Application for Permanent Extension

Arizona Department of Liquor Licenses and Control

https://www.azliquor.gov DLLC USE ONLY
(602) 542-5141 Job #:
Date Accepted:
PERMANENT EXTENSION OF |} Fic
PREMISES/PATIO PERMIT ceraz a:

NON-REFUNDABLE $50.00 FEE WILL APPLY

*OBTAIN APPROVAL FROM LOCAL GOVERNING BOARD BEFORE SUBMITTING TO THE DEPARTMENT OF LIQUOR?
** Notice: Allow 30-45 days to process permanent change of premises**

License#, 912070035928

Specific purpose for change: To allow for outdoor patio dining

1. Agent Name: __Repinski Jared Michael

lat First Middte
2. Business Name: _Capital Farms

3. Business Location Address: 410 W Wickenburg Way Wickendurg AZ 85358

Street City State Zip Code

4. Mailing address: _P-O. Box 6252 Chandler AZ 85246

Street city State Up Code
5. Email Address: _jrepinski22@yahoo.com

6. Business Phone Number: 928-671-2060 Contact Phone Number; 480-664-0389

7. ts extension of premises/patio complete? CO N/A [Yves CNo
lf no, what is your estimated completion date?

8. Do you understand Arizona Liquor Laws and Regulations? Yes [[] No

9. Does this extension bring your premises within 300 feet of a school? OC Yes No

10. Have you received approved Liquor Law Training? YJ Yes [J No

11. What security precautions will be taken to prevent liquor violations in the extended area?
Barriers defining outdoor patio area and staff will monitor as well

5/5/2025 Page | of 2 UC-GEN-EXT-PERM-00]
Indiviciuals requiring ADA accommodation: plaase call [602}542.2999

IMPORTANT
MUST ATTACH A DIAGRAM, clearly depicting your licensed premises along with the new

extended area, if the extended area is not outlined and_marked “extension” we cannot
accept the application.

BARRIER

(Jparrier Exemption: an exception to the requirement of barriers surrounding a patio/outdoor
serving area may be requested. Barrier exemptions are granted based on public safety, pedestrian
traffic, and other factors unique to a licensed premises. List specific reasons for exemption:

Dapprovat | Disapproval by DLLC:

SIGNATURE

Declaration:
1, (Print Name) Jared Michael Repinski , declare under penalty of perjury that 1 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 complete.
re

oF Signghdee

GOVERNING BOARD

After completion, and BEFORE submitting to the Department of Liquor, please take this application to your local
Board of Supervisors, City Council or Designate for their recommendation. This recommendation is not binding on
the Department of Liquor.

Oo Approval 0D Disapproval

Authorized Signature Agency

Investigation Recommendation: C) Approval Oo Disapproval by:

Director Signature required for Disapprovals:

$/$/2025 Page 2 of 2 UC-GEN-EXT-PERM-COl
Individuals requiring ADA accommodations please call {602)542-2999

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