339774 06/10/19CITY OF CARMEL, INDIANA
ONE CIVIC SQUARE
CARMEL, INDIANA 46032
VENDOR: 355486
INDIANA ALCOHOL & TOBACCO COMIVGHECK AMOUNT: • $ * * * * * 1,000.00*
302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 339774
INDIANAPOLIS IN 46204 CHECK DATE: 06/10/19
DEPARTMENT
1207
ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
4355300 ANNUAL 1,000.00 ORGANIZATION & MEMBER
Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
VOUCHER NO. WARRANT NO.
ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
Vendor# 355486
INDIANA ALCOHOL &TOBACCO COMM IN SUM OF$ CITY OF CARMEL
302 W WASHI NGTON ST ROOM E114 — -- 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.
INDIANAPOLIS, IN 46204
Payee
$1,000.00
ON ACCOUNT OF APPROPRIATION FOR Purchase Order#
Brookshire Golf Course Terms
Date Due
PO# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
Permit 2019 43-553.00 $1,000.00 I hereby certify that the attached invoice(s),or 6/12/19 Permit 2019 BGC 2019 Permit $1,000.00
1207 101 1207 101
bill(s)is(are)true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
Wednesday,June 12,2019
I hereby certify that the attached invoice(s),or bill(s),is(are)true and correct and I have
audited same in accordance with IC 5-11-10-1.6
, 20
Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
` FOR_OFfIClrti§ ONL _
;$� 'PPLI ATION FOR RENEWAL OF I xamtnedty/date(mm/dd/yyr
k it LCO OLIC BEVERAGE PER IT ' I I lea ing,date.(mm/dd/yy)
•tateFor 47(R17/8-16) I
•pprove by State Board of Accounts,2 16 Issue:date(mm/dd/yy) 1
• 1 :YI
II.ST"UCTIONS: 1.Typ or print legibly. New expiration date(mm%dd/yy)
II 2.Inc de payment.
3.Ap /)cat)on must be received b our office ninetyReleese dateNin/dd/10.: -' _1
' (90)days before permit expires.
' 4.Do of complete shaded areas.
5.Ple se attach completed Property Tax Clearance-i Fe rm 1.
6 Ple se attach a copy of the Retpll tylerchant Certificate from Indiana Department of Revenue. Base fee
,,,STER_i GEN.E WiNFO_RMATIO_N
Ni me;o applicant as. inted on'xisting permit Permit nun1ber Permit type i
pity of Carm-I FIZ C
R2903542 210-1 1
ate(ng
Na e o business(d/b a) I Permitexpirationdate(mm/dd/yy) I
Ero;•kshire golf CI b i 7-13-19
Bu'ines address num.erandstret ci state,ZIP code
� ( 4: 1 i • Business telephone area/number Nam;Of 121 :0 Brook-hire "kwy (317)846- 7431 processor l
Home telephone area/number
dar eI, IN 4�.Q33 ( ) Date.frenewaljmm/dd/yy) 1
1
Mailing:ddress(numb r and stre t,city,state,ZIP code) IA Sa' a as above Status (-�Active Exds district
I4.
❑Non-operational/escrow F
I (Attach escrow letter.) local':oard-
1) iav,-there been.ny changes in the existing operation,floor plans,or seating ac ornmodations since you last applied for or renewed
trhis!.ermit?(If Ye,attach affidavit of changes and copies of arnended floor plan on 8.5"x 11"paper,if applicable.) ®Yes ❑No
2) Do y•u consent fo the duration of the permit to inspection and search by an enfor'ement officer,without a warrant or other process,
of yo r licensed p emises and vehicles to determine compliance with the provisiin of Indiana Code 7.1? la Yes ❑No
3)Do a y individuals corporations,limited liability companie,limited liabilit
y ty part er'ships,partnerships or stock owners,members,or
;irart ers of such e tities have any interest,either:directly or indirectly,in any other permits of any kind issued under Indiana Code 7.1
donn cted with,b t not limited to,the production,distribution!(transportation,qr sale of alcoholic beverages? El Yes ®No
(1f ye,attach a Hs of all permits.)
4)Since your last ren-wal,have you or anyone with!an interest in'this permit been convicted of a misdemeanor or felony? -
(ff yg please atta h letter with dates,court,conviction,and sentence of conviction. El Yes ®No
5)Do V.u have the ri:ht to possess(rent,mortgage,!or own)the permit premises fir t e term of the permit?
1 ' 1 I ®Yes ❑No
6) Have-pplicant's s.les taxes,withholding taxes,and properly tax obligation for ttje past year and those due at this time been paid in full?
®Yes 0 No
7)Do yo sell tobacc.product's? I 1 ! If yes,list Tobacco Sales Certificate Number.
j ❑i Yes ®No
8)qo yo have a Typ: II Gaming endorsement? Q Yes ®No If yes,list Gaming Endorsement Number.
. 3 ,'-'°, '"" a :S1EP 2n BUSINESSiOWNERSHIP` -
Checkq e: i I I I I _ -
ID Corporation ❑Limited liability company y Partnership ❑Limited partnership ❑Club
0
Limited liabi'ty partn rship ElSole ownership ®Government entity CORPORATIONS ONLY
Not :If,he ownershi• has cha ged(by death,transfer,or sae oflstock or interest!efic.)since you last applied for renewal,the
process,•r should be otified a once before completing this section. I I
Provide he informati•n forth individuals associated with your permit as follows: ' Total shares authorized
CL B—Highest -nking o icer and the financials secretary or treasurer
CO^PORATION Preside ,secretary,and all stockholde js
List tota shares authorized/issued and individual shares held and percent of shares issued.)
LI:IITED LIABLI COMPA Y—All members and percent of interest held
j 1 Total shares issued
LI gTED PARTN:RSHIP/P RTNERSHIP/LIMITED LIABLITY f)ARTiNERSHIP—AII partners and percent of interest held
SO E OWNERSHIr—Own r ' I
GO ERNMENT E TITy— vernment official(s)responsib)e for permit I '
TITLE(En lose additlo al NAME AND HOME ADDRESS 1 *SOCIAL SECURITY NUMBER& SHARES OR INTEREST %**
sheei if P-cessary.) (number and street,city,sate,and ZIP code) I I DATE OF BIRTH(mm/dd/yy) HELD IF APPLICABLE
Mr. Robert Higgins 1 SSN
I 309-98-7324
20971 Shoreline Ct.#210 NoOlesviile, IN46062 j DOB 07-29-71
SSN
DOB
SSN
I DOB
*Socia Sec:rity Number-are required by federal child support la}.v. This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1;
disclo ure is mandato and this record cannot be processed withoutit.
**Percent':. ust be inclu ed,except for a club,sole owner,or goernriient entity. Ash'reholder with more than 50%ownership may individually sign transfer paperwork.
;
T EP L ANNUA.SALES/PRODUCTION.
(All figares are bfeet to.verificatTgn y�thejniffana Departmen of t Revenue.1 , 'u�t
Retail _or dealer permit(Skip tep 3 if permit was in escrow r the prior permit year.)
1) Do you hold a be:r,wine,and liquor retail perm t Issued in an unincorp rated area or a type 209 permit? ❑Yes ®No
2 Do you hold a be:r,wine,and liquor retail permit with limited bar/famlil room separation? ElYes ®No
34 Do you of erate a onvenience store or ifood mart as defined by Indiana Code 7.1-1-3-18.5(a)(2)? El Yes ®No
41 Do you h ld a ret-II or dealer permit through a partnership,corporation limited partnership,or limited liability ❑Yes ®No
company that do- not meet the residency requirements of Indiana Cod 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 quest!.ns 1-4,skip to Section 4.
Dale of beginning report(mm/dd ) Date of ending report(mm/dd/yy)
A. Gross food sales (For reta I permits,exclude all carryout and c'(rtering sales.) B. Gross alcoholic beverage sales C. Total Cross Sales(Column A+B)
(For con enience stores,exclude gasoline and automotive oil product.)
I
Manufacturing permit( inery,farm winery,artisan distillery,distillery,and brewery)
Date of,t eginning report(mm/dd ) i I l Date of ending report(mm/dd/yy)
Gallons;Varm winery or distillery) ,r barrels(brewery)manufactured
STEP 4.OPI±RATIQN fiNFORM14TfiN _ _. a..
.:
Is there a contract of any kind o"sell the permit/business at this
is tune?
Dyes ®No
Have all of your employees or.ervers obtained employee perhiitsiand completed a ployee training if required by Indiana Code
7.1p I I I
®Yes El No
As he'owner do you manage .he premises? If no,des the manager of tie premises have a valid manager's questionnaire on file with the ATC?
1 ! Dyes ®No
®Yes ❑No
Are you a grocery store or pha macy? ❑Yes(If yes,move o'n to Step 5.)
RI No(if no,then,you MUST complete the rest of this section.)
The Alcohol and Tobacco Corn ission requires managers as follows: -
•They must have be-n and Indiana resident for five f5)years or work in a-eitaurant with a minimum of$100,000 annual food sales;
•They must be a Uni ed States citizen or resident alien; a
•They must be of so nd mind,twenty-onei(21)years of age and of good modal character;
•They cannot be a is enforcement officer;and 1
•They cannot have a conviction within thellast ten(10)years of
• zn B or C felony,or itsjequivalerit in.another state, 1
• z I:vel 1,2,3,4,or 5 felony,or its equivalent in another t te,or
• a f:deral crime with a sentence of t least one(1)year. �f
Do youiunderstand the rlequire ents and attest thatthe manger listed below meet these qualifications? (�° g (Initial)
The ATC requires the=ollowing I I !
• At least one( )own-r or manager for each permit remises;
1 i The mana er�must ave an employee permit unles he or she is a sole prop ietor,partner,or stockholder;
• The mana er is scm-one who has day-to-iiay authority over:
Em,loyees that hold employee permits(i.e.bartenders,se ers),•
2. Th•receipt,inventory,stocking an l marketing of alcoho is everages;and
3. The premises,in the event of an emergency.
LIST THE MANAGERS FO' THIS PREMISES?(ENCLOSE AN ADDITIONAL SHEET IF NECESSARY.)
NAME EMPLOYEE PERMIT NUMBER or OWNERSHIP TYPE EMERGENCY TELPHON E NUMBER
Rdbgrt Higgins j BR1606858 317-501-2146
1
,. 4, _,� f . 1 = STEPS AFFIDAVIT'OFAPPI-IC:ANI .
I certify,That there ha+bee no changes regarding my Oreviious application except those noted herein. I certify that this application was completed by
mys If or by the prepa�rer d-ntified herein. I certify thatif this application wais completed by a preparer,I have read the completed application.I certify
that the ownership of my pr-mises 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 ha ie met any applicab e food and beverage sales iequirements. I certify that all information provided herein and on any attached schedules or
doc ments are true a c+cor ect. I UNDERSTAND THAT IT IS A FELONY UNDER LAW TO MISREPRESENT OR FALSIFY ANY PORTION OF THIS APPLICATION
OR TTACHED DOCUMENT I }
Prin Z
e of applicant I Signapure' cant Date mm dd
I
1 i I
'', ` -. . ;. SfEe 6.AFFIDA%it Q 100ARER(tF#(.04 4-0. X : ,f
I ertify that I have examined this application,and the accompanying forms,)schedules,and statements, x e ,t e
are tr i I and to the best of my knowledge and belief,they
orrect an rr plete. I certify that the applicant reviewed the cqmpleted form prior to signing.
S" atu prepay ` T'317e number _
�_ I ( j 846 7422 Date(mm/dd/yy)
1
PlOase remit business check,certified check,or money oriler—application Mail to:
will n t be processed without payment. (Seeattache fee schedule.) Indiana Alcohol&Tobacco Commission
302 West Washington Street,Room E114
Indianapolis,Indiana.46204
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. ._ P-OPERTY TAX CLEARANCE,SCHEDULE-FORM NO.1 ATC permit number
,; ( •r a ❑Person 0 Busine s ❑Corporation'
..
._ •,, _`% RR2903542
St=eForm1462(R6/7-10)
Expiration date(month,day,ye:
+'.�•`� - Ap•rovetl by State Board of Accounts,2011 7-13-19
t+ 'o"•'' IN•lANA ALCOHOL AND TOBACCO COMMISSION
Name of inch M •ny I TM E
• City of Cann (Check al/hat apply)
If transfer,giv former name of business
❑New
Mailing Addre•s(street and umber of rural route)\. I • I m Renewal
One Civic S.uare , •
0 Transfer(Check all th:t apply)
City Staten j I ZIP Code 0 Ownership
Cannel Initiate g8032
❑Location
Doing busines as(DBA) - -- ['Stock
Brookshire ealf Club :y
Permit locatio (street add•ss) -
12120 Brook-hire Golf CI b-
C ty ® - 48033 ❑CI Permit escrow
Cannel. - ZIP Code DBA change
Treasurer•• -Hammon ! I ( Court ,Hereby tartly that the person or company named above has
•ald allprope taxes 20'•. I',. for 20 assessment)and properly taxes for at prior years,or Is exempt from property tax by
``a on of Y"•1. - ' _'I' ` ` j 5 I ► et,II,/ •' it.��i. ' I t
r�tttttttlit•t�-
Signature of C i y Treesu - Date(month,day,year)
•-o-ERTY TAX CLEARANCESCHEDULE-FORM NO'1 ATC permit number
;( • (F•r a 0 Person 0 Business I 0 Corporation) RR2903542
1r'. '1I1 Stet,Form 1462(R6/7-10 I Expiration date(month,day,year) •
a,-.;1r` 7-13-19
App oved by State Board o Aceou ts,2011
F .` " •IND.NA ALCOHOL AND TOBACCO COMMISSION •
tar
•
• Name of Indivi•ual or'conipa y -• -
ifi
• City of Carm ' " I TMP'
If transfer,give ormer nameiof business -.-,�
(Check all th=
❑New
Mailing Address(street and umbero rural route), - 1 its Renewal
One Civic So are a•- CI Transfer(Check all the apply)
City • State; ZIP Code 0 Ownership
Carmel Indiana
46032 0 Location
Doing business as(DBA) �,_ •-- 0 Stock
Brookshire G.If Club- ,r _
Permit location steered.-) • S
12120 Brooks ire Golf Clup • ❑Permit escrow
City State- ZIP Code ❑DBA change
Carmel Indiana I l 48033
Treaeuteraf Ham tr,h-•''_`-"`.. ! Count),hereby certify that the person or company named above has
•:id all property taxes n 20'1 9 (for 20 I II assessment)and property tex
. as fo all prior years,or is exempt from property tax by
.4. :_ +O
1416111111111U P_'fir AI I
I Itttt=ttttttttEVltttl,tttttttttttttttitttttttttttttttrr sorelametan
Signature ofEjill'iMMIMIMIMIMIEEmmnm.11r
Date(month,day,year) Ur r-//
I ,. I R HAMILTON COUNTY !
•
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