Reset Form APPLICATION FOR NEW OR TRANSFER PERMIT FOR OFFICE USE ONLY State Form 51189 (R2 / 7-10) Approved by State Board of Accounts, 2011 Date received Permit number INSTRUCTIONS: . Type or print legibly. 1 2. 3. 4. 5. Permit type Submit in duplicate. Include payment. Do not complete shaded areas. Mail to the address at the end of this application form. If there is no opening for this applied permit or there is an omission, this application will be returned. Quota check Jurisdiction STEP 1. GENERAL INFORMATION This Permit Type will allow you to sell? his Permit Type is for? T Checked by Application type? Beer On-premise consumption (Retailer) Wine Off-premise consumption (Dealer) Transfer owner Liquor Other (Specify Below) Base fee receipt number New application Transfer location Transfer stock Please briefly describe your business that qualifies you for this permit type Permit number (Required for transfers) This ownership entity is: (Check one ) Balance due Sole Owner Limited Partnership Municipality Simple Partnership Limited Liability Partnership Club Association Corporation Limited Liability Company Business entity making this application Refund Club Corporation Business telephone number Catering receipt number Location where alcoholic beverages will be dispensed (number and street ) Premise telephone number Balance due City / Town State ZIP code Refund Indiana retail merchant's certificate number Home telephone number (including area code ) Email address Doing business as (DBA) General Questions Part 1 1. The proposed premise is located in what county? _________________________ 2. Is the proposed permit premise located inside the corporate limits of a city / town? 3. If yes, please name the incorporated city / town. Yes No Date reviewed _________________________ Local Board hearing date 4. If no, please name the unincorporated community which has been known by that name for more than ten years. (This is only required for a beer or a beer and wine application.) _______________________ 5. Is there at least 200 feet between this premise and any church or school? Yes No If no mail receptacle at this location or you wish to have your correspondence sent to another address: Commission approved Name Address Permit issued City, State, Zip General Questions Part 2 Expiration date 1. Do you understand that you must apply for a Federal ID number? Yes No Yes No Permit released 2. Do you understand that you must apply for a Federal Stamp from the Bureau of Alcohol, Tobacco, and Firearms (BATF)? Remarks 3. Does the permittee have an interest in any distiller, vintner, farm winery, rectifier, brewer, primary source of supply, or wholesaler permit? 4. As owner do you manage the premise? Yes No Yes No Yes No Yes No Yes No If no, please complete the Manager's Questionnaire and attach it to this application. 5. Do you sell tobacco products? 6. Do you know that an Excise Officer may enter, inspect, and search your permit premise without a warrant or other process to determine if you are complying with the provisions of the Indiana alcoholic beverage laws / rules? 7. Do you have the right to possess (rent, lease, mortgage, or own) the permit premise for the term of the permit? American LegalNet, Inc. www.FormsWorkFlow.com STEP 2. ANNUAL FOOD SALES **FOR EXISTING BUSINESSES ONLY** 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) Gross food sales (excluding all carryout and catering sale s) Date of ending report (month, day, year) Gross alcoholic beverage sales Total gross food and beverage sales STEP 3. QUALIFICATIONS SOLE OWNER / PARTNERSHIP PERMIT: If applying as a sole owner or partnership for any type of permit, answer the following questions: Yes No Are you now and have you been a continuous and bona fide resident of this state for five (5) years? CORPORATION PERMIT: (PLEASE ATTACH COPY OF "CERTIFICATE OF EXISTENCE" FROM THE INDIANA SECRETARY OF STATE) If applying as a corporation for any type permit, answer the following questions: Yes No Is at least 60% of the outstanding common stock owned by persons who have been continuous and bona fide residents of this State for five (5) years? (For exceptions, see IC 7.1-3-21-6.) Yes No If you are a corporate wholesaler, is at least one (1) of the stockholders a resident of the county in which the licensed premise is situated for at least one (1) year immediately prior to making application for the permit? Yes No Is the applicant a retailer corporation with 41% or more of the common stock held by out of state stockholders? (If the answer is yes, you must agree to and initial below.) _______I hereby affirm that the annual gross food sales at the permit location currently exceed One Hundred Thousand Dollars ($100,000) or in the case of a new applicant are expected to exceed Two Hundred Thousand Dollars ($200,000) by the end of the two year period commencing on the date of issuance of the permit will, thereafter, exceed One Hundred Thousand Dollars ($100,000) per annum. LLC / LLP PERMIT: (PLEASE ATTACH COPY OF "CERTIFICATE OF EXISTENCE" FROM THE INDIANA SECRETARY OF STATE) If applying as a limited partnership, limited liability company, or limited liability partnership for any type permit, answer the following questions: Yes No Is at least 60% of the ownership interest held by persons who have been continuous and bona fide residents of this State for five (5) years? (For exceptions, see IC 7.1-3-21-6.) If a limited partnership, limited liability company, or limited liability partnership wholesaler, at least one (1) of the stockholders must have been a resident of the county in which the licensed premise is situated for at least one (1) year immediately prior to making application for the permit. Yes No Is the applicant a retailer limited partnership, limited liability company or limited liability partnership applying with 41% or more of the ownership interest held by out of state residents? (If the answer is yes, you must agree to and initial the statement below.) _______I hereby affirm that the annual gross food sales at the permit location currently exceed One Hundred Thousand Dollars ($100,000) or in the case the case must have of a new applicant are expected to exceed Two Hundred Thousand Dollars ($200,000) by the end of the two (2) year period commencing on the date of issuance of the permit will, thereafter, exceed One Hundred Thousand Dollars ($100,000) per annum. THE FOLLOWING QUESTIONS PERTAIN TO ALL INDIVIDUALS HAVING AN INTEREST IN THIS APPLICATION. Yes No Have any individuals with an interest in this permit been convicted of a felony or a misdemeanor? (If yes, please attach letter with dates, court, conviction, and sentence of new conviction.) Yes No Have any individuals with an interest in this application ever been convicted of a violation of the Indiana Alcoholic Beverage laws, rules, regulations, or orders of the Commission? Yes No Are all individuals with an interest in this application citizens of the United States? Yes No Are all individuals with an