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219587 04/30/2013 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1 0 `:) 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: 219587 CHECK DATE: 4130/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4355300 1, 000 . 00 LIQUOR LICENSE RENEWA "�r• APPLICATION FOR RENEWAL OF ALCOHOLIC BEVERAGE PERMIT - State Form 47(R14/7-10) Approved b State Board of Accounts,2011 FOR OFFICE USE ONLY PP Y 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 WASSWERM ME &IMMOMMUSQ,001 MGE RAI-N. F...O R MdTIQN 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 Brppkshire Golf Club 0031201550 7-13-2013 Business Address(numberand street,city,state,and ZIP code) Business Telephone Number(include area code) Base fee 12120 Brookshire Pkwy. ( 317 ) 846 - 7431 Carmel, IN 46033 Home Telephone Number(include area code) ( ) Mailing address(number and street,city,state,and ZIP code) Status ❑Active ❑ Non-operational/Escrow Catering (Attach escrow letter) 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 © 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 ED 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 © 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? El 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? IZI Yes ❑ NO 7)Do you sell tobacco products? ❑ Yes ❑ NO ' � v� �STEP2" ;BUSINESS;01111NERSHIRAW-0012 ��'' � ��« � eig; �:'n3ft2f, J ;Jk •n..._a Lfi,.. p"r""... Check one: ❑ Corporation ❑Limited Liability Company ❑Partnership ❑Limited Partnership 0 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 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 I PARTNERSHIP I LIMITED LIABILITY PARTNERSHIP-All partners and percent of interest held SOLE OWNERSHIP-Owner r* y S RE&O , ..NX. .. -..s, 5'�'j.,� y� '�?�� fi��s�?:�"r- ,�P ��` 'd�+i��11'�9 �.w. 7(TLE> a` rN.AM ANDS }" p x HOME ADQRESS ratiSfOG:.SEC:NO:;&aDOB INTEREST HELD /o z'� c» u ti Nu µ IAP.pLICABLEf Robert Higgins S$.IV �Q�� S.SIV �D6.666� SSN DOB$ SS�N� DOB! *Social Security Numbers are required by federal child support law Enclose an additional sheet if necessary EVSTEPa3VAANNtJALFOODSALES% v• ' �° s�y� ( �i4 �:h :.!0. .vd vYn�L....n`ti�,,.�.j.$`+....+.�..—i... ". 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/family room 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 655ffrg STEP??OPERATtION,INFQRMATIO,N` 1 ;;Mr _. MM r. Is there a contract of any kind to sell the permit/business at this time? ❑Yes 2 No Have you conducted server training since your last renewal? ❑Yes m No As owner do you manage the premises? m 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 17 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 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. 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 Robert Higgins BR1606858 317-501-2146 11 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 Sign of applicant Date(month,day,year) Robert Higgins 4/30/2013 STEP 6 fAFFIDAUIT PREPARER IFaAPPLIGABL'E°�o� cI-1 16 -... --- ,V,I,.4.`��.:-�-"'---_a - --. ... .TR< fie, .,.. _. _ .�`- ?.':i 'Y4' 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 tr ,ce ect,and com e. IS(i at o reparer 7Telephon,number Date(month,day,year) ) 846-7431 4/30/2013 9,*,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)_ $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 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 2013 Renewal 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, April 30, 2013 / Director, Bro shire 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 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)) 04/30/13 2013 Renewal Permit Renewal $1,000.00 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