Sections A-C listing all business activity
SECTION F — HOME- BASED BUSINESS (only if located in the Town of Wickenburg)
Lagree to not have any signs at my residence.
| agree to not have employees report to work every day at my home-based business.
_l agree that my business will not contribute to additional traffic or cause parking issues within my nei eighborhood.
Lagree not to store anything outside my home for my home-based business.
yee not to store hazardous materials at my home.
“"T agree with all the statements above regarding my home-based business and agree to not cause a
disturbance in my neighborhood with my business
t certify that | have read and agree to comply with Article 14-4-3C Home Occupation from the Wickenburg
aN, Town Code. _ .
Version December 2022
SOS
TOWN OF WICKENBURG BUSINESS LICENSE APPLICATION
SECTION G — MOBILE VENDORS (MUST provide copies of ALL of the following documents)
a County Health inspection (If food vendor) 2 Driver's License of Driver
u License Plate No. o Fire Inspection within preceding 12 months
o Photograph of Mobile Sales Unit a Certificate of Liability Insurance (If on Town Property)
a Letter from private property owner for permission to operate on their property or permit/agreement from the
Town if on town property including streets, parks, parking spaces and right-of-way.
| certify that the applicant or controlling person has not been convicted of a felony or misdemeanor other
initial__ than minor traffic in the last five years.
{ certify that | have read and agree to comply with Article 9-4 Mobile Merchants from the Wickenburg Town
Initial Code.
SECTION H - RENTAL PROPERTY / PROPERTY MANAGEMENT
(List all Rentai Properties in the Town of Wickenburg)
Property Address in Wickenburg Description
i.e. single family, multi-family, commercial,
aS Trenton shinee
a Wass =
he frkzd $Paiding
sonyer _\Irh). &
SECTION I - DOOR TO DOOR SALES
The Sponsoring Business must provide a signed letter detailing the proposed activity (i.e. advertising, sales,
soliciting, etc.) with this business license application. All persons selling in Town must keep a copy of the signed
letter and the business license with them at all times that they are selling.
Please list the times and dates for sales:
Please list the information below for each person who will be on the streets selling (attach additional sheets if
needed) and include a copy of their driver's licenses.
Name Date of Birth Phone Number Driver's License #
Residential Address (Street, City, State and Zip)
List any felony / misdemeanor convictions, date of conviction & grounds for such convictions (exclude minor traffic)
Name Date of Birth Phone Number Driver's License #
Residential Address (Street, City, State and Zip)
List any felony / misdemeanor convictions, date of conviction & grounds for such convictions (exclude minor traffic)
Please list the information below for all vehicles being used in Town for this business.
License Plate Number_| State of License Plate | Make, Model and Color of Vehicle
Version December 2022
TOWN OF WICKENBURG BUSINESS LICENSE APPLICATION
SECTION J — SPECIAL EVENTS
The Sponsors / Promotors of an event must provide a list that includes their name, event name, dates of the event,
each vendor's name, vendor's company name, vendor's TPT ficense number, vendors address and vendor's
telephone number. Vendor's can apply for an annual or seasonal business license or they can pay the sponsor of
the event $25 for each event up to 4 days or $10 for each one-day event. The sponsor/promotor is responsible for
providing the information to the Town and the Dept. of Revenue at licensecompliance@azdor.gov.
* SECTION K — LICENSE ELIGIBILITY REQUIREMENTS (ARS 41-1080) *
In accordance with ARS 41-1080, individuals must present ONE of the following documents indicating that they are
allowed to conduct business in the United States in accordance with federal law:
AZ Driver's License or ID License issued after 1996 or | Paperwork showing Corporation or LLC is in good
any state's driver's license that is REAL 1D compliant. Standing with the Arizona Corporation Commission.
Driver's license issued by a state that verifies lawful A birth certificate or delayed birth certificate issued in any
presence in the United States. Does not include CA, State, Territory, or possession of the United States
CO, CT, DE, HI, iL, MD, NM, NV, NY, OR, UT, VT, WA
A United States citizenship and immigration services United States Passport or foreign passport with US Visa.
employment authorization document or refugee travel
document.
A United States certificate of birth abroad An |-94 form with a photograph
AUS certificate of naturalization or citizenship A tribal certificate of Indian Blood or affidavit of birth
* SECTION L — APPLICANT SIGNATURE *
Under penalty of perjury, |, the applicant, deciare that the information provided on this application and with the
attachments is true and correct. | understand that the issuance of a Business License by the Town of Wickenburg
does not necessarily mean that my business has complied with County, State and/or Federal requirements which
may apply tomy business.
Print Name:
Date:
2 oalas-
Signature:
Title: ‘ c
FOR TOWN USE ONLY
a In-Town Limits Zoning Approval for In-Town Businesses Date Zoning Approved
G Out-of-Town Limits
Date Issued issued By
Arizona Revised Statute § 9-495 requires in any written communication between a city or town and a person to
provide the name, telephone number, and email address of the employee who is authorized and able to provide
information about the communication if the communication does any of the following:
1. Demands payment of a tax, fee, penalty, fine or assessment:
2. Denies an application for a permit or license that is issued by the city or town; or
3. Requests corrections, revisions or additional information or materials needed for approval of any
application for a permit, license or other authorization that is issued by the city or town.
