Free Renewal.PDF - Indiana

APPLICATION FOR RENEWAL OF ALCOHOLIC BEVERAGE PERMIT
State Form 47 (R12 / 7-05) Approved by State Board of Accounts, 2005 FOR OFFICE USE ONLY Examined by / date

INSTRUCTIONS:

1. Type or print legibly. 2. Submit in duplicate. Include payment 3. Application must be received by our office 77 days (11 weeks) before permit expires. 4. Do not complete shaded areas.

Hearing date Issue date New expiration date

STEP 1. GENERAL INFORMATION
Name of applicant as printed on existing permit Name of Business (d/b/a) Business Address (number and street, city, state, ZIP code ) Permit Number State Tax I.D. number Business Telephone Area / Number Permit Type Permit expiration date Base fee Release date

( (
Mailing address (number and street, city, state, ZIP code ) Status

) )
o Active

o Non-operational / Escrow (Attach escrow letter )
Catering

Home Telephone Area / Number

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) 2) Do you consent for the duration of the permit to inspection and search by an enforcement officer, without a warrant or other 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? 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) 5) Do you have the right to possess (rent, mortgage, or own) the permit premise for the term of the permit?

o Yes o Yes o Yes o Yes o Yes o Yes o Yes

o No o No o No o No o No o No o 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?

7) Do you sell tobacco products?

STEP 2. BUSINESS OWNERSHIP
Check one:

o Corporation

o Limited Liability Company o Sole ownership

o Partnership

o Limited Partnership

o Club

o Limited Liability Partnership

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:
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 ) 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

Total shares authorized

Total shares issued

TITLE

NAME AND HOME ADDRESS

*SOC. SEC. NO. & DOB SSN DOB SSN DOB SSN DOB SSN DOB

SHARES OR INTEREST HELD IF APPLICABLE

%

*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 / family room separation. Date of beginning report (month, day, year) Date of ending report (month, day, year)

Gross food sales (exclude all carryout and catering sales)

Gross Alcoholic beverage sales

Gross food and beverage sales

STEP 4. OPERATION INFORMATION
Is there a contract of any kind to sell the permit/business at this time? Have you conducted server training since your last renewal? As owner do you manage the premises? Are you a grocery store or pharmacy?

o Yes o Yes

o No o No o No

o Yes

o No

If No, do you monitor the premises?

o Yes

o o

Yes No

(If yes, then you do NOT need to complete the rest of this section) (If no, then you MUST complete the rest of this section)

The Alcohol and Tobacco Commission requires the following of all managers:
n n n n n

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:
n n n

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

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 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 Signature of applicant Date (month, day, year )

STEP 6. AFFIDAVIT OF PREPARER (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, correct, and complete.
Signature of preparer Telephone number Date (month, day, year )

(

)
STEP 7. FEE Submit in duplicate and MAIL TO:
INDIANA ALCOHOL & TOBACCO COMMISSION 302 West Washington Street, Room E114 Indianapolis, Indiana 46204

Please remit business, certified checks, or money order - application will not be processed without payment

One-way (beer only) = Two-way (beer & wine only) = Three-way (beer, wine, & liquor) = (Except Fraternal Clubs) =

$500 $750 $1,000 $250