HomeMy WebLinkAbout06/02/2008 Item 023
ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL
800 W Washington 5th Floor. 400 W Congress # 150
Phoenix AZ 85007-29:34 -,' Tucson AZ 85701-1352
(602) 542-5141 . .. (520) 628-6595
APPLICATION FOR SPECIAL EVENT LICENSE
Fee = $25.00 per day, for 1-10 day events only
A service fee of $25.00 will be charged for all dishonored checks '(A.R.S. 44-6852)
PLEASE NOTE: THIS DOCUMENT MUST BE FULLY COMPLETED OR IT WILL BE RETURNED.
I DBPT USB ONLY I
**APPLlCA nON MUST HE APrROVED UY LOCAL GOVERNMENT LIC#
J{ ~.,
1. Name of Organization: ;h 17170171 ~ / AI RECE~VED
2. N6n-ProfitfLR.S. Tax Exempt Number: 1..3... 7/3 JX i! 3' MAY 2 2 l008
3. The organization is a: (check one box only) CLERK OF THE BOARD
o Charitar' ~ m- Fratemal (must have regular membership and in existence for over 5 years)
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o Civic 0 Political Pmty, Ballot Measure, or Campaign Committee
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, 0 Religious' t
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4. What is the purpose of this event? . ;f V I' L
5. Location of the event: HUQ/. n. flAi~ 'R..! 1/ _hf~11W' f/o/hQe U w/
I Address of physical location (Not P.D. Box) City' COIIJlty ZIp
Applicant must be a member of,the Qualifving organization and authorized bv an Officer. Director or
. Chai~IPerson of the Or2:anizatiollnamed in Ouestion #1. (Signature required in section #18)
6. Applicant: C. L; } J on:...- j /f!..J. > Ii l-f -.? ~ -Sj
Last., IrSt 1 Middle Date of Birth
7. Applicant's Mailing Address: 1.. t 4 3 9/t:;. M c..' 11 d l? tI r /1;" q #r f,f >7 /~ J>' J r b/
'. Street City I State Zip
8. Phqne Numbers: ( ) ( ftl) 1.5.1" .1 l' ~l (940) t j J - If ~ 'f J'
Site Owner # ApplICant's BusIneSS # Applicant's Home #
9. Date(s) & Hours of Event: (Remember: you f1ll1l1Q1 sell alcohol before 10:00 alTL on Sunday)
, :
Date Day of Week Hours from A.M./P.M. To AM./P.M.
; Day 1: b "Jr-p~ ~'t<.Y) jt/po ;i/1 ~ .'pti jJ/7
:' Day 2:
..Day 3:
Day 4:
Day 5:
'Day 6:
Day 7:
"
'Day 8:
.Day 9:
:nay 10:
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l.Jc 0106 05/1999 *Disabled inividuals requi . g s
10. Hac;; the applicant been convicted of a felony in the past five years, or had a liquor license revoked?
<
o YES 11f NO (attach explanation if yes) "
11. This organization has been issued a special event license for 3
days this year, including tins event
(not to exceed 10 days per year).
12. I Is the organization using the services of a promoter or other person to manage the event? 0 YES 19 NO
I ~ If yes, attach a copy of the agreement.
13. List all people and organizations who will receive the-proceeds. Account for 100% of the proceeds.
THE ORGANIZATION APPLYING MUST RECEIVE 25% of the gross revenues of Alcoholic
Beverage Sales.
Name Address
Percentage
I it. -1' ?tlb 8k')"''''; /'-~ ~
) ~v )iy
, 1'/7mt:;~ l-/ i 'jl'/J
(Attach additional sheet if necessary)
14. Knowledge of Arizona State Liquor Laws 'J itle 4 is important to prevent liquor law viulatiuns. If you lJa\.e
any
questions regarding the law or this application, please contact the Arizona State DepmtlTlcnt of Liquor Licenses
and Control for assistance. '
NOTE: ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY.
"NO ALCOHOLIC BEVERAGES SHALL LEAVE SPECIAL EVENT PREMISES."
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15. What security and control meac;ures will you take to prevent violations of state liquor laws at this event?
