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Home My WebLink About210202 06/26/2012 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1 ONE CIVIC SQUARE INDIANA ALCOHOL TOBACCO COMM CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK AMOUNT: $1,000.00 INDIANAPOLIS IN 46204 CHECK NUMBER: 210202 CHECK DATE: 6126/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4358300 RENEWAL 1,000.00 OTHER FEES LICENSES APPLICATION FOR RENEWAL OF ALCOHOLIC BEVERAGE PERMIT State Form 47 (111417-10) FOR OFFICE USE ONLY g. g Approved by State Board of Accounts, 2011 rere'`' 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 dale �sSTEP _1GENEI2ALNINFORMAfI,ONt��_ Name of applicant as printed on existing permit Permit Number Permit Type Release date City of Carmel RR2903542 210 -1 Name of Business (d/b /a) State Tax I.D. number Permit expiration date Brookshire Golf Club 0031201550 1 7/13/2012 Business Address (number and street, cht 6 state, and ZIP code) Business Telephone Number (include area code) Base tee 12120 Brookshire Pkwy. 317 846 7431 Carmel, IN 46033 Home Telephone Number (include area code) Mailing address (number and street cit)4 state, and ZIP code) Status 0 Active Non operational Escrow Catering 12120 Brookshire Pkwy. (Attach escrow letter) Carmel, IN 46033 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 0 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 permittee have an interest in any distiller, vintner, farm winery, rectifier, brewer, primary source of supply, or Yes 0 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 0 NO court, conviction, and sentence of conviction) 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? 0 Yes No 7) Do you sell tobacco products? Yes 0 No x M r s<, z r rs t`" rim 0 STEP 2 Bl1S1NE$S "QWNERSHIP�iF.ffAE Check one: Corporation Limited Liability Company Partnership Limited Partnership 0 Club Limited Liability Partnership Sale 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 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) Total shares issued LIMITED LIABILITY COMPANY All members and percent of interest held LIMITED PARTNERSHIP PARTNERSHIP LIMITED LIABILITY PARTNERSHIP- All partners and percent of interest held SOLE OWNERSHIP Owner aDE 3rd 'RE r t r- rF 'mac* ':ere: 4 s NAME AND HOMEADDRESS"'S DpB s INTEREST HELD /a' OC SEC NO 1 tt IFAP.PLABLE Robert Mgglna t? ASSN$ 309-9 &7324 O Manager S f b t Z; DOS; ?Mal `SSN �QOB� zSSN YQQB. !SSN 0.0 W, 'Social Security Numbers are required by federal child support law it Enclose an additional sheet if necessary stir., w� r STEP3ANNUALFQODI$AL S.,i� WO, 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 ro=separation; All grocery store permits. Date of beginning report (month, day, year) Date of ending report (month, day, year) Gross sales (exclude all gasoline and auto oil products) Gross Alcoholic beverage sales Gross food and beverage sales I S;TiEP. 4 ?IQPERATIQN�{NFwORMA ?{QN r u m Is there a contract of any kind to sell the permit/business at this time? Yes 0 No Have you conducted server training since your renewal? m Yes No As owner do you manage the premises? m Yes No If No, do you monitor the premises? Yes No I Are you a grocery store or pharmacy? 11 Yes If business is a grocery store, are 25% or less of the gross sales in alcoholic beverages? C7 Yes No m 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 I 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, 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, in any state, or a federal crime with a sentence of at least one (1) year. A Do you understand the requirements and attest that the managers listed below meet these qualifications? �tJ initial) The Alcohol and Tobacco Commission requires managers as follows: i 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 someonel 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. :1 LIST THE MANAGERS FOR THIS PREMISE ENCLOSE AN ADDITIONAL SHEET IF NECESSARY) NAME EMPLOYEE PERMIT or OWNERSHIP TYPE EMERGENCY TELEPHONE NUMBER Robert Higgins BR1606858 317 501 -2146 i ,�M STEP,,S' z AFFIDAYIi )',MA MUICANT� I certify that there have been no changes regarding my previous application except those noted herein. 1 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 i 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 y Printed name of applicant I gnat of ap 'cant Date (month, day, year) Robert Higgins 6/2 6/2012 STEP 6 AF .1 AVIT QF�PR ,ARER IF APPLICABLE b h 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 t rrect, and complete nature f preparer Telephone number Date (month, day, year) 317 846 7422 6/2612012 �,:;S,TEI?,7 �F�EE�.�, .ter,, Please remit business, certified checks, or money order- application will not be processed without payment Submit in duplicate and l 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 El 14 (Except Fraternal Clubs) $250 Indianapolis, Indiana 46204 PROPERTY TAX CLEARANCE SCHEDULE FORM NO. 1 ATC permit number a (For a Person Business Corporation) RR2903542 z State Form 1462 (R6 7 -10) Expiration date (month, day, year) A Approved by State Board of Accounts, 2011 7/13/2012 INDIANA ALCOHOL AND TOBACCO COMMISSION Name of individual' or company TYPE City of Carmel (Check all that apply) If transfer, give former name of business New Mailing Address (street and number of rural route) 0 Renewal One Civic Square Transfer (Check all that apply) City State ZIP Code Ownership Carmel IN 46032 Location Doing business as (DBA) Stock Brookshire Golf Club Permit location (street address) STA p 12120 Brookshire Pkwy. P I tl OO U I tl U R E R City State ZIP Code 112 Carmel IN 46033 I, Treasurer of Hamilton County, hereby certify that the person or company named above has Von l property taxes in 20 12 property P Y Pt property y N O B LESVI LLE I 460 p p ope y (for 20 11 assessment and ro taxes for all rior ears, or is exem from ro tax b 1 e )of� a Signatur4ffCobrity �TreasureF`"ti ivl i L I UIN UU "N F y Date (month, day, year) PROPERTY TAX CLEARANCE SCHEDULE FORM NO. 1 ATC permit number (For a Person Business Corporation) RR2903542 State Form 1462 (R6 7 -10) Expiration date (month, day, year) A Approved by State Board of Accounts, 2011 7/13/2012 INDIANA ALCOHOL AND TOBACCO COMMISSION re�eF Name of Individual or company TYPE City of Carmel (Check all that apply) If transfer, give former name of business New Mailing Address (street and numberof rural route) El Renewal One Civic Square Transfer (Check all that apply) State ZIP Code y Ownership Carmel IN 46032 Location Doing business as (DBA) Stock Brookshire Golf Club Permit location (street address) STATUS 12120 Brookshire Pkwy. Permit escrow City state ZIP Code DBA change Carmel IN 46033 I, Treasurer of Hamtitnn County, hereby certify that the person or company named above has paid all property taxes in 20 12 (for 20 i f assessment) and property taxes for all prior years, or is exempt from property tax by re4i7h of A Signal uT fEiTUy'RTRr�t �Ah S �T0N 001 -01AI Date (month, day, year) /7 /3 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 I I 43- 553.00 I $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 Tuesday, June 26, 2012 Director, Brooks'hWeyGolf Club Title Cost distribution ledger classification if claim paid motor vehicle highway fund 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 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 06/26/12 Renewal Liquor Permit $1,000.00 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