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Home My WebLink About182886 03/03/2010 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1 ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CHECK AMOUNT: $1,000.00 CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 roy INDIANAPOLIS IN 46204 CHECK NUMBER: 182886 CHECK DATE: 3/3/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4358300 210 -1 1,000.00 GOLF LIQ LIC n APPLICATION FOR RENEWAL OF 1£ ALCOHOLIC BEVERAGE PERMIT j State For 47 (R1312 -09) FOR OFFICE USE ONLY ale y Approved by State Board of Accounts, 2005 Examined by date INSTRUCTIONS: 1. Type or print legibly. Hearing date 2. Submit in duplicate. Include payment 3. Application must be received by our office 75 days (2 112 months) before permit expires. Issue date 4. Do not complete shaded areas. New expiration date �STEPg1,GEN,ERAL, Name of applicant as printed on existing permit Permit Number Permit Type Release date City of Carmel RR2903542 210 -1 Name of Business (dlbla) Slate Tax I.D. number Permit expiration dale Brookshire Golf Club 0031201550 07/13(2010 Business Address (number and street, city, state, ZIP code) Business Telephone Area Number Base fee 12120 Brookshire Parkway 317 846 8431 Carmel, IN 46033 Home Telephone Area /Number Mailing address (number and street, city, state, Z1P code) Status Active Non- operational Escrow Catering 12120 Brookshire Parkway, Carm IN 46033 (Attach escrow letter) It 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 121 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 0 Yes NO process, of your licensed premise and vehicles to determine compliance with the provisions of I.C. 7.1? 3) Does the permitlee have an interest in any distiller, vintner, farm winery. rectifier, brewer, primary source of supply, or Yes 'n 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 IZI NO court, conviction, and sentence of conviction) 5) Do you have the tight to possess (rent, mortgage, or own) the permit premise for the term of the permil? El Yes No 5) Have all your sales taxes and property tax obligations for the past year and those due at this time been paid in full? 0 Yes NO 7) Do you sell tobacco products? Yes NO H Bl)SINE�S t Check one: Corporation Limited Liability Company Partnership Limited Partnership 10 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 authonzed CLUB Highest ranking officer and the financial secretary or treasurer Q CORPORATION President, secretary, and all stockholders (list total shares authorized /issued and individual shales held and percent of shares issued) Total shares issued LIMITED LIABILITY COMPANY All members and percent of interest held LIMITED PARTNERSHIP 1 PARTNERSHIP 1 LIMITED LIABILITY PARTNERSHIP- All partners and percent of interest held 0 SOLE OWNERSHIP Owner HARE l TITLE NAME AND HOME'ADDRESS SOC SEC NO 'DOB INTEREST HELD IF.APPL° ICA'BLE pV^' Robes Hyyns ;SSN,. 309 -9B -7524 16133 Hyme,a, Wesrfeld IN 40674 pDQB 7129171 ;SSN aDQ6 «SSN" DOB; `wSSN `Social Security Numbers are required by federal child support law Enclose an additional sheet if necessary STEP 3. ANNUAL FOOD SALES 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 I family room separation; All grocery store permits. Date of beginning report (month, day, year) "report ending report (month, day, year) Gross sales (exclude all gasoline and auto oil products) Gross Alcoholic beverage sales Gross food and beverage sales t STEP 4. OPERATION INFORMATION Is there a contract of any kind to sell the permittbusiness at this time? D Yes ❑f No Have you conducted server training since your last renewal? Yes m No As owner do you manage the premises? 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 ED No 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? 1 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 (ENCLOSEAN ADDITIONAL SHEET IF NECESSARY) NAME EMPLOYEE PERMIT ff or OWNERSHIP TYPE EMERGENCY TELEPHONE NUMBER Robert Higgins BR1606858 317 -501 -2146 Brian Ballard BR1614295 765 215 -1303 STEP 5. AFFIDAVIT OF APPLICANT 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 1 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 8)9iiatti7 of applicar t pate (month, day, year) Robert Higgins 2/15/2010 STEP 6. AFFIDAVIT OF R ARER (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 and complete. Sign re of reparer Telephone number Date (month. day, year) 4t J 317 846 -7431 2/15/2010 STEP 7. FEE 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) S750 INDIANA ALCOHOL 8 TOBACCO COMMISSION Three -way (beer, wine, liquor) S1,00D 302 West Washington Street, Room El 14 (Except Fraternal Clubs) $250 Indianapolis, Indiana 46204 PROPERTY TAX CLEARANCE SCHEDULE FORM NO. 1 ATC permit number tTAi� (For a Person d Business Corporation) 0 1z o'c d 1 4 State Form 1462 (RS 110-01) Expiration dat 2 W (Month, day ea) q •f Approved by State Board of Accounts, 1992 INDIANA ALCOHOL AND TOBACCO COMMISSION In idu I's name or �ompany TYPE G (Check all that apply) If transfer, ive former business name New M fling Address (Street and number of rural route) r enewal nr Transfer (Check all that apply) City State Zip Code Ownership A [Q j a Location ig business as (DBA) Stock Permit location (Stre ddress) STATUS '2 G it✓5ff hH? (C ❑Permit escrow City State ZipC o de ❑DBA change Tt/� 5 I, Treasurer of lZ M County, hereby certify that the person or company named above ha paid all property taxes in 20 (for 20 assessment) and properly taxes for all prior years, or is exempt from property tax b, reason of Signature of County Treasurer Date (Month, day, year) PROPERTY TAX CLEARANCE SCHEDULE FORM NO. 1 ATC permit.number tit q (fora ❑Person El Business El Corporation) State Form 1462 (R51 10 -01) Expiration date (Month, day, year) Approved by State Board of Accounts. 1992 INDIANA ALCOHOL AND TOBACCO COMMISSION Individual's name or company name TYPE (Check all that apply) If transfer, give former business name New Mailing Address (Street and numberofruraf route) Renewal Transfer (Check all that apply) City State Zip Code Ownership Location Doing business as (DBA) Stock Permit location (Street address) STATUS Permit escrow City State Zip Code DBA change I, Treasurer of County, hereby certify that the person or company named above ha paid all property taxes in 20 (for20 assessment) and property taxes for all prior years, or is exempt from property tax b reason of Signature of County Treasurer Date (Month, day, year) 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 210 -1 Renewal 43- 583.00 $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 which charge is made were ordered and received except Monday, February 15, 2010 Director, BrogAhire 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 199! 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)) 02/15/10 10 -1 Renewal Jan Permit Renewal $1,000.0 1 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 Clerk- Treasurer