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Home My WebLink About256719 03/24/16 yA* CITY OF CARMEL, INDIANA VENDOR: 355486 / Fi ® ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMNGHECK AMOUNT: S*****1,000.00* sq ,?� CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 256719 M,�TON�°' INDIANAPOLIS IN 46204 CHECK DATE: 03/24/16 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4358300 2016BGCPERMI 1,000.00 OTHER FEES & LICENSES VOUCHER NO. WARRANT NO. ALLOWED 20 INDIANA ALCOHOL&TOBACCO COMM 302 W WASHINGTON ST ROOM E114 IN SUM OF $ INDIANAPOLIS, IN 46204 $1,000.00 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Course PO#/Dept. INVOICE NO. ACCT#/Fund AMOUNT Board Members 12016 BGC Permit I 43-583.00 I $1,000.00 1 hereby certify that the attached invoice(s), or Renewal 1207 101 bill(s) is (are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except Monday, March 21, 2016 Cost distribution ledger classification if claim paid motor vehicle highway fund 'FOR0FFICEUSE,6NLY •" APPLICATION FOR RENEWAL OF � xamtnedby/date(mm/dd/yy) ALCOHOLIC BEVERAGE PERMIT lHearmgdate{mm/dd/yy) , State Form 47(1116/4-15) �b Issue date(mm/dd/yy) �•�•" Approved by State Board of Accounts,2015 w r: INSTRUCTIONS: 1.Type or print legibly. {New expiration date(Mm/dd/yy) 2.Include payment. ,,Release date(mmldd/yy) 3.Application must be received by our office ninety(90)days before permit expires. 4.Do not complete shaded areas. , N 1 r-' 5.Please attach completed Property Tax Clearance—Form 1. ! 6.Please attach a copy of the Retail Merchant Certificate from Indiana Department of Revenue. ease fee STE1GENERvAYLINFORMATIOIV ;* Name of applicant as printed on existing permit Permit number Permit type City Of Carmel RR2903542 210-1 ='catering t, i, Name of business(d/b/a) Permit expiration date(mm/dd/yy) Brookshire Golf Club 7/13/2016 l Business address(number and street city,state,ZIP code) Business telephone area/number Name of processor 12120 Brookshire Pkwy (317)846-7431 Home telephone area/number Date ofrenewal:(mm/dd/yy)•-, Carmel, IN 46033 ( ) Mailing address(number and street city,state,ZIP code) E]same as above Status Active Excise disfrict ❑Non-operational/escrow (Attach escrow letter.) i Lo6af 1) Have there been any changes in the existing operation,floor plans,or seating accommodations since you last applied for or renewed ❑Yes 0 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 process, of your licensed premises and vehicles to determine compliance with the provision of Indiana Code 7.1? 0 Yes ❑No 3) Do any individuals,corporations,limited liability companies,limited liability partnerships,partnerships or stock owners,members,or partners of such entities have any interest,either directly or indirectly,in any other permits of any kind issued under Indiana Code 7.1 ❑Yes Q No connected with,but not limited to,the production,distribution,transportation,or sale of alcoholic beverages? (If yes,attach a list of all permits.) 4)Since your last renewal,have you or anyone with an interest in this permit been convicted of a misdemeanor or felony? (If yes,please attach letter with dates,court,conviction,and sentence of conviction.) Yes Q No 5) Do you have the right to possess(rent,mortgage,or own)the permit premises for the term of the permit? 0 Yes ❑No 6) Have applicant's sales taxes,withholding taxes,and property tax obligation for the past year and those due at this time been paid in full? Yes ❑No 7) Do you sell tobacco products? El Yes 0 No If yes,list Tobacco Sales Certificate Number. 8)Do you have a Type II Gaming endorsement? E]Yes ®No If yes,list Gaming Endorsement Number. x :rx � BUSINESSOWNEItSHIP. '. . :R ,? r _ Check one: ❑Corporation ❑Limited liability company ❑Partnership ❑Limited partnership 0 Club ❑Limited liability partnership ❑Sole ownership 0 Government entity 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.) LIMITED LIABLITY COMPANY—All members and percent of interest held Total shares issued LIMITED PARTNERSHIP/PARTNERSHIP/LIMITED LIABLITY PARTNERSHIP—All partners and percent of interest held SOLE OWNERSHIP—Owner GOVERNMENT ENTITY—Government official(s)responsible for permit TITLE(Enclose additional NAME AND HOME ADDRESS *SOCIAL SECURITY NUMBER& SHARES OR INTEREST %** sheet if necessary,) (number and street,city,sate,and ZIP code) DATE OF BIRTH(mm/dd/yy) HELD IF APPLICABLE Mr Robert Higgins SSN 309-98-7324 1895 West 211th Sheridan, IN 46069 DOB 7/29/71 SSN DOB SSN DOB Social Security Numbers are required by federal child support law. **Percent must be included,except for a club,sole owner,or government entity. k shareholder with more than 50%ownership may individually sign transfer paperwork. O � (All figures•dre subfect�to'v`e[ificgtron by"the.Ipdi6na Department of Revenue)„ ,, . Retail or dealer permit(Skip Step 3 if permit was in escrow for the prior permit year.) 1) Do you hold a beer,wine,and liquor retail permit issued in an unincorporated area or a type 209 permit? ❑Yes ®No 2) Do you hold a beer,wine,and liquor retail permit with limited bar/family room separation? ❑Yes No 3) Do you operate a convenience store or food mart as defined by Indiana Code 7.1-1-3-18.5(a)(2)? ❑Yes ®No 4) Do you hold a retail or dealer permit through a partnership,corporation,limited partnership,or limited liability ❑Yes ®No company that does not meet the residency requirements of Indiana Code 7.1-3-21-4,7.1-3-21-5,7.1-3-21-5.2,or 7.1-3-21-5.4? If you answered no to questions 1-4,skip to Section 4. Date of beginning report(mm/dd/yy) Date of ending report(mm/dd/yy) A. Gross food sales (for retail permits exclude all carryout and catering sales) B. Gross alcoholic beverage sales C. Total Gross Sales(Column A+B) (for convenience stores exclude gasoline and automotive oil products) Manufacturing permit(winery,farm winery,artisan distillery,distillery,and brewery) Date of beginning report(mm/dd/yy) Date of ending report(mm/dd/yy) Gallons(farm winery or distillery)or barrels(brewery)manufactured ♦- . a, ,a nt � RERATIQN4 - Y' s INFORMATION P , O '� r .z. �• � ur,E t;.. Is there a contract of any kind to sell the permit/business at this time? ❑Yes 0 No Have all of your employees or servers obtained employee permits and completed employee training if required by Indiana Code ®Yes ❑No 7.1? As the owner do you manage the premises? If no,does the manager of the premises have a valid managers questionnaire on file with the ATC? El Yes ®No 2 Yes E]No Are you a grocery store or pharmacy? ❑Yes(If yes,move on to Step 5.) 52 No(If no,then you MUST complete the rest of this section.) The Alcohol and Tobacco Commission requires managers as follows: •They must have been and Indiana resident for five(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,twenty-one(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 ten(10)years of • an A,B or C felony,or its equivalent in another state, • a level 1,2,3,4,or 5 felony,or its equivalent in another state,or • a federal crime with a sentence of at least one(1)year. �AA_ Do you understand the requirements and attest that the managers listed below meet these qualifications? (Initial) The ATC requires the following: • At least one(1)owner or manager for each permit premises; • 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;and 3. The premises,in the event of an emergency. LIST THE MANAGERS FOR THIS PREMISES( CLOSE AN ADDITIONAL SHEET IF NECESSARY.) NAME EMPLOYEE PERMIT NUMBER or OWNERSHIP TYPE EMERGENCY TELPHONE NUMBER Robert Higgins BR1606858 317-501-2146 Brian Ballard Br1614295 765-215-1303 `I4FFICIA VfWF' P'UANT,4 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 if this application was completed by a preparer,I have read the completed application.I certify that the ownership of my premises is true and that I will provide a copy of any applicable lease or purchase by contract upon request of the ATC. 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. Printed name of applicant Signatur of applicant Date(mm/dd/yy) Robert Higgins - 3-21-16 "=" Req ' z> ;:� g STEP 6 PAFFIDAVIT OF PREPARER(IFAPPCICABLEj f 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 rue, orrect,and co e. I certify that the applicant reviewed the completed form prior to signing. Si of prepa r Telephone number Date(mm/dd/yy) ( 317 ) 846 - 7422 3/21/16 �'-: $�1 ,p. y � '�, ��• C? rt � �` '�;'ec^n d,}�;: �zM f x 3 i S dr!n � r . � STEPr7 'FEETr�1..H.,-. t .-�,,,t rs Please remit business check,certified check,or money order—application Mail to: will not be processed without payment. (See attached fee schedule.) Indiana Alcohol&Tobacco Commission 302 West Washington Street,Room E114 Indianapolis,Indiana 46204 J PROPERTY TAX CLEARANCE SCHEDULE-FORM NO. 1 ATC permit number (For a ❑ Person El Business ❑ Corporation) RR2903542 = State Form 1462(R6 f 7-10) Expiration date(month,day,year) 0 Approved by State Board of Accounts,2011 7/13/16 rareINDIANA 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 of rural route) El 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 JIN 46033 I,Treasurer of Hamilton 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 reason of Signature of County Treasurer Date(month,day,year) PROPERTY TAX CLEARANCE SCHEDULE-FORM NO. 1 ATC permit number +r (For a ❑ Person 0 Business ❑ Corporation) RR2903542 State Form 1462(R617-10) Expiration date(month,day,year) Approved by State Board of Accounts,2011 7/13/16 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 of rural route) El 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 Hamilton 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 reason of Signature of County Treasurer Date(month,day,year)