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HomeMy WebLinkAbout2002.1217.TCSEM.PacketNOTICE OF SPECIAL AND EXECUTIVE SESSION OF THE FOUNTAIN HILLS TOWN COUNCIL Mayor Beydler Councilman Melendez Vice Mayor Fraverd Councilman Archambault Councilwoman Nicola Councilman Kavanagh Councilwoman Ralphe WHEN: TUESDAY, DECEMBER 17, 2002 TIME: 4:00 P.M. WHERE: TOWN HALL TELECONFERENCE ROOM 16836 E. Palisades, Building A • CALL TO ORDER — Mayor Beydler • ROLL CALL l.) Pursuant to A.R.S. 38-431.03.A.1; VOTE TO GO INTO EXECUTIVE SESSION for discussion or consideration of employment, assignment, appointment, promotion, demotion, dismissal, salaries, disciplining or resignation of a public officer, appointee or employee of any public body, except that with the exception of salary discussions, an officer, appointee or employee may demand that such discussion or consideration occur at a public meeting. The public body must provide the officer, appointee or employee with such personal notice of the executive session as is appropriate but not less than 24 hours for the officer, appointee or employee to determine whether such discussion or consideration should occur at a public meeting. The Council will be interviewing applicants for the Parks and Recreation Commission. 2.) RETURN TO SPECIAL SESSION AND ADJOURNMENT. DATED this 12th day of December 2002. By: Cassie B. Hansen, Director of Administration/Town Clerk The Town of Fountain Hills endeavors to make all public meetings accessible to persons with disabilities. Please call 837-2003 (voice) or 1-800- 367-8939 (TDD) 48 hours prior to the meeting to request a reasonable accommodation to participate in this meeting. k'rAIN fir NOTICE OF PE Y EXE U % d° / OF TH `�• �that isA ' ©U T N HILLS T � O ► �,� f, Councilman ]Wlende �! Councilwoman Nicola Vice Mayor Fraverd V Councilman Kavanagh Councilman Arehambault Councilwoman Ralphe TUESDAY, DECEMBER 17, 2002 4:00 P.M. TOWN HALL TELECONFERENCE ROOM 16836 E. Palisades, Building A CALL TO ORDER — Mayor Beydler ROLL CALL Pursuant to A.R.S. 38-431.03.A.1; VOTE TO GO INTO EXECUTIVE SESSION for discussion or consideration of employment, assignment, appointment, promotion, demotion, dismissal, salaries, disciplining or resignation of a public officer, appointee or employee of any public body, except that with the exception of salary discussions, an officer, appointee or employee may demand that such discussion or consideration occur at a public meeting. The public body must provide the officer, appointee or employee with such personal notice of the executive session as is appropriate but not less than 24 hours for the officer, appointee or employee to determine whether such discussion or consideration should occur at a public meeting. The Council will be interviewing applicants for the Parks and Recreation Commission. RETURN TO SPECIAL SESSION AND ADJOURNMENT. DATED this 12`h day of December 2002. Cassie B. Hansen, Director of Administration/Town Clerk ,1,G I VNI, UL ruunia,n nuts enucavors Lo maKe all pubuc meetings accessible to persons with uisabtltttes. Please call 837-2003 (voice) or in 367-8939 (TDD) 48 hours prior to the meeting to request a reasonable accommodation to narticinate this meeting ' - ZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL .sait '` 00 ashington 5th Floor 400 W Congress #150 Phoenix AZ 85007-2934 Tucson AZ 85701-1352 (602) 542-5141 Iv ,�'f� (520) 628;¢S,.9�EIVED • r1/41Iir APPLICATION FOR LIQUOAMENSE NOV -1 8 2002 TYPE OR PRINT WITH BLACK INK FOUNTAIN HILLS ktldltiers V fl , TOWN RK day Effective Nov. 1, 1997, All Owners, Agents, Partners, Stoc fl 1 rs,�or Managers actively involved in the day to day operations of the business must attend a Department approved liquor law training course or provide proof of attendance within the last five years. See page 5 of the Liquor Licensing requirements. Pt t 11•(q•e SECTION 1 This application is for a: SECTION 2 Type of ownership: D n I.)