An employee who is authorized and able to provide information about any communication that is described above
shall reply within five (5) business days after the city or town receives that communication.
Pam Black pblack@wickenburgaz.gov 928-684-5451 x1569
Amy Brown abrown@wickenburgaz gov 928-684-5451 x1517
Version December 2022
ron W-Q Request for Taxpayer Oy
(Rev. March 2024) Identification Number and Certification requester. Bo not
fealty hd Go to wwrw.ire. #9 tor end the tateet tion. send to Go (t=
Before you begin. For guidance reiated to the purpose of Fon W-9, see Purpose of Form, below,
1 Name of entityindlvidual. An entry In required. (For a sole proprietor or dleregarded entity, enter the owner's name on Ene 1, and enter the businesa/tieregarded
erdity’s name on line 2}
[Robin Gasser - Clyde Gasser
2 Business neme/disragarded entity name, 7 different fom above.
© [9a Check the approprsie box for federal tx classification ofthe ertiy/indiddusl whoee nee le tered on ine 1 Check 4 Exernptions (oodes apply only fo
§ Only one of the following seven boxes. cartain entities, not
5| De Cl Scoporntion ~ O ses eetuctons on Page Sr:
é (01 UC. Enter the tex classification (C » C corporation, S = 5 corporation, P= Partnership) Exempt payee code #1 erty)
Note; Ghack he "LLC bax shove and, the etry space, ener he appropies code, 9, of Pix the tax —
cdezelfication of the LLC, urtess Its a dleregarded entity. A dleregerded entity should Inetand check the appropriate | Exemption from Foreign Account T
8 bn for te tax clasefication of Bs owner Compliance Ad (FATEA reporting
E C1 Othe fave instructions) code OF ary}
3% ton Ine 3a you oor "LLC" and entered “P* an its tex clasatication,
wz you re rtd frm a peri. a eat th here en ownership interest, check Montes © account rektebed
i Gin hou ¥ you Reve any ereign you "Dp outaide the Undied Stxtes.)
& | 8 Atsress (uber crest, and apt. or eute no}. See inetructions. Rlequester’s nema end ecdresa (optional)
18625 Moonlight Mesa Rd
@ Cty, eae, and ZIP code
Wickenburg, Az 5390
7 st account number(s) here joptionat}
[EERE Taxpayer Identification Number (TIN)
Enter your TIN In the appropriate box. The TIN provided must maich the name given on lina 1 to avoid
backup withholding. For individuals, this is generally your social security number {SSN}. However, for a
ellen, sole 1, OF ‘entity, 998 the inetructions for Part §, later. For other
entities, It is your employer identification number (EtN). if you do not have a number, sae How io get a
TIN, Inter.
Note: if the account is in more than one name, see the instructions for fine 1. See also What Name and
Number To Give the Requester for quideines on whose number to enter. -
Certification
Under penalties of perjury, | certify that:
1. The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to be issued to me}; and
2. Lam not subject to backup with ian from withholding, or (b} | have not been notified by the Internal Revenue
‘Service (RS) that | an eubject to beckup withholding #3 @ result of a falture to repart all interest or dividends, or (¢) the IRS has notified me that | am
0 longer subject to backup withholding; and
9. 1am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA codela) entered on this form (f any} indicating thet t am exempt from FATCA reporting Is correct.
Instructions. You must cross out em 2 sbove if you have been notified by the IRS that you are currently subject to beckup withholding
because you have talled to report all interest and dividends on your tax retum. For real estate transactions, item 2 does not spply. For mortgage interest paid,
‘acquisition
or abandonment pf secured j, Cancellation of debt, contributions to an individual retirement arrangement (RA), and, generally, payments.
other than interest and dl youere to sign the certification, but you must your correct TIN. See the : 8 for Past ll, tater.
Sign | signature of
Here | US. perecn iY), AL Deve
Ls
neral i New Hine 3b hes bean added to thie form. A flow-through entity is
Ge ! Instructions required to compiate this line to indicate that It has direct or indirect
‘Section references are to the Intemat Revenue Code unless otherwise foreign parinera, owners, or beneficiaries when It provides the Form W-9
noted. So mother Row Soudh ently in which k has an ownership interest. This
Fuse For the latest es — topro 2 Row through entity with information
Talated to Form W-0 and iis inetructions, euch ‘cs toisleson onacied ag status of Ie indirect foreign partners, owners,
after they wern published, go to www-ine gov/FormW9. beneficiaries, 90 thet t can eatisty any appicabie
requirements. For aper ‘that has any foreign
What's New Barner ray be regres to compo Schedule K-2 and 9, So he
Partnership instructions for Schedules K-2 and K-S (Form 1065),
rennet ey asin doherty eo Form
this ling. An LLC that is a check
appropriate tn bette ar ee oe Oe rn Purpose of
cain chaek is ste ‘dassification _An Individual or entity (Form W-0 requestor} who ts requirad to file en
Ee iie arisen eras SOProtaaie ha information retum with the IRS is ghing you this form beomzes they
Cat. No. 10231X Form W-9 (ev, 3.2024)