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309238 03/16/1 7
�,,*F CITY OF CARMEL, INDIANA VENDOR: 355486 ONE CIVIC SQUARE INDIANA ALCOHOL &TOBACCO COMMCHECK AMOUNT: $.......150.00* s ?Q CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 309238 �,M, INDIANAPOLIS IN 46204 CHECK DATE: 03/16/17 <TON DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1096 4239039 APP 150.00 GENERAL PROGRAM SUPPL 0 0 0 - % 0 / 0 z 0 2 D 0 0 \ ) 0 k / k 7A 0 0 w z§ $ o / E^ m < \ ƒ 5 z2 CD > CL 2 k 7 / \ / = \ 0 7 q J N) 0 � 2 5 _ — / \ \ / cn k OR- co0 J ƒ % ¥ / 7 2 2@ m E a { w \ / 0 E > 3 7 0 2 k E \ 0 0 / k k ® q / � » ] E & D Q / 0 m « :Z � ° 2 $ & & m CL CD ° 0 q 3 n (a - R + 0 CD / m — k 2 M § = a ° a 0 / 0 CD — / ) ƒ A w I . - k Q \ - k - = m 0 w \ / A / \ 0 R \ \ 7: . o% T m | § / o a Carmel • Clay Parks&Recreation CHECK REQUEST Date: 03.01.2017 IBNR 0 2 1011 BY: Check payable to: Name: Indiana Alcohol&Tobacco Commission Address: Indiana Government Center South,Room E-114;302 W.Washington St. City,State,Zip Indianapolis,IN 46204 Mail check to payee _X Return check to requestor Check Amount:$150.00 Date Required: 05.01.2017 Purpose of Check: Temporary Beer/Wine Permit for Monon Mixers to be held on June 22,July 13, and August 3,all held at The Waterpark Supporting documentation or invoice(s)MUST be attached. To be paid from: (��7 PO#(if applicable) xX_ t Budget account-GL# 109640-4239039 Budget Line Description General Program Supplies Requested by(print): Amanda Jackson (� Requested by(signature/date): : : {l \� -�ti Approved by(print): Shauna Lewallen / Approved by(signature/date) ��r�� 31 1-7- Form 7Form recreated 3/10/15(Business Services) Send,deliver,or mail to: BEER t WINE AUTHORITY/TYPE 118 DISTRICT I DISTRICT 4 State Form 35494(R8/11-15) 52422 County Road 17 651 S.Commerce Dr. + , J Approved by State Board of Accounts,2015 Bristol,IN 46507 Seymour,IN 47274 I Telephone:(574)264-9480 Telephone:(812)523-8314 INSTRUCTIONS: 1. Applicant must complete all requested information. DISTRICT 2 DISTRICT S 2. Please type or print clearly. 1353 South Governors Drive 3650 South US Hwy 41 3. Submit application and payment to the local excise Columbia City,IN 46725 Vincennes,IN 47591 Telephone:(260)244-4285 Telephone:(812)882-1292 district office. DISTRICT 3 DISTRICT 6 279 West 300 North 6400 East 30th Street Crawfordsville,IN 47933 Indianapolis,IN 46219 Telephone:(765)362-88,15 Telephone:(317)5414100 .............. ................................_.._,,,..,,A STEP 1. GENERAL INFORMATION _ Name of applicant applying for permit(organization,club,corporation,individuao ITM Permit number(issued byATC) Carmel Clay Parks&Recreation { i _.... _ .............._,.�......_. ..._._...._.........................._..........................._....._..._....._..........__........_..._.................._._.......__............._.._......................._............................_............................_........_.....................__..___......_.......................... Address of applicant(number and sheet city,state,and ZIP code) r E-mail address 1235 Central Park Dr. E.Carmel, IN 46032ajackson@carmelclayparks.com Name of person making application �Fax number Emergency contact telephone number Amanda Jackson f 317 1 848-7275 _._ _ ._. Pri . nted name of contact person of event Emergency contact telephone number Amanda Jackson 317> 843-3861 STEP 2. EVENT INFORMATION Beginning day Beginning date(month,day,year) Ending day Ending date(month day year) Thursday 06 22.2017 06.22.2017 06.22 2017 Time of event ............... _ Start time 8:00 ❑AM Q✓ PM End time 10:00 []AM ©PM _..-- _ .....�..__ .._ _...__..... Type or description of event Monon Mixer-Adult, over 21 event at The Waterpark Exact address of event(number and street city,state,and ZIP code) 1195 Central Park Dr.West Carmel,IN 46032 Map attached. _.._........ — _._._......_..........................._................_................_.._.......__............................_............................................._.........................................._............................._._........................_................._..................................._........................ _—_......._.....,.. _......._...., STEP 3. FLOOR PLAN(See SW 4,Number 2) R ' � -D (SNR 0 3 2017 BY: I __ ------- ----- ..--- _._ __......... I Page 1 of 2 z F. oil 'k 4 My Omm all S �j y v c �j-t gnsg w/ it SPA 1A *4 ✓ ' 10 4001, LO O a Ilk, qt C M m` 'boaNo .f� o Li STEP 4. ACKNOWLEDGEMENT In order to qualify for this authority to serve beer and wine,the following guidelines must be met: 1. There must be a well defined premises,i.e.building,tent,enclosure,or fenced-in or designated area. i 2. You must have a defined floor plan or diagram. This is to be drawn on Page 1,Step 3 of this application. If minors are to be present,you must have a defined separation between the bar area and family area. (Must be on floor plan.) 3. There shall be NO carry-out privileges,NO carry-in privileges and NO spirituous beverages allowed. 4. Each applicant must designate an individual to be responsible for the event and such person shall sign the authority. 5. ANY and ALL persons dispensing or accepting payment for alcoholic beverages MUST P033ESS a valid ATC employee permit. 6. The event must meet applicable Indiana State Board of Health requirements,particularly with regard to restroom facilities. 7. If the event is held in a town park,you must have approval from the town board. 8. Legal Hours of dispensing alcoholic beverages:(Prevailing time) Monday through Saturday—7 AM to 3 AM the following day Sunday—7 AM to 3 AM the following day 9. Applicant must file with the district office at which the event will be hold at least five(5)days prior to the event. 10. The authority must be posted in the most conspicuous place at the location of the event.An excise officer or commissioner,for good cause,has the authority to revoke the authority during the event. STEP S. COMMUNITY CLEARANCE 1.Signature of a countyChief of Police r Marshall of jurisdiction where the event will be held Date signed(m nth,day,year) 2. Signator the mayor(if the event is held in Fort Wayne) Date sign (month,day,year) Note: Please post your approved request in a conspicuous place where the alcoholic beverages are being dispensed at the location. If for any reason this request Is denied,you may be notified either in person or by telephone. ................................__ I swear or affirm under penalties of perjury that the information is true and accurate. Signature of permittee l agent(Your signature acknowledges that you have read and will abide by the rules and guidelines.) Date signed(month,day,year) ; FOR DISTRICT USE ONLY District number Date issued(month,day,year) �t Reviewed by Excise Police District Representative Approved Denied 1. ALL EVENTS ARE$50.00 PER DAY. BUSINESS CHECKS OR MONEY ORDERS ARE ACCEPTED MADE OUT TO THE INDIANA ALCOHOL AND TOBACCO COMMISSION. 2. SERVING PAST MIDNIGHT, NO LATER THAN 3 AM,IS ONE 1 DAY. 3. NO RAIN CHECKS ON ANY OF THE ABOVE EVENTS. Page 2 of 2 Send,deliver,or mall to: BEER/WINE AUTHORITY/TYPE 118 DISTRICT 1 DISTRICT 4 State Form 35494(R8 111-16) 52422 County Road 17 651 S.Commerce Dr. Avnmyej by Stare Eardt E._ .;a r Bristol,IN 46507 Seymour,IN 47274 Telephone:(574)264-9480 Telephone:(812)523-8314 INSTRUCTIONS: 1. Applicant must complete all requested information. DISTRICT 2 DISTRICT 5 2. Please type or print clearly. 1353 South Governors Drive 3650 South US Hwy 41 3. Submit application and payment to the local excise Columbia City,IN 46725 Vincennes,IN 47591 district office. Telephone:(260)244-4285 Telephone:(812)882-1292 z DISTRICT 3 DISTRICT 6 279 West 300 North 6400 East 30th Street I Crawfordsville,IN 47933 Indianapolis,IN 46219 Telephone:(765)362-6815 Telephone:(317)541-4100 STEP 1. GENERAL INFORMATION _.................._.........._.1111_._.... " _...........m..._�............................. ._ m............._............_ _..r_.-.—.............._._. I Name of applicant applying for permit(orgenizaffon,club,corporation,individuaq TM Permit number(issued by ATC) [ Carmel Clay Parks&Recreation _._ ._..__ ....._. Address of applicant(number and street city,state,and ZIP code) E-mail address 1235 Central Park Dr.E.Carmel, IN 46032 ajackson@carmelclayparks.com Name of person making application Fax number Emergency contact telephone number Amanda Jackson ( ) 317 184&7275 ___.....__....._....__.... __1111. _ 17 � _ m Printed name of contact person of event Emergency contact te.phone number l Amanda Jackson 317 ) 843-3861 STEP 2. EVENT INFORMATION .._____. ....._... Beginning day Beginning date(month,day,year) Ending day Ending date(month,day,year) Thursday 07 13.2017 07 13 2017 07.13.2017 § Time of event Start time 8:00 AM ©PM ` End time 10:00 ❑AM n PM ,....1111.....-.___ "__..._... _._._. _ .1111.."........................ ____ __.._ __111................ __... Type or description of event Monon Mixer-Adult over 21 event at The Waterpark __. of ev...__._._ �.__.. _ — , Exact address of event(number and street,sty,state,and ZtP code} � 1195 Central Park Dr.West Carmel, IN 46032 Map attached. ! STEP 3. FLOOR PLAN(See Step 4,Number 2) t� I 1 I Page 1 of 2 S M � r j Pro At E � P y- r it _ it .d .. z UJ G _ O G Q N STEP 4. ACKNOWLEDGEMENT In order to qualify for this authority to serve beer and wine,the following guidelines must be met: 1. There must be a well defined premises,i.e.building,tent,enclosure,or fenced-in or designated area. 2. You must have a defined floor plan or diagram. This is to be drawn on Page 1,Step 3 of this application. if minors are to be present,you must have a defined separation between the bar area and family area. (Must be on Boor plan.) 3. There shall be NO carry-out privileges,NO carry-in privileges and NO spirituous beverages allowed. 4. Each applicant must designate an individual to be responsible for the event and such person shall sign the authority. 5. ANY and ALL persons dispensing or accepting payment for alcoholic beverages MUST POSSESS a valid ATC employee permit. 6. The event must meet applicable Indiana State Board of Health requirements,particularly with regard to restroom facilities. 7. if the event is held in a town park,you must have approval from the town board. 8. Legal Hours of dispensing alcoholic beverages:(Prevailing time) Monday through Saturday—7 AM to 3 AM the following day Sunday—7 AM to 3 AM the following day 9. Applicant must file with the district office at which the event will be held at least five(5)days prior to the event. 10. The authority must be posted in the most conspicuous place at the location of the event.An excise officer or commissioner,for good cause,has the authority to revoke the authority during the event. STEPS. COMMUNITY CLEARANCE i.Signature of unty,o hief dice n Marshall of Jurisdiction where the event will be held Date signed(month,day,yeat) i 717 2. Signatu a mayor(f the event is held in Fort Wayne) Date signed(month,day,year) Note: Please post your approved request in a conspicuous place where the alcoholic beverages are being dispensed at the location. If for any reason this request is denied,you may be notified either in person or by telephone. I swear or affirm under penalties of perjury that the information is true and accurate. Signature of permittee/agent(Your signature acknowledges that you have read and wilt abide by the rules and guidelines.) Date signed(month,day,year) FOR DISTRICT USE ONLY District number Date issued(month,day,year) -.._....„„.— ” ._......rr�................... Reviewed by Excise Police District Representative Approved [) Denied 1. ALL EVENTS ARE$50.00 PER DAY. BUSINESS CHECKS OR MONEY ORDERS ARE ACCEPTED MADE OUT TO THE INDIANAALCOHOL AND TOBACCO COMMISSION. 2. SERVING PAST MIDNIGHT,NO LATER THAN 3 AM,IS ONE(1)DAY. 3. NO RAIN CHECKS ON ANY OF THE ABOVE EVENTS. Page 2 of 2 #� r BEER/WINE AUTHORITY/TYPE 118 send,deliver,or man to: State Form 35494(R8111-15) DISTRICT 1 DISTRICT 4 Approved by State Board of Accounts,2015 52422 County Road 17 651 S.Commerce Dr. Bristol,IN 46507 Seymour,IN 47274 Telephone:(574)264-9480 Telephone:(812)523-8314 INSTRUCTIONS. 1. Applicant must complete ad requested information. i DISTRICT 2 DISTRICT 5 2. Please type or print clearly. 1353 South Governors Drive 3650 South US Hwy 41 3. Submit application and payment to the local excise Columbia City,IN 46725 Vincennes,IN 47591 district office. Telephone:(260)244-4285 Telephone:(812)882.1292 DISTRICT 3 DISTRICT 6 279 West 300 North 6400 East 30th Street Crawfordsville,IN 47933 Indianapolis,IN 46219 Telephone:(765)362-8816 Telephone:(317)5414100 .__..........__....................._.. ...__ ___._............,......_.... .... ._._............ _ STEP 1. GENERAL INFORMATION Name of applicant applying for permit(organization,club,corporation,Individual) TM Permit number(issued byATC) Carmel Clay Parks&Recreation __._ _ _ ....___._.._...__.................................................. ..._....._ _.___.__...__._ .._..___.___..._..__....__._.__....__ ._...................._.....____.__......_.._... Address of applicant(number and sheet,city,state,and ZIP code) E-mail address 1235 Central Park Dr.E.Carmel,IN 46032 ajackson@carmek:layparks.com __.—...._.__..__......_... Name of parson making application Fax number Emergency contact telephone number Amanda Jackson ( ( 317 ) 848-7275 Printed name of contact person of event Emergency contact telephone number Amanda Jackson t 317) 843-3861 STEP 2- EVENT INFORMATION ............................................ ....._.: Beginning day Beginning date(month,day,year) Ending day Ending date(month,day,year) Thursday 08.03.2017 08.03.2017 08.03.2017 _. ................. ........_..._.— ; Time of event �� Start time 8:00 E]AM ©PM End time 10:00 []AM ©PM _....... ......._........._..__.................... - -_-— ........... Type or description of event Monon Mixer-Adult, over 21 event at The Water ark -._W__._ _.._..._....._... ._____._ _ Exact address of event(number and street,city,state,and ZIP code) 1195 Central Park Dr.West Carmel, IN 46032 Map attached. STEP 3. FLOOR PLAN(See Step 4,Number 2) 1 3 i I( i I Page 1 of 2 �- , 040 & I uk , lit, �i t JJC o h %Wpm"= do 'look. 96 as F , Jaw y,` � «� .3 � � e Af OF CT _ ~O414 O 'a NJ1111F lit it Air STEP 4. ACKNOWLEDGEMENT In order to qualify for this authority to serve beer and wine,the following guidelines must be met: 1. There must be a well defined premises,i.e.building,tent,enclosure,or fenced-in or designated area. i 2. You must have a defined floor plan or diagram. This is to be drawn on Page 1,Step 3 of this application. If minors are to be present,you must have a defined separation between the bar area and family area. (Must be on floor plan.) 3. There shall be NO carry-out privileges,NO carry-in privileges and NO spirituous beverages allowed. 4. Each applicant must designate an individual to be responsible for the event and such person shall sign the authority. 5. ANY and ALL persons dispensing or accepting payment for alcoholic beverages MUST POSSESS a valid ATC employee permit. 6. The event must meet applicable Indiana State Board of Health requirements,particularly with regard to restroom facilities. J 7. If the event is held in a town park,you must have approval from the town board. 8. Legal Hours of dispensing alcoholic beverages:(Prevailing time) Monday through Saturday—7 AM to 3 AM the following day Sunday—7 AM to 3 AM the following day 9. Applicant must file with the district office at which the event will be held at least five(5)days prior to the event. 10. The authority must be posted in the most conspicuous place at the location of the event.An excise officer or commissioner,for good cause,has the authority to revoke the authority during the event. STEPS. COMMUNITY CLEARANCE 1.Signature o county Chief of Police r wn Marshall of jurisdiction where the event will be held Date sign (m nth,day,year) 2. Signa the mayor(if fhe event is held in Fort Wayne) Date sign64(month,day,year) Note: Please post your approved request in a conspicuous place where the alcoholic beverages are being dispensed at the location. If for any reason this request Is denied,you may be notified either in person or by telephone. I swear or affirm under penalties of perjury that the information is true and accurate. Signature of permittee t agent(Your signature acknowledges that you have read and will abide by the rules and guidelines.) Date signed(month,day,year) FOR DISTRICT USE ONLY District number Date issued(month,day,year) Reviewed by Excise Police District Representative Approved F-1 Denied 1. ALL EVENTS ARE$50.00 PER DAY. BUSINESS CHECKS OR MONEY ORDERS ARE ACCEPTED MADE OUT TO THE INDIANA ALCOHOL AND TOBACCO COMMISSION. 2. SERVING PAST MIDNIGHT, NO LATER THAN 3 AM,IS ONE 1 DAY. 3. NO RAIN CHECKS ON ANY OF THE ABOVE EVENTS. Page 2 of 2