•9 3- - .'Zl TERIM PERMIT Complete Section," VW.R.O.S. Complete Section , , , , , , , WIDUAL Complete Section 6 PERSON TRANSFER(B &Liquor Stores ONL .,. PARTNERSHIP Complete Section 6 Complete Sections 2 ,d;e,t?, 13, 4 ,1, 0 '-JRPORATION Complete Section 7 0 LOCATION TRANSFER (Bars and Liquor Stores ONLY) _, LIMITED LIABILITY CO. Complete Section 7 Complete Sections 2, 3, 4, 12, 13, 15, 16, 17 0 CLUB Complete Section 8 ❑ PROBATE/WILL ASSIGNMENT/DIVORCE DECREE 0 GOVERNMENT Complete Section 10 Complete Sections 2, 3, 4, 9, 13, 15, 17(fee not required) 0 TRUST Complete Section 6 ❑ GOVERNMENT Complete Sections 2, 3, 4, 10, 13, 15, 16, 17 0 OTHER Explain SECTION 3 Type of license and fees: LICENSE#: 0401 ( CeLp 1. Type of License: (p" 2. Total fees attached: $ APPLICATION FEE AND INTERIM PERMIT FEES (IF APPLICABLE)ARE NOT REFUNDABLE. A service fee of$25.00 will be-charged for all dishonored checks (A.R.S. 44.6852) 1 4tr7 ION 4 Applicant: (All applicants must complete this section) Mr. 1. Applicant/Agent's Name: Ms. C � ( -. j?-- VtZ. (Insert one name ONLY to appear on license) Last First Middle 2. Corp./Partnership/L.L.C.: xactly as it appears on Articles of Inc.or Artiiles of Org.) t 3. Business Name: \sAkcje Q i% S � E `'SQ�� }� �j `L (Exactly as it appears on the exterior of premises) C • ()Business Address: 'LQ131 G , \I1E CO6 tAlL1—: M s1.(pg (Do not use PO Box Number) City COUNTY 5. Business Phone: (4) iC OZ g p ~ Residence Pho : ( Lip. ) 1D( t4 " l 3ep� 6. Is the business located within the incorporated limits of the above city or town? MYES ONO Address: 1 Lp1�� 6 , g ,/1�J to I l--t uS P DMailing t - YS-' cat City State 8. Enter the amount paid for a 06, 07, or 09 license: $ �5 t A1. ( (Price of License ONLY) DEPARTMENT USE ONLY Accepted by: c�.sil Date: 11/`02-- Lic. # 6‘ 67 Q 6' 4 Fees: l(�a.,( !Q(J�®o �-- 2 f "6r,) $ „7)___ ,- ad Application Interim Permit Agent Change Club F. Prints TOTAL (...„ PROCESSING APPLICATIONS TAKES APPROXIMATELY 90 DAYS, AND CIRCUMSTANCES OMEN RESULT IN A LONGER WAITING PERIOD. You ARE CAUTIONED REGARDING PLANS FOR A GRAND OPENING, Ea-., BEFORE FINAL APPROVAL AND ISSUANCE OF THE LICENSE. LIC 0100 11/2000 *Disabled individuals requiring special accommodation, please call (602) 542-9027. SECTION 5 Interim Permit: 1. If you intend to operate business while your application is pending you will need an Interim Permit pursuant to A.R.S. 4-203.01. 2. There MUST be a valid license of the same type you are applying for currently issued to the location. 3. Enter the license number curre�ntlly t the location. 0 4070 9446 C. 4. Is the license currently in use?Lrl YES 0 NO If mat• ng has it been out of use? ATTACH THE LICENSE CURRENTLY ISSDEDA I'yI2E IACATION TO THIS APPLICATION. I, LV b12.ee S, ‘- o RGI t.rA-lel , declare that I am the CURRENT OWNER, AGENT, CLUB MEMBER, (Print full name) • PARTNER, STOCKHOLDER OR LICENSEE of`the stated license and location. State of Al,;zo na County of Al rsCoPa- X A Gt&—:t g The foregoing instrument was acknowledged before me this (Signature) yfh day of A/oven/16(r , goo oZ Day of Month Month Year My commission expires on: J u r'P 30) Z00 Co (Signal of NOTARY PUBLIC) I art JON GONZALEZ ice%, Notary Public-Arizona (�'� Maricopa County SECTION 6 Individual or Partnership Owners: 1 (',. - • My Commission Expires June 30,2006 EACH PERSON LISTED MUST SUBMIT A COMPLETED FORM"LIC0101",AN"APPLIC• '• '+ •' b►, •'u'I >• ' FOR EACH CA 1. Individual: Last First Middle %Owned Residence Address City State Zip 2,S Z K 1 % ?CC3' Q 'Z.eQ. 6Q. ,c c Partnership Name: (Only the first partner listed will appear on license) General-Limited Last First Middle %Owned Residence Address City State Zip • ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ % (ATTACH ADDITIONAL SHEET IF NECESSARY) a. Is any person, other than the above, going to share in the profits/losses of the business? 0 YE / NO 2 Business License Verification To: Town Marshal Todd Tate From: Bev Bender,Executive Assistant to the Town Clerk Date: November 19, 2002 Applicant: Nick Morgan's "The Sports Grill" Applicant's address: 16737 E. Parkview, FH Business License: 5081 Business License effective period: through 10/31/2003 COMMENTS: Attached is the Liquor License Application for Nick Morgan's "The Sports Grill". Please review the application and provide your staff report. This item will be presented to the Council for their consideration at the 12-19-02 Town Council meeting. Mr. Morgan does have a valid business license through 10 -31-03 as noted above. SE ' ION 7 Corporation/Limited Liability Co.: EACH P SON LISTED MUST SUBMIT A COMPLETED FORM"LIC0101",AN"APPLICANT"TYPE FINGERPRINT CARD,AND$24 FEE FOR EACH CARD. ❑ CORPORATION Complete questions I, 2, 3, 5, 6, 7, 8. L.L.C. Complete questions 1, 2, 4, 5, 6, 7 and atlarh copy of Articles of Org. and Operation Agreement. 1. ame of rporation/L.L.C.: _ _ D(Exactly as it appears on Arnuca.,:'..'a... es of Org.) DDate Incorporat Organized: Statq to cr2x)rod/?rg.anized: 3. AZ Corporation Co ' sion File No.: Date authorized to do business in AZ: -- 4 J AZ L.L.C. File No: Date authorized to do business in AZ: 5. Is Corp./L.L.C. non-pro i 9 0 YES LI..d O If yes, give IRS tax exempt number: D List all directors/officers in oration/L.L.C.: Last First Middle Title Residence Address City State Zip .\ _ ____,____ .--,. • (A I ACH ADDITIONAL SHEET IF NECESSARY) 70 List stockholders or controlling members owning 10 or more: Last First Middle %Owned Residence Address City State Zip t, 1 (ATTACH ADDITIONAL SHE. IF NECESSARY) 8. If the corporation/L.L.C. is owned by another entity, attach an ownership, .,d director/officer/members disclosure for the parent entity. Attach additional sheets as necessary in order to disclose real people. SECTION 8 Club Applicants: EACH PERSON LISTED MUST SUBMIT A COMPLETED FORM"LIC0101",AN"APPLICANT" "E FINGERPRINT CARD,AND$24 FEE FOR EACH CARD. 1. Name of Club: Date Chartered: (Exactly as it appears on Club Charter) (Attach a copy of Club Charter) 2. Is club non-profit? ❑ YES ❑ NO If yes, give IRS tax exempt number: 3. List officer and directors: Last First Middle Title Residence Address City State Zip L (ATTACH ADDITIONAL SHEET IF NECESSARY) \. 3 SECTION 9 Probate, Will Assignment Divorce Decree of an existing Bar or Liquor,,Lore: 1. Current Licensee's Name: (Exactly as it appears on license) Last ' First Middle 2. Assignee's Name: Last First Middle 3. License Type: License Number: Date of Last Renewal: Id 4. ATTACH TO THIS APPLICATION A CERTIFIED COPY OF THE WILL, PROBATE DISTRIBUTION INSTRUMENT, OR DIVORCE DECREE THAT SPECIFICALLY DISTRIAUT,,ES THE LIQUOR LICENSE TO THE ASSIGNEE TO THIS APPLICATION. LILL. 1uUl NOV SECTION 10 Government: (for cities, towns, or counties t'1 ') p I• ` / S 1. Person to administer this license: - Last First Middle 2. Assignee's Name: Last First Middle A SEPARATE LICENSE MUST BE OBTAINED FOR EACH PREMISES FROM WHICH SPIRITUOUS LIQUOR IS SERVED. SECTION 11 Person to Person Transfer: Questions to be completed by CURRENT LICENSEE(Bars and Liquor Stores ONLY). • 1. Current Licensee's Name: / ()P 0 2 ill Irk 4!1�'C en .S Entity: ,4 /I ' (Exactly as it appears on license) Last First - Middleidiv.,Agent,etc.) 2. Corporation!L.L.C. Name: 1t2U/17 C , i A L -rIt/ C 061 n. -e a (Exactly as it appears on license) f i • 3. Current Business Name: , f 0an—l-Cj • 17 6041E - (Exactly as it appears on license) *41110) 4. Current Business Address: / K 73 7 pa dL k U; t iv 4 'r , roef •41✓i 1, l aS A. 55,5-Z4. 5. License Type: (3 61 i License Number: ! �� Last Renewal Date: 1'-1/- 2 Oa 2 �urrent Mailing Address(other than business): -StQZ,SQ •- , ( o 7. Have all creditors, lien holders, interest holders, etc. been notified of this transfer? g YES 0 NO 8. Does the applicant intend to operate the business while this application is pending? V1 YES ❑ NO If yes, complete section 5, attach fee, and current license to this application. 9. I hereby relinquish my rights to the above described license to the applicant named in this application and hereby declare that the statements made in this section are true, correct and complete. I, 0!2-e S- J Z`•°'r��� , declare that I am the CURRENT OWNER, AGENT, CLUB MEMBER, PARTNER, (Print full name) STOCKHOLDER or LICENSEE of the stated license. I have read this section and the contents and all statements are true, correct4-1--i--;C.V and complete. K/G-, 1µ�0 / State of,,. y7�m i County of c • 5': eQ/� The f e oing instrum-nt was aclmowledt-• before me thi (Signature of C LICENSEE) day of ' 2 C7a �� r,,,,.4S, OFFI IIAL,SEAL pa) • •n'nth Month , Year Har►S y G� � Notary Pubs j�St`.f �j My commission expires on: /—2d Vy''`-;' • .,.1 . (9� • , Conxnission Ex Tres March 9,‘i r, .ignat of NOTARY PUBLI ) SECTION 12 Location to Location Transfer: (Bars and Liquor Stores ONLY) APPLICANTS CANNOT OPERATE UNDER A LOCATION TRANSFER UNTIL IT IS APPROVED BY THE STATE. it Trent Business Name and Address: ®pL L C II"Exactly as it appears on license) i1002NOV 12 P 1: i ; 2. New Business Name and Address: (Do not use PO Box Number) 3. License Type: License Number: Last Renewal Date: 4. What date do you plan to move? What date do you plan to open? SECTION 13 Questions for all in-state applicants: 1. Distance to nearest school: 52& ft. Name/Address of school: 4—&(.5 j *J 4 .-5 . \-'\(EA (Regardless of distance) _ ,o pT ' t > 0 . P CS(4c PZ ( �q 2.' istance to nearest church: Z(o ft. Name/Address of church: cs +" (Regardless of distance) 1C-s<S (--k.s , - pic) 1 CSC cc (Acc S 3. n the: LESSEE 0 SUBLESSEE ❑ OWNER P SER(of premises) .pr3�,6....-k- ts. e�,vrB pt-z. % _, .t 1 4. If the premises is leased-give lessors name and address: PcL 4 I`)(S P .1 e0( (pr(_L`ic 161,31 6 . i .q\ -p,. € _ .1 l- +1- ((-)- o 4a. Monthly rental/lease rate$ 3 fiba . . What is the remaining length of the lease? bl. yrs. mos. Q� dA.S�1. 4b. What is the penalty if the lease is not fulfilled? $ L1�S 1 .6e or" 'o�Iie � (give details-attach additional sheet if necessary) 5. at is the total business indebtedness of the applicant for this license/location excluding lease? $ )23 Does any one creditor represent more than 10% of that sum? 0 YES ENO If yes, list below. Total must equal 100%. Last First Middle %Owed / Residence Address City State Zip (ATTACH ADDITIONAL SHEET IF NECESSARY) 6. What type of business will this license be used for? (BE SPECIFIC) 5r e- C . 7 . Has a lice , or a transfer license for the premises on this application been denied by the state within the past one (1)year? 0 YESi NO If yes, attach explanation. 8 :s any spirituous liquor manufacturer, wholesaler, or employee , have any interest in your business? ❑YESXNO 9. Is the premises currently licensed with a liquor license? YES 0 NO If yes, give li ense number and licensee's name:il License# b(4)67 C)(i LPG' (Exactly as it appears on license) Name I i <J .i w2. . 5 SECTION 14 Restaurant, or Hotel-M. Applicants: ___________. —~ 1. Is there a valid restaurant or hotel-motel liquor license at the proposed location? YES ❑ NO If yes, give licensee's name: and license#: Last First Middle 2. If the answer to Question 1 is YES, you mar9mlifr.for an Interim Permit to operate while your application is pending;.consult A.R.S. Section 4-203.01; and complete Sec o 'this application. 3. All restaurant applicants must complete a Restafft peratiotIlan(Form LIC0114)provided by the Department of Liquor. 4. Do you understand that 40%of your annual gross revenue must be from food sales? 0 YES ❑ NO SECTION 15 Diagram of Premises: (Blueprints not accepted, diagram must be on this form) 1. Check ALL boxes t apply to your licensed premises: I`J Entrances/Exits Liquor storage areas ❑ Tho rive-in windows ❑ Patio enclosures M Service windows ❑ Under construction: estimated completion date 2. Restaurants and Hotel/Motel applicants must explicitly depict kitchen equipment and dining facilities. 3. The diagram below is the only area where spirituous liquor is to be sold, served, consumed, dispensed,possessed, or stored. Give the square footage or outside dimensions of the licensed premises. DO NOT INCLUDE PARKING LOTS, LIVING QUARTERS, ETC. _7L(> \S 2�cs ,`:;k. s -€CTA-- 1‘4‘35CLII'A \ blga..S... .0<octe.4sti„3C5i 0,1,15 . --.L\ 3, .._______-t-PicJ co.... lt? 51"..7r t2 : �23 0 � ass '\ 01-4‘ � O r7 'b b 6 Z} p d t:, .,,,,,.. . c,,,,,,,, ats Q(511--- �, � uC 2 a (15 (` 7� O o J v , a cg7 C7 C) L C7 �, 6 C Szl. '\--7-16-'et4.1.„1,;';,e-t . / L t:osz_.\:elckl_ce.s,.. -- YOU MUST NOTIFY THE DEPARTMENT OF LIQUOR OF ANY CHANGES OF BOUNDARIES, ENTRANCES, EXITS, OR SERVICE WINDOWS MADE AFTER SUBMISSION OF THIS DIAGRAM. 6 SECTION 16 Geographical Data: A F A MPLE FOR THIS SECTION IS PROVIDED(IN THE BACK OF THIS PAGE. ''.ist below the exact names of all churches, schools, and spirituous liquor outlets within a one half mile radius of your proposed location. 1. "t-� C— 3�E CO ( Qkt-�. . , • 5. *P156 PkZ 2 6. R C.I a X ► .ig 7. &t'k , L ,Ncz C"_I 4 8. C4 l 6, ,51 e. z,-I . IL_ 9. i IV* - i RjE i.C-ID- - Q 10. aeS pl ..2,A CAIW C-lD aC2) ' C4)N. 11. sF •. 12. • `i1 13. di 3 14. 15. (ATTACH ADDITIONAL SHEET IF NECESSARY) A = Your business name and identify cross streets. S�ION 17 Signature Block: I, \R�ef\- , declare that: 1) I am the APPLICANT(Agent/Club Member/Partner), making this (Print name of APPL CANT/AGE listed in Section 4 Question I) application; 2) I have read the application and the contents and all statements are true, correct and complete; 3) that this application is not being made to defraud or injure any creditor, taxing authority, regulatory authority, or transferor; 4) that no other person, firm, or corporation, except as indicated, has an interest in the spirituous liquor-license for which these statements are made; and 5) that none of the owners,partners, members, officers, directors or stockholders listed have been convicted of a felony in the past five (5)years. State of R.�i,2 #County of h,1 Ol .,par X The foregoing instrument was acknowledged before me this (Sim - OFFICIAL SEAL 1a day of )000�,b9 , C2 • t Day of Month Month Year *s,r't._ MARGIE PEREZ My commission expires •.e ,,y' Notary Public-State Arizona � � MART •''K (Sigtature of PLWIC)fii.1P my comm.Expires Feb.14,2006 - 7 4 SAMPLE • GEOGRAPHICAL DATA In the area adjacent to the map provided below indicates your proposed location and the exact names of all church<:s, schools, and alcoholic beverage outlets ,within a 1/2 mile radius of y ur proposed location. (See example below) ULLC k = Applicant ZUU1 NOV /;e ies 12 01 Pink Elephants Series 0 02 Mama ' s Rest. Series 12 03 Corner Liquors Series 09 04 Joe ' s Groceries Series 10 05 Lions Club Series 14 06 Burgers R Us Series 07 • 07 Pizza Perfect Series 07 08 Billy Bobs Bar Series 06 ' Mi. 09 St . Anthonys Church Latrobe 10 St . Anthonys School 1 . 11 vid) 11 Burbank Middle School i Mi. Lockwood , 4 2 7 Mi . 12 First United Baptist Church 1 13 1111111111 14 9 10 8 15 • A.R. S . Section 4-207 .A reads as follows : Mi. • A. No retailers license shall be issued for any premises which are . at the time the license application is received by the Director, within three hundred (300) horizontal feet of a church, within three hundred (300) horizontal feet of a public or private school building with kindergarten programs or any of grades one (1 ) through twelve (12) . or within three hundred (300) horizontal feet of a fenced recreational area adjacent to such school building. 1111) • A NA DEPARTMENT OF LIQUOR LICENSES&CO )L 800 W Washington 5th Floor -o -' 400 W Congress#150 Phoenix AZ 85007-2934 Tucson AZ 85701-1352 (602)542-5141 QUESTIONNAIRE (520)628-6595 • \ttention all Local Governing Bodies: Social Security and Birthdate Information is Confidential. This information may be given to ocal law enforcement agencies for the purpose l aof ground checks only but must be blocked to be unreadable prior to posting DLO.; or any public view. Read Carefully , this instrument is a swpr document. Type or print with black ink An extensiye inye$tigation of ypur_Iia o will thcbnducted. Falsg or incomplete answers:could resu • in crimm proseEuittlon id t e al1br tfbsequent revocation of a license or permit. /dElae TO BE COMPLETED BY EACH OWNER, AGENT, PARTNER,STOCKHOLDER(10% OR MORE), MEMBER, OFFICER OR MANAGER. ALSO CH PERSON • COMPLETING THIS FORM MUST SUBMIT AN "APPLICANT"TYPE FINGERPRINT CARD WHICH MAY BE OBTAINED AT THE DEPT. FINGERPRINTING MUST BE DONE BY A BONA FIDE LAW ENFORCEMENT AGENCY OR A FINGERPRINTING SERVICE APPROVED BY THE DEPARTMENT OF LIQUOR. THE DEPARTMENT DOES NOT PROVIDE THIS SERVICE. There is a$24.00 processing fee for each fingerprint card submitted. Liquor License # 6 7 y Q ' A service fee of$25.00 w' be charged for all dishonored checks(A.R.S.44.6852) (If the location is currently licensed) 1. Check Owner❑Partner❑Stockholder 0Member JOfficer 0 Agent ❑ Manager(Only) appropriate ❑ Other (Complete Questions 1-20 & 24) :Complete All Questions except# 14, 14a &25) box— - Licensee or Agent must complete#25 for a Manager _ Licensee or Agent must complete#25 2. Name: 181E-,S4. •4N ( N ‘ ,(a._ Q 1(� Date of Birth: 1 —2S—�p, • Last F' st Middle (This Will Not Become a Part of Public Records) _15 Z?-Z 5 -col. 3` ()Social SecurityNumber: & ' :% ,fii_�►�i►i it �_Gc`n. f ,r ', �Z�—�5'�Lp 3 Drivers License#�-��: .• _ �� (This Will Not Become a Part of Public Recor... VS " 4 . Place of Birth: t L' (J Height: �pl3it Weight: 225 Eyes: M Hair: isQ,f;� City State Country (not county) • . 5. Marital Status ❑ Single livlarried❑ Divorced❑ Widowed Residence (Home) Phone: (1480 ) e.pe( , - (p , Name of Current or Most Recent Spouse: 4&Ui3V(\ �t (Q Date of Birth: 1-24-6 1 .st all for last 5 years-Use additional sheet if necessary) Last First Middle Maiden • 7. You are a bona fide resident of what state? PV4a\ . c�'G°c If Arizona, date of residency: . `2COr4 8 Telephone number to contact you during business hours for any questions regarding this document. (1 E6) Z� - 3 T (P• 9. If you have been a resident less than three (3)months, submit a copy f driver's license or toter ark g� Rl c AIIvke Name of Licensed Premises: — (;I< �emises Phone: ( J6) EI(o - O fl • icensed Premises Address: \(c 1 1 E ; 4 ev\r( c�\*.- t'tiu s MAC MAYE1 t .T SaliD Street Address (Do not use PO Box it) City County 1 -1 �p 12.List your employment or type of business during the past five(5)years, if unemployed part of the time, list those dates. List most recent 1st. FROM TO DESCRIBE POSITION EMPLOYER'S NAME OR NAME OF BUSINESS Month/Year Month/Year OR BUSINESS (Give street address,criitty,state&zip) CURRENT LTI✓D �i 1C� �3�e�+� �� �- S--i -`�5 ts�o-cs J ef6e -) A ��b voc_ -Re6- 5 r r t SD CA 12167 ATTACH ADDITIONAL SHEET IF NECESSARY FOR EITHER SECTION Q 13 Indicate your residence address for the last five (5) years: FROM TO Rent or RESIDENCE Street Address Month/Year Month/Year Own If rented,attach additionalp� sheet giving name,address and phone number of landlord ;r,,City -��1 �S1tate Zip it-J-a. CURRENT eeNT LS(4)2t= �t� l-L - 1�e, i 1104 6 t?..£�Z 1'�s-c-� Of-t AdK (1 SZ (e -3- iWiz. " IZS. �`. l'c-►`�I� J L e.0 - "(2. 6 Q-(44: oa ie fZ& 2` 1--0 2(..-ot r 33c S (Y).(Sf p- J Z ff G-C- a-0 _7?!(? J .. 1 b-3i-aJ (r� 551&' EZc (1 L cam- ott 14 eA S'z(\ .. IC 016. 10/2001 Disabled individuals requiring special accommodations please call(602)541-9027 If you checked the Manager box on tl )nt of this form skip to # 15 V14.As an Owner, Agent, Partner, Stocktulder, Member or Officer, will you be physically present and operating S ENO the licensed premises? If you answered YES, how many hrs/day? IC) , answer#14a below. If NO, skip to#15. �..� 14a. Have you attended a Department approved Liquor Law Training Course within the last 5 years? (Must provide proof) ❑ YES C/J NO If the answer to# 14a is "NO", course must be completed before issuance of a new license or approval on an existing license. 15. Have you EVER been detained, cited, arrested, indicted or summoned into court for violation of ANY law or S 0 NC,, ordinance (regardless of the disposition even if dismissed or expurl�� ltor traffic violations, include only those that were alcohol and/or drug related. 