224264 09/23/2013 CITY OF CARMEL, INDIANA VENDOR: 355486 Page 1 of 1
ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMM CHECK AMOUNT: $50.00
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM El 14
INDIANAPOLIS IN 46204
CHECK NUMBER: 224264
CHECK DATE: 9/23/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1096 4239039 APP 50 . 00 GENERAL PROGRAM SUPPL
Carmel ® Clay
Parks&Recreation CHECK REQUEST
Date: Tuesday, September 17, 2013
Check payable to:
Name: Indiana Alcohol &Tobacco Commission
Address: Indiana Government Center South, Room E-114; 302 W. Washington Street
City, State, Zip Indianapolis,.IN 46204
Mail check to payee X Return check to requestor
Check Amount: $ 50.00 Date Required: September 30, 2012
Check needed for: Temporary BeerNVine Permit for Fall Food Festival &Benefit
To be paid from:
PO#(if applicable) Requisition#: MC004609
Budget account-GL# 1096.60.4239039
Budget Line Description General Program Supplies
Invoice(s) MUST be attached.
Requested by(print):Traci Broman
Requested by(signature):
Approved by(signature of Division Manager
on this date I I I 11s
Form revised 7-7-08 Shared/Forms/Business Services/Check Request Form/Check Request(rev 7-7-08)
sw�� APPLICATION FOR TEMPORARY BEER/WINE PERMIT K iA7 1 Y `
i� Y State Form 35494(R61 10-06) Type of permit
.»,,, + Approved by State Board of Accounts 1996 118
0`•1 I
Amount received
INSTRUCTIONS: 1.You must attach floor plan
2.You must obtain authority from local officials. Permit number
TM
Return permit to
Carmel Clay Parks & Recreation
Address(number and street)
1141 E. 116th Street
City,ZIP code
Carmel,46032
Telephone number
317.843.3875
Name of applicant(organization,club,corporation,individual
Carmel Clay Parks & Recreation
Name of person making application
Traci Broman
Address of applicant(number and street,city,state,ZIP code)
1235 Central Park Drive East, Carmel, IN 46032
County of event Telephone number of person making application
Hamilton 317.573.5243
Date(s)(month,day,year)
From: October 12, 2013 To and including: October 12, 2013
Hours of event - -
From: 5.00 ❑AM ❑✓ PM To:8:00 ❑AM ✓❑PM
Exact address of event(number and street,city, state,ZIP code) Jurisdiction(town,city,county name)
1235 Central Park Drive East, Carmel, IN 46032 Carmel
„� � STEP EY,EIV�'INF
.ter"
1.State the name of person in charge Q'n case of emergency) Telephone number 1 Telephone number 2
Traci Broman 1317.473.7652 1317.502.6330
2.Is the event open to the public?
21 Yes ❑No
3.Has the applicant or any partner or any officer ever been convicted of a felony,misdemeanor,or a violation of the ATC laws?
❑Yes El No
If yes,explain:
4.How many persons can you expect in daily attendance?
250-300 Security provided ❑ Yes 21 No If yes,name of security
5.Name of event:
Fall Food Festival& Benefit Q Not-for-profit ❑For profit
6.Is the applicant,partnership,or corporation the holder of any kind of Indiana alcoholic beverage permit?
If Yes,state:
❑Yes ❑No
a.type of permit b.permit number
C.name on permit
S- .,+' '-_
-MR In order to quality for a temporary permit,the following guidelines must be met:
1.There must be a well defined premises,i.e.building,tent,enclosure,or fenced-in or designated area.
2.You must submit a floor flan or diagram(8 112 x 11)showing either a beer garden/bar room(for adults only)or beer garden/bar room and family area
(for families to consume food). All alcoholic beverages must be dispensed from the beer garden/bar room. Minors will be allowed in the family area
with a parent or guardian to consume food.
3.There shall be NO carry-out privileges,NO carry-in privileges,and NO spirituous beverages allowed.
4.Each applicant must designate an individual to be responsible for the event and such person must sign the application.
5.ANY and ALL persons dispensing or selling,or accepting payment for alcoholic beverages MUST POSSESS a valid ATC employee permit.
6.The event must meet applicable Board of Health requirements,particularly with regard to restroom facilities.
7.Legal hours of dispensing alcoholic beverages(Prevailing time)
Monday through Saturday--7a.m.to 3 a.m.the following day
Sunday--10:00 a.m.to 12:30 a.m.the following day
8.Applicant must file with the ATC at least 15 days prior to the event. Failure to comply is grounds for denial.
9.The temporary permit must be posted in the most conspicuous place at the location of the event. An excise officer or commissioner,for good cause,
has the authority to revoke a temporary permit during the event.
The applicant,swears or affirms under penalties of perjury that the information in this application is true and accurate. The applicant also acknowledges
the following:
Initial
It is a crime to drive with a blood-alcohol content of.08.
It is a class B Misdemeanor,punishable by up to 6 months in jail and a$1,000 fine for knowingly serving an intoxicated person.
That an excise officer may enter,inspect,and search your premises without a warrant and you must produce your permit on demand.
That an excise officer may,for good cause,revoke a temporary permit during the event.
Signature Date(month,day,year)
IMPA
1d j 13
_ ` �F ,�aSTEP5C0 MU IN N CLEARAICWE ' 3 � �' �s
SIGNATURES MUST BE RECEIVED IN ORDER LISTED
Before the Commission will consider the issuance of such temporary alcoholic beverage permit,the following signatures of the law enforcement
officials of the community shall be obtained:
We,the undersigned,hereby do not object to the issuance of a temporary alcoholic beverage permit to:
1.Signature of Sheriff of county,Chief of Police,or Town Marshall of jurisdiction where event will be held Date signed
2.Signature of the mayor(if the event is held in Ft.Wayne) Date signed
3.Signature of Excise Police representative Dale signed
on
1. ALL EVENTS ARE$50.00 PER DAY.
The fee must be paid by business check,money order,certified check or
2. SERVING PAST MIDNIGHT,NO LATER THAN 3 A.M.,IS ONE DAY. cashiers check. Cash will only be accepted if the application is hand-
3. NO RAIN CHECKS ON ANY OF THE ABOVE EVENTS. delivered to the ATC in Indianapolis.
RETURN COMPLETED APPLICATION AND PROPER FEE TO THE LOCAL EXCISE OFFICE AT LEAST 15 DAYS PRIOR TO EVENT
INFORMATION ON HOW TO CONTACT YOUR LOCAL EXCISE OFFICE CAN BE FOUND AT http://www.in.gov/isep
Page 2
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
355486 Indiana Alcohol &Tobacco Commission Terms
IN Government Center South, Room E114
302 W. Washington Street
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s)) PO # Amount
9/17/13 Application Temporary Alcohol permit for Fall Food Festival $ 50.00
Total $ 50.00
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
Voucher No. Warrant No.
355486 Indiana Alcohol &Tobacco Commission Allowed 20
IN Government Center South, Room E114
302 W. Washington Street
Indianapolis, IN 46204 In Sum of$
$ 50.00
I
ON ACCOUNT OF APPROPRIATION FOR
109 - Monon Center
PO#or INVOICE NO. ACCT#/TITL AMOUNT Board Members
Dept#
1096-60 Application 4239039 $ 50.00 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
19-Sep 2013
Signature
$ 50.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund