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311576 05/25/17 ��� ��'"•� CITY OF CARMEL, INDIANA VENDOR: 355486 ONE CIVIC SQUARE INDIANA ALCOHOL &TOBACCO COMIVCHECK AMOUNT: $*****1,000.00* `. CARMEL, INDIANA 46032 302 w WASHINGTON ST ROOM E114 CHECK NUMBER: 311576 ` `roM.. INDIANAPOLIS IN 46204 CHECK DATE: 05/25/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCROTHER FEES &ION LICENSES 1207 4358300 1,000.00 < < / m 0 O / q K q O w 2 > > 0 > m \ O k \ q q C" 2 2 \ o Z B M -P6 0 0 } M � O / ; # � � q 2 90 @ D C) 2 \ 0 / O0 = § k � o 0 0 / c0 n O 0o D Cl)° \ 0 � 0 ƒ ¥ 3 § © a 2 m o k CD \ z R > k O � a O / / § m | \ 8 H to w i 3 9 # z E 0 [ k ƒ ) 0 % i g / E 7 0 m x a) \ \ � Q 2 k - � 2 f ) } J E » § / (D k§ k / 0 § [ M / k 5- § co % 2 0 g to R % C § � / e - = 7 Q %m G m§ / m \ 2i rE � �) 0) m -A } \ \_ 0 0 / N } m m C � 0 ° k 3 \ / ik k k \ 2 e2. \ 2 0 > ° M 0 D §\ \ q - > /g « £ § m 8 f 3 / $ \ 0 E n \ k z E N I / CD c0 CA U C ¥ ; m n / A n B k CL / - § CD ƒ 7 / § g \ { § E � > & & s / C) \ . m a § ? o FOR OFFICE USE ONLY APPLICATION FOR RENEWAL OF Examined by/date(mm/dd/yy) ALCOHOLIC BEVERAGE PERMIT Hearing date(mm/dd/yy) State Form 47(R17/9'16) Approved by State Board of Accounts,2016 Issue date(mm/dd/yy) INSTRUCTIONS: 1.Type or print legibly. New expiration date(mm/dd/yy) 2.Include payment. Release date(mm/dd/yy) 3.Application must be received by our office ninety(90)days before permit expires. 4.Do not complete shaded areas. S.Please attach completed Property Tax Clearance—Form 1. 6.Please attach a copy of the Retail Merchant Certificate from Indiana Department of Revenue. Base fee SEEP 1.GENERALjWfbRMA116N Name of applicant as printed on existing permit Permit number Permit type City Of Carmel RR2903542 201-1 Catering Name of business(d/b/a) Permit expiration date(mm/dd/yy) Brookshire Golf Club 07/13/2017 Business address(number and street,city,state,ZIP code) Business telephone area/number Name of processor 12120 Brookshire Parkway (317)846-7431 Home telephone area/number Date of renewal(mm/dd/yy) Carmel, IN 46033 ( ) Mailing address(number and street,city,state,ZIP code) Same as above Status Active Excise district ❑Non-operational/escrow (Attach escrow letter.) Local board 1)Have there been any changes in the existing operation,floor plans,or seating accommodations since you last applied for or renewed ❑Yes Q 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, ®Yes ❑No of your licensed premises and vehicles to determine compliance with the provision of Indiana Code 7.1? 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? ❑Yes 0 No (If yes,please attach letter with dates,court conviction,and sentence of conviction.) 5) Do you have the right to possess(rent,mortgage,or own)the permit premises for the term of the permit? 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? If Yes No yes,list Tobacco Sales Certificate Number. ❑ 0 8)Do you have a Type II Gaming endorsement? E]Yes No If yes,list Gaming Endorsement Number. � STEP 2.BUSINESS.OVMERSHIP Check one: ❑Corporation ❑Limited liability company ❑Partnership ❑Limited partnership ❑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 COM PANY—All members and percent of interest held Total shares issued LIMITED PARTNERSHIP/PARTNERSHIP/LIMITED LIABILITY 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. This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it. **Percent must be included,except for a club,sole owner,or government entity. A shareholder with more than 50%ownership may individually sign transfer paperwork. STEP 3.ANNUAL SALES/PRODUCTION All u►es are subject to*verlftcadon by th► Indiana 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? ❑Ycs ®No 2) Do you hold a beer,wine,and liquor retail permit with limited bar/family room separation? I 0 Yes 0 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 liah;iity ❑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 STEP 4.OPERATION INFORMATION Is there a contract of any kind to sell the permit/business at this time? ❑Yes ®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? FTn—o,does the manager of the premises have a valid manager's questionnaire on file with the ATC? ❑Yes ®No ®Yes ❑No Are you a grocery store or pharmacy? Lj Yes(If yes,move on to Step 5.) ®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. 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(ENCLOSE 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 g g g . � - 7 .S�P�`°�F�lAA1/IT-�PI�PP C/1NT�,;:. .. .� ;• .r:- . 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 Sigpat a of ap licant ^ Date(mm/dd/yy) Robert Higgins J 05/19/17 -J STEP 6.AFFIDAVIT OF PREPARER(IF APPLICABLE) 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,correct,and com fete. I certify that the applicant reviewed the completed form prior to signing. natu of prep er Telephone number Date(mm/dd/yy) 317 ) 846 - 7422 05/19/17 STEP 7.FEE Please remit business check,certified check,or money order—application Mail to: will not be processed without payment. (See attached fee schedule.) 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" ❑❑ 110❑� CD CD 7 d vv SO r- f d a d H v _0 cnr0 � m F d 3 1 N ° o N m m c I c tD ° o ° f CD fDCD m m n x (D d o d s 3 F m m ° O N o C1 y CD n o v W ? CD m 3 v CD m £ x x t f C, m 'c N d m lb c wS4 m d c m m m c CA m � a a 0w r*e CITY OF CARMEL, INDIANA VENDOR: 355486 ONE CIVIC SQUARE INDIANA ALCOHOL &TOBACCO COMNGHECK AMOUNT: $.....1,000.00' CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 311576 1!" •�. INDIANAPOLIS IN 46204 CHECK DATE: 05/25/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT _ DESCRIPTION 1207 4358300 1,000.00 JTHER FEES & LICENSES 3 REMITTANCE ADVICE-DETACH AND RETAIN FOR YOUR RECORDS TO VERIFY AUTHENTICITY.SEE REVERSE SIDE FOR DESCRIPTION OF THE 11 SECURITY FEATURES APPROVED BY THE STATE BOARD OF ACCOUNTS FOR THE CITY OF CARMEL 2002 CHECK NU. CITY OF CARMEL, INDIANA PAYABLE AT 71-7166 311576 ONE CIVIC SQUARE UNITED FIDELITY BANK 2863 EVANSVILLE,INDIANA DATE:05/25/17 CARMEL, INDIANA 46032 GENERAL ACCOUNT AMOUNT $*****1.000.00* PAY THE SUM OF ONE THOUSAND DOLLARS & ZERO CENTS THIS WARRANT IS VOID TWO 121 YEARS AFTER i DECEMBER 31 OF THE YEAR OF ISSUE TO INDIANA ALCOHOL & TOBACCO COMM THE 302 W WASHINGTON ST ROOM B114 - ORDER INDIANAPOLIS IN 46204 OF I 1. -------------- ----- -- ---- - -------------- - ------------------ --- ----- --- - --- ---__ - - --_ ------ -- - II. 3LL576111 1: 2863711, 6634 900022L0411■