16. Have you EVER been convicted, fined, posted bond, begif'orile ted'te?dePsit paif imprisoned, had sentence YES El NO suspended, placed on probation or parole for violation of ANY law or ordinance (1"egardless of the disposition even if dismissed or expunged)? For traffic violations, include only those that were alcohol and/or drug related. 17. Are there ANY administrative law citations, compliance actions or consents, criminal arrests, indictments or 0 YES 1ii1N0 summonses PENDING against you or ANY entity in which you are now involved? V 18. Have you or any entity in which you have held ownership, been an officer, member, director or manager EVER S 0 NO had a business, professional or liquor APPLICATION OR LICENSE rejected, denied, revoked, suspended or fined in this or any other state? 19. Has anyone EVER filed suit or obtained a judgment against you in a civil action, the subject of which 0 YES VO involved fraud or misrepresentation of a business, professional or liquor license? 20. Are you NOW or have you EVER held ownership, been a controlling person , been an officer, member, director, , 'Y or manager on any other liquor license in this or any other state? ® ES 0 NO If any answer to Questions 15 through 20 is "YES" YOU MUST attach a signed statement giving complete details. Please be sure to include dates, agencies involved and dispositions. If you checked the Manager box on the front of this form, fill in#21-23 and 24, all others skip the following box(21-23) and go to#24 Manager Section 21. Have you attended a Department approved Liquor Law Training Course within the last 5 years? (Must provide proof) OYES ❑t If the answer to#21 is "NO" course must be completed BEFORE ISSUANCE of a new license OR APPROVAL on an existing license. 22. Do you make payments to the licensee? ❑ YES ❑ NO If"yes", how much? $ per month. Total debt to licensee$ 23. Is there a formal written contract or agreement between you and the licensee relating to the operation or management of this business? ❑ YES E NO If"yes", attach a copy of such agreement 24. I, C ;,, )4�— l� , hereby declare that I am the APPLICANT filing this questionnaire. t full name of Applicant) I have read this questionnaire and the contents and all statements are true, correct and complete. State of f)_Q i 2.0iJ County of / !f)--1—{Crp v X 0,sk?..._ .\\ 1\5s,.. ....,_____, The foregoing instrument was acknowledged before me this ?..� 4sifin In.at..ppplicanf) , '^ o.- OFFICIAL SEAL y s �►, ) day of `"�'�``:. MARGIE PEREZ �§Da of Moat Mouth Year t744 Notary Public-State of Arizona + Mycommissior1 • .� , ` `tv D 1'n 2fXIE;4 reaRe14,_COUNTY Y'r (Sigiature of TAR PUBLI ) _ . FILL IN THIS SECTION ONLY IF YOU ARE A LICENSEE OR AGENT APPROVING A MANAGER PLICATION Licensee or Agent Approval of Manager , 25. I, (Print Licensee/Agent's Name)• Last Middle First Hereby authorize the applicant to act as manager for the named liquor license. State of County of The foregoing instrument was acknowledged before me X day of (Signature of LICENSEE/AGENT) Day of Month Month Year My commission expires on: Day of Month Month Year (Signature of NOTARY PUBLIC) T�;tP \Cs ' c� uclt43 - - Nc\A 1/4uz \t _% 1� �d� otokj cm% <_.kz-q (*)-vo 64 Ar.oc \( )0 - DLIr 1001 Nov l2 p is lb , • • 261 NOV 12 P I: lb A. "!l1 � Number 527256833 - , 3 \ ( Expires 03128/202S Driver License Date of Birth — Issued 11112/ CHRtSTOPNER KIEL NOTEBOOM'` 700 N CC}RQNADO#2076 CHANDLER AZ 85224 f �< � ; ..k x �' �:§�`Paz,-' 4,75„ ^ 54 J H.. f Y C -'0".."•,- .:eaw 'Fn • • col o _