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246164 06/16/15 %g.�,x4`f. CITY OF CARMEL, INDIANA VENDOR: 355486 ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMWHECK AMOUNT: S*'""*1,000.00* s _� CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 246164 9y.,..._,. INDIANAPOLIS IN 46204 CHECK DATE: 06/16/15 fiON� DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4355300 PERMIT2016 1,000.00 ORGANIZATION & MEMBER •*� APPLICATION FOR RENEWAL OF ° ALCOHOLIC BEVERAGE PERMIT : State Form 47(R13/2-09) FOR OFFICE USE ONLY Approved by State Board of Accounts,2005 rete>= Examined by/date INSTRUCTIONS: 1.Type or print legibly. Hearing.date Z Submit in duplicate. Include payment 3.Application must be received by our office 90 days(3 months)before permit expires. Issue date 4.Do not complete shaded areas. New expiration date STEP 1 ;:'GENERAL,I�IFQRMAT,ION ,F Name of applicant as printed on existing permit Permit Number Permit Type Release date City of Carmel RR2903542 210-1 Name of Business(d/b/a) State Tax I.D.number Permit expiration date Brookshire Golf Club 0031201550 7/13/2015 Business Address(numberand street,city,state,ZIP code) Business Telephone Area/Number Base fee 12120 Brookshire Parkway (317 ) 846 - 7431 Home Telephone Area/Number Carmel, IN 46033 Mailing address(number and street,city,state,ZIP code) Status ❑Active ❑ Non-operational/Escrow Catering (Attach escrow letter) Name of Processor Date of Renewal Excise District Local Board 1)Have there been any changes in the existing operation,floor plans,or seating accommodations since you last applied for ❑ Yes El No this permit? (If Yes,attach affidavit of changes and copies of amended floor plan on 8.5"x 11"paper if applicable) 2)Do you consent for the duration of the permit to inspection and search by an enforcement officer,without a warrant or other EI Yes ❑ No process,of your licensed premise and vehicles to determine compliance with the provisions of I.C.7.1? 3)Does the permittee have an interest in any distiller,vintner,farm winery,rectifier,brewer,primary source of supply,or ❑ Yes EI No wholesaler permit? 4)Since your last renewal have you been convicted of any misdemeanor or felony? (If Yes,please attach letter with dates, ❑ Yes 0 No court,conviction,and sentence of conviction) 5)Do you have the right to possess(rent,mortgage,or own)the permit premise for the term of the permit? 0 Yes ❑ No 6)Have all your sales taxes and property tax obligations for the past year and those due at this time been paid in full? El Yes ❑ No 7)Do you sell tobacco products? Yes ❑r No n 7, I1 S,4TEP,2-'yBUSINESS Check one:M ❑ Corporation ❑Limited Liability Company ❑Partnership ❑Limited Partnership O Club ❑ Limited Liability Partnership ❑Sole ownership CORPORATIONS ONLY Note:If the ownership has changed(by death,transfer or sale of stock or interest,etc.)since you last applied for renewal, the processor should be notified at once before completing this section. Provide the information for the individuals associated with your permit as follows: Total shares authorized CLUB-Highest ranking officer and the financial secretary or treasurer CORPORATION-President,secretary,and all stockholders(list total shares authorized/issued and individual shares held and percent of shares issued) Total shares issued LIMITED LIABILITY COMPANY-All members and percent of interest held LIMITED PARTNERSHIP/PARTNERSHIP I LIMITED LIABILITY PARTNERSHIP-All partners and percent of interest held SOLE OWNERSHIP-Owner „ I,”r :4' ,.a'"M`"..a ,.+ "n4 ,.r -�r"vk+P. 4^f +gists' to •,? rt,_J*,R,m I r t 7 t ; ',3` ,may ;yv:;r 3 , ,i�03 o- f S ARE �V;R� ,S ��NAME-AND HOME ADDRESS " i , t i*SOC SEC NO+&DOB : INTEREST HELD', onj r ' ., IF APPLICABLE Ro6erl Nlggins SSN 309-88-7324-{ Mr. 7895 W 27701 SL SOerlCan,IN 46069 DOS 07-2&71 - r�DOB'; -QOB *Social Security Numbers are required by federal child support law Fnr-inca nn ariditinnnI eh,--at if nrraccary STEP,3 ;`ANNUAL'rFO,O,DzSALES,'z j, Required for the following permits:Type 209(except golf courses); All retail permits with less than 60%ownership by Indiana residents; Retail permits with limited bar/family room separation;All grocery store permits. Date of beginning report(month,day,year) Date of ending report(month,day,year) rsod sales(exclude all carryout and catering sales) Gross Alcoholic beverage sales Gross food and beverage sales ,• .4� .. , ,. ., �: . ,.. .6 ST.EP.4 OPERATIQ,N INFO.RMA7IQN _ < Is there a contract of any kind to sell the permil/business at this time? ❑Yes 0 No Have you conducted server training since your last renewal? ❑Yes 0 No As owner do you manage the premises? 0 Yes ❑No If No,do you monitor the premises? ❑Yes ❑ No Are you a grocery store or pharmacy? ❑ Yes If business is a grocery store,are 25%or less of the gross sales in alcoholic beverages? ❑Yes ❑ No 0 No (If no,then you MUST complete the rest of this section) The Alcohol and Tobacco Commission requires the following of all managers: • They must have been an Indiana resident for 5 years or work in a restaurant with a minimum of$100,000 annual food sales; • They must be a United States citizen or resident alien; • They must be of sound mind,21 years of age and of good moral character; • They cannot be a law enforcement officer;and • They cannot have a conviction within the last 10 years of an A,B or C felony,in any state,or a federal crime with a sentence of at least one year. Do you understand the requirements and attest that the managers listed below meet these qualifications? © 01 ( initial) The Alcohol and Tobacco Commission requires managers as follows: • At least one for each permit premise; • The manager must have an employee permit unless he or she is a sole proprietor,partner or stockholder • The manager is someone who has day-to-day authority over: 1.employees that hold employee permits (i.e.bartenders,servers); 2.the receipt,inventory,stocking,and marketing of alcoholic beverages; 3.the premises,in the event of an emergency. LIST THE MANAGERS FOR THIS PREMISE(ENCLOSE AN ADDITIONAL SHEET IF NECESSARY) NAME EMPLOYEE PERMIT#or OWNERSHIP TYPE EMERGENCY TELEPHONE NUMBER Robert Higgins BR1606858 317-501-2146 allSTEP 5 *AFFIDAVIT OF AP..PLICANT{ I certify that there have been no changes regarding my previous application except those noted herein. I certify that this application was completed by myself or by the preparer identified herein. I certify that my premise ownership is true and that I will provide a copy of any applicable lease or purchase by contract upon request of the Commission. I certify that I have met any applicable food and beverage sales requirements. I certify that all information provided herein and on any attached schedules or documents are true and correct.I UNDERSTAND THAT IT IS A FELONY UNDER LAW TO MISREPRESENT OR FALSIFY ANY PORTION OF THIS APPLICATION OR ATTACHED DOCUMENTS. I hereby consent for the duration of the permit term to inspection and search by an enforcement officer,without a warrant or other process,of my licensed premise and vehicles to determine compliance with the provisions of I.C.7.1 Printed name of applicant Sign f applicant Date(month,day,year) Robert Higgins 6-12-15 A."". a ,k`•,x ,!.STEP'::6 AFFIDAVIT OF;P ARER(IF"AP,PLICABLE),b qs7, ti'; I certify that I have examined this application and the accompanying forms,schedules,and statements,and to the best of my knowledge and belief,they are true,cprreqt,and complete. Signaturb of parer Telephone number Date(month,day,year) (317 ) 846-7422 6-12-15 S r. 7 d - �.� _ y s c I.y §'h ",ri 7 , 4;: ✓i k ' i,"� 4 :&� yv t *A`d tyr: HI E �. . Please remit business,certified checks,or money order-application will not be processed without payment Submit in duplicate and One-way(beer only)= $500 MAIL TO: Two-way(beer&wine only)_ $750 INDIANA ALCOHOL&TOBACCO COMMISSION Three-way(beer,wine,&liquor)= $1,000 302 West Washington Street,Room El 14 (Except Fraternal Clubs)_ $250 Indianapolis,Indiana 46204 i i PROPERTY TAX CLEARANCE SCHEDULE-FORM NO. 1 ATC permit number (For a ❑ Person ❑ Business ❑ Corporation) 7 Stale Form 1462(R6/7-10) Expiration date(month,day,year) Approved by State Board of Accounts,2011 rae INDIANA ALCOHOL AND TOBACCO COMMISSION Name of individual'or company TYPE City of Carmel (Check all that apply) If transfer,give former name of business ❑New Mailing Address(street and number ofrural route) ❑Renewal One Civic Square ❑Transfer(Check all that apply) City State ZIP Code ❑Ownership Carmel IN 46032 ❑Location Doing business as(DBA) ❑Stock Brookshire Golf Club Permit location(street address) STATUS 12120 Brookshire Parkway ❑Permit escrow City State ZIP Code ❑DBA change Carmel IN 46033 I,Treasurer of 14 Q ft/,? County,hereby certify that the person or company named above has paid all property taxes in 20 / (for 20 assessment)and property taxes for all prior years,or is exempt from property tax by IN reas of Signal f CountyT asurer Date(month, ay,year) ER HAN S—TA PROPERTY TAX CLEARANCE SCHEDULE-FORM NO. 1 ATC permit number Qe (For a ❑ Person ❑ Business ❑ Corporation) State Form 1462(R6/7-10) Expiration date(month,day,year) Approved by State Board of Accounts,2011 'y vee. INDIANA ALCOHOL AND TOBACCO COMMISSION Name of Individual or company TYPE City of Carmel (Check all that apply) If transfer,give farmer name of business ❑New Mailing Address(street and numberofrura/route) ❑Renewal One Civic Square ❑Transfer(Check all that apply) City State ZIP Code ❑Ownership Carmel IN 46032 ❑Location Doing business as(DBA) ❑Stock Brookshire Golf Club Permit location(street address) STATUS 12120 Brookshire Parkway ❑Permit escrow City State ZIP Code ❑DBA change Carmel IN 46033 I,Treasurer of H a t/YI 1 f! +In--\ County,hereby certify that the person or company named above has paid all proerty taxes in 20 _(for 20�_assessment)and property taxes for all prior years,or is exempt from property tax by as =yn? -,� Signatd,of County Treasurer Date(month,day,year) TREASURER HAMILTON COUNTY VOUCHER NO. WARRANT NO. ALLOWED 20 Indiana Alcohol & Tobacco Commission IN SUM OF $ 302 West Washington Street, Room E 114 Indianapolis, IN 46204 $1,000.00 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 1207 I Permit 2016 I 43-553.00 I $1,000.00 1 hereby certify that the attached invoice(s), or bill(s) is (are)true and correct and that the materials or services itemized thereon for n which charge is made were ordered and received except Friday, June 12, 2015 Director, Broo ire Golf Club Title Cost distribution ledger classification if claim paid motor vehicle highway fund Prescribed by State Board of Accounts City Form No.201(Rev.1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit,etc. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s)or bill(s)) 06/12/15 Permit 2016 RenewalRR2903542-2016 $1,000.00 I hereby certify that the attached invoice(s), or bill(s), is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 120 Clerk-Treasurer