171183 04/22/2009 *f CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
b ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM
CHECK AMOUNT: $1,000.00
GARMEL, INDIANA 46032 CHECK NUMBER: 171183
CHECK DATE: 412212009
DEPARTMENT ACCOUNT PO NU MBER I NUMB AMOUNT DESC RIPTIO N
1205 4355300 1,000.00 ORGANIZATION MEMBER
I
h3
fJ� APPLICATION FOR RENEWAL OF
ALCOHOLIC BEVERAGE PERMIT
d State Form 47 (R1312 -09)
1s1� Approved by State Board of Accounts, 2005 FOR OFFICE USE ONLY
Examined by I date
INSTRUCTIONS: 1. Type or print legibly. Hearing date
2. Submit in duplicate. Include payment
3. Application must be received by our office 90 days (3 months) before permit expires. Issue date
4. Do not complete shaded areas.
New expiration date
STE P ':GENE_RAL-INFORAflATION .7�•''
Name of applicant as printed on existing permit Permit Number Permit Type Release date
City of Carmel RR29 -03542 Type 210 -1
Name of Business (d /b /a) State Tax I.D. number Permit expiration date
Brookshire Golf Course 0031201550 07/13/2009
Business Address (number and street, city, state, ZIP code) Business Telephone Area Number Base fee
12120 Brookshire Pkwy 317 846 7431
Carmel, IN 46033 Home Telephone Area I Number
Mailing address (number and street, city, state, ZIP code) Status NrActive Non operational Escrow Catering
Stephen C. Engelking 1, 1 (Attach escrow letter) 1.
City Hall, Mayor's Office, One Civic Square, Carmel, IN 46032
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
this permit? (If Yes, attach affidavit of changes and copies of amended floor plan on 8.5" x 11" paper if applicable) Yes NO
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 permittee have an interest in any distiller, vintner, farm winery, rectifier, brewer, primary source of supply, or
wholesaler permit?
Yes p No
4) Since your last renewal have you been convicted of any misdemeanor or felony? (If Yes, please attach letter with dates,
court, conviction, and sentence of conviction) Yes No
5) Do you have the right to possess (rent, mortgage, or own) the permit premise for the term of the permit? 0 Yes NO
6) Have all your sales taxes and property tax obligations for the past year and those due at this time been paid in full? Yes NO
7) Do you sell tobacco products? Yes 0 NO
STEP=2',-13U ,SINES$ "0,WNERSHIP
Check one: 0 Corporation Limited Liability Company rt� Panership 13 Limited Partnership d Club
Limited Liability Partnership Sole ownership 1 i ti Corporation
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: See Exhibit "A" Total shares authorized
CLUB Highest ranking officer.and the financial secretary or treasurer N/A
CORPORATION President, secretary, and all stockholders (list total shares authorized issued and individual shares held
and percent of shares issued) Total shares issued
LIMITED LIABILITY COMPANY -AII members and percent of interest held
LIMITED PARTNERSHIP I PARTNERSHIP I LIMITED LIABILITY PARTNERSHIP- All partners and percent of interest held N/A
SOLE OWNERSHIP Owner
s k rag w ag r* rx
�n, Yta ra 1 sc+rys KxT p FSHARESORc�r
,T1TL =E fi r NAMExANDHOMEADDRESS��tz� 'SOC SEC�NO BDOg� INTERE3THED
5-
i'.,x.:._arr' r`9's Fti.9.. Ia- C�a"'... x�..; t�..•..,``' 2�": xta�t :}IF,?APPLIC.ABLESa,a..t ;tY`
'5.�.�,,,w. A
Director of Admin. ee
S ahibil A: S1eDhm C. Engelkng .$$Ns 505 -Oi -1713 5221 WNW WNW Dr.., Indianepali; N/A N/A IN 90230 'SdQ�„ 7- 3.1941
xSSNi'
DO 8 j,
SS
17oa
aSSN'
rb08
'Social Security Numbers are required by federal child support law
Enclose an additional sheet if necessary
STEPjl ANNUAL.FOQP. "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) Date of ending report (month, day, year)
NIA: The premises has limited separation but it is not required for a golf course
Gross food sales (exclude all carryout and catering sales) Gross Alcoholic beverage sales Gross food and beverage sales
Is there a contract of any kind to sell the permit/business at this time? Yes Irk No
Have you conducted server training since your last renewal? Yes IZI No
As owner do you manage the premises? 0 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 No
0 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? 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 (ENCLOSE AN ADDITIONAL SHEET IF NECESSARY)
NAME EMPLOYEE PERMIT or OWNERSHIP TYPE EMERGENCY TELEPHONE NUMBER
Dave VanBruaene BR1570245 317- 650 -9276
OFAPPLICANT
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 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.
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 SignA ur 0 applican Da (month, day, year)
City of Carmel, by Stephen Engelking, DOA /d OUL
s kj, ..:STEP 6 ;�AFFIC?A1fIT OFT .;REPARER° IF APPLICABLE
1 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 complete.
Signature of p Telephone number Date (month, day, year)
L� (317 637 -1321 4110/09
.ST'ER ,7:jFEE
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) $750 INDIANA ALCOHOL TOBACCO COMMISSION
Three -way (beer, wine, liquor) $1,000 302 West Washington Street, Room E114
(Except Fraternal Clubs) $250 Indianapolis, Indiana 46204
Exhibit "A"
The City of Carmel is a municipality that does not issue stock and
does not have stockholders. Therefore, no one person has an
"interest" in the organization for purposes of this application.
However, the Director of Administration, Stephen C. Engelking, has
signed this renewal application on behalf of the City of Carmel and
answered various questions in Step 1 and Step 2 as they apply to
him.
PROPERTY TAX CLEARANCE SCHEDULE FORM NO 1 ATC permit number
(For a Person Business Corporation)� Corporation RR29 -03542
State Form 1462 (R5 10-01) Expiration date (Month, day, year)
tt x- i Approved by State Board of Accounts, 1992 07/1312009
INDIANA ALCOHOL AND TOBACCO COMMISSION
rm•
Individual's name or company name TYPE
City of Carmel Check all that apply
If transfer, give former business name
New
Mailing Address (Street and number of rurat route) 0 Renewal
Attn: Stephen C. Engelking, City Hall, Mayor's Office, One Civic Square Transfer (Check all that apply)
City State Zip Code Ownership
Carmel IN 46032 Location
Doing business as (DBA) Stock
Brookshire Golf Course
Permit location (Street address) STATUS
12120 BROOKSHIRE PKWY Permit escrow
City State Zip Code DBA change
Carmel n1� IN 46033
I, Treasurer of 4i1 tl C r e�►L County, hereby certify that the person or company named above ha
paid all property taxes in 20„ O (for 20 U> assessmertfJ and property taxes for all prior years, or is exempt from property tax b:
realon of
di4gbl�� btjIWAWLTON COUN Date (Month, day, ear) Q
PROPERTY TAX CLEARANCE SCHEDULE FORM NO 1 ATC permit number
(For a Person Business Corporation0municipal Corporation RR29 -03542
State Form 1462 (R5 10 -01) Expiration date (Month, day, year)
Approved by State Board of Accounts, 1992 07/13/2009
y f INDIANA ALCOHOL AND TOBACCO COMMISSION
rer
Individual's name or company name TYPE
City of Carmel (Check all that apply)
It transfer, give former business name
New
Mailing Address (Street and number of rural route) M Renewal
Attn: Stephen C. Engelking, City Hall, Mayor's Office, One Civic Square Transfer (Check all that apply)
City State Zip Code Ownership
Carmel IN 46032 Location
Doing business as (DBA) Stock
Brookshire Golf Course
Permit location (Street address) STATUS
12120 BROOKSHIRE PKWY
Permit escrow
city State Zip Code DBA change
Carmel IN 46033
I, Treasurer of A-(/L tttf* w County, hereby certify that the person or company named above he
paid all property taxes in 20 0 (for 20_jQ� assessment) and property taxes for all prior years, or is exempt from property tax b
V easoR of v
Sig U 14 Date (Month, day, year)
_4
005 -26)b
ms s. At APPLICATION FOR ALCOHOLIC BEVERAGE PERMIT ATC USE ONLY
SCHEDULE MQ Remlved
ManagefS Questionnaire EMored
State From 40767 (R 6 /10102)
INSTRUCTIONS: Every application must be filled In duplicate Processors tn(tlare
This form to be completed by the manager
PERMIT PREMISE NUMBER
(Please print) d 1� Z
1: GENERAL INFORMATION'
Nom e te
Norms of manag first, middle Initial) SoGOI Sew
nI E I m l
6A all ATC loyee permit number F�IDI� n det Age Sex Dafe I n Holght
W� R D� ,ZO( Male Female
Home address (num andstraet)
R) lvE
city, stela, zip
033
2: GENERAL QUESTIONS
Are you a citizen of the United States? Yea No
Are you at least twenty -one (21) years old? Yes No
Is it true that you are not an officer or employee of a person engaged In the alcoholic beverage traffic, which person is a non resident of
this state, or Is engaged In carrying on any phase of manufacture of, traffic In, or transportation of alcoholic beverages without a permit Yes No
when one is required?
Are you a State law enforcement officer, or a non elected officer of a municipal corporation or government subdivision charged with Yes No
any duty or function In the enforcement of Alcoholic Beverage laws?
Has your alcoholic beverage permit been revoked within one year prior to the date of this application for a permit? Yes No
Have you made an application for a permit of any type which has been denied less than one year prior to this application for a permit? Yes No
(Unless the application was denied by a reason of a procedural or technical defect.)
Are you now, and have you been for the last five years a continuous and bona fide resident of the State of Indiana? If no, does the Yes No
permit premise you are managing have a minimum annual gross food sales of at least $100,000?
Do you hold any other permit of any kind for the sale of alcoholic beverages In Indiana, or do you have any interest In any such permit, Cl Yes Z No
directly or Indirectly, through ownership of stock or otherwise? If yes, explain below:
Have you been convicted of a felony? If yes, attach places and dates of arrest, court of record, and conviction and attach relevant Yes K No
court record.
Have you been convicted of a vlolation of the Indiana Alcoholic Beverage Laws, rules, regulations, or orders of the Commission? If Yes No
yea, explain on a separate attachment-
SIGNATURES
Slgnatu r one er or age referred to In We schedule
Signature or owner vertflee that the manager listed above meets the above listed qualifications
Prescribed-by State Board of Accounts City Form No. 201 (Rev. 1995)
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
Indiana Alcohol Tobacco Commission Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
beverage permit $1,000.00
Golf Course
Total
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
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
J; 04/21/09 ALLOWED 20
.Indiana Alcohol Tobacco Commission
IN SUM OF
$1,000.
ON ACCOUNT OF APPROPRIATION FOR
GENERAL FUND
1205 Administration
Board Members
PO# or D PT. INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
ignat
JfA l
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund