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) I o Civic 0 Political Pmty, Ballot Measure, or Campaign Committee I , 0 Religious' t I . U I, 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: I 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." , 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. . , 'I "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\~ ~ <J- ri\o ~ I I 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) I 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 I 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) .....-+rq... ~ I'. I ~......:. _.. . SPMMAlt~~~T&~M ~. . - (T~~.mua.l1(!5@IltIlJfllM~i~fB_~ftbn) I ~: .' SP.ii~ol:liliJ!lJfiJJlirr!.S~sMb4jlll~rAA~M~d!?\ldaqab~RYplf 6P~Mq~~~~a~ns) '. N~.ESlt9Nof;\eft~f~8~~~IY.~~ r1iq%afI~fffiolP8&e~dIflH8*aW~~SS. , " ....' ;t . . ~'\ ~ '" ,,~_, ~ . . --" -~- '; , . ,,~, -i _~ _' ..'_:~ ._-.~ _____:=f,,,';:", _ '..:~.:; .,. ~.,; .:.__~.:~ .';s:.....::..,:...L~:i-'o5.:.~-::.-_~-:::i.i.;.;:.i;,;;;.~i~":,,,-:.;:\';'\\,;.c?A..;-d;;".f;"-':,,"'_~~.~_~~ :,\jL~o-~ '.:. :, ., - >' / C.' (JuAC IJf ~ j N1'r: ~-- -lv jJ,l ,., '~~'___ _. _ . ...~ ,.- L \ "~ ~_ ", , / "f'./_______- , ". _ _ -",,- ./ ~ n ~ \-\ /' /' '-0. //" /'" " .... " ... --------- " , ,.. ~ ') " " \ .' - - ... .'ff / I"} If;' .....) , "T , I \. Ii I l'-- J!j/'l / ~ /~./ ~ J." } L-. / C.v I t"O \\ I ~ ~ L-..... "': If ~ \ - ~l - fur - ~J~ ! Qo - PyIJ , A I '1 ~ rd{ , i l .. - ,. - "J ),f'r-- ,Il'". . , ~ - _ J ....- '.... _.: .~'\;' _ > .,. _ ~, "'- _,_ ~ ~~ _ _ .- -~" ~ ,~ - ....1 e- ...- - \L ' - - \ oJ ~f/1/1 L/htJr f !f~ / "..-- ~/ -." ..--' ~- -,...-' , 'I " I' ,I , ,. ': TO: Tom Sheaban, Mohave Coanty Sherift" " FROM: TIle Clerk of the Board's Office Mohave County Board of Supervison " I DATE: May 23, 200s " I, I 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 1 ( ) Agent Change Series No; I, I, Por tho following applicant: Kingman Elks 'I h II I, June 15, 2008 i' " 1 " " " y l~approvaI ( ) I do not rE\cOmmend approval " !: rP.5/~ . ~e ounty Sheriff Date I I I, i 1 1: ~e ~d mMJB: 3H.L .:10 >Ra'D ~eL9ESLB2:& lE:eB 899~/etI99 2:~'/2:9 39'Vd 9999999 LE:B9 B992:/E2:/S9 . I !