(List type and number of security/police personnel and type of fencing or control barriers if applicable)
- # Police o Fencing
_ # Security personnel' I:J.... Barri ers
16. Is there an existing liquor license at the location where the special event is being held?
o YES Jgj NQ
, If yes, does the existing business agree to suspend their liquor license during the time
period, and in the area in ~hich the special event license will be in use?
DYES 0 NO
(ATTACH COpy OF AGREEMENT)
( )
Name10f Business
Phone Number
,
17. Your licensed premises is that area in which you are authorized to sell, dispense, or serve spirituous liquors
" under the provisions of yqur license. The foUowing page it to be used to prepare a diagram of your special
:' event licensed premises..: Please show dimensions, serving areac;, fencing, barricades or other control.
measures and security positions.
.
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"rIDS SECTION TO BE COMPLETED ONLY BY AN OFFICER. DIRECTOR OR CHAIRPERSON OF THE
Oi~~~ZATION NAMED IN OUESTION #1
18. ' I, ~ 'C \~ p.. n. 0 C '. ~N 11/ ~!) , declare that I am an OfficerlDirector,(Ctiair~ appointing the
(Print full name) ,
" applicant listed in Question 6, to apply on behalf of the foregoing organization for a Special Event Liquor
i~ License. '
~A.~~: ~/4A~'II\(;\lI D~;;''S.j\~
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X I ~7 ) ~.'-.~
Sig~ture) , (TitleIPosition)
(Date) (Phone #)
. OFFICIAL SEAL State of tI12.o.oY\A
County of Mol-tiq1)E""
TONI K. WEDDLE
B NOTARVPUBUC - '"'00' "",,'" The foregoing instrument was acknowledged before me this
. MOHAVE COUNTY ' ~...J dayof ~ . .:2IDg'
ji My Comm Expires Marcb 31,2011
My Commission expires on: '"f'Y'vMc-k!3J J.;;wll DaYof~ e;f ~ Year
.11
(Da~)
(Sil!:lJature of NOTARY PUBLIC)
, 1
THIS iSECTION TO BE COMPLETED ONLY BY THE APPLICANT NAl\1ED IN OUEST ION #6
19. : t, /1/ f"h IV. CL/ I~Jr-f?fJ ' declare that I am the APPLlCfu~r filing this app'icatlOn as .
(Print full name) ,
as listed in Question 6. I ha~e read the application and the contents and all statements are tme, COlTcct and
. .. complete. :{J)1 State of~.2bAJA
County ot ~~____
X tf&iP G ~ llle foregoing ins/JUment was adnowledged before me this
.'..... FFICIAl SEAL ~rv::l day of
fY)tuj~JIl1 ' ~OlJ<<
TONI K. WEDDLE'
~ NOTARY PUBUC - '"Ie. """ti, Day of Month
Year
. MOHAVE COUNTY ~ ';{. '1JJd.-~
I My Comm Expires M 1 011 ;roJl
M .. .
(D~te)
(Signature
of NOTARY PUBLIC)
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You must obtain locall!Overnment aooroval. City or County MUST recommend event & complete item #20.
The local city or county jurisdiction may reouire additional apolications to be completed and additional
: licen~nfl fees before approval may be flranted.
LOCAL GOVERNING BODY APPRO V AL SECTION
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20. I, , , hereby recommend
this special event application on
(Government OffICial) (TIt Ie)
behalf of
(City, Town or County) (SIgnature ofOFAClAL)
(Date)
FORDLLC DEPARTMENT USE ONLY
Department Comment Section:
(Employee)
(Date)
o APPROVED o DISAPPROVED BY:
(Title)
(Date)
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TO: Tom Sheaban, Mohave Coanty Sherift"
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FROM: TIle Clerk of the Board's Office
Mohave County Board of Supervison
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I DATE: May 23, 200s
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I have reviewed
the attached Liquor License application:
,
( ) Interim Pemtit
,I ( ) New License
':
I, ( ) Person TranSfer
I,
( ) Location Transfer
(X) S}*w Event
( ) Extension of
PremiseslPatio Pennit
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( ) Agent Change
Series No;
I,
I, Por tho following
applicant: Kingman Elks
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II
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June 15, 2008
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y l~approvaI
(
) I do not rE\cOmmend approval
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~e ounty Sheriff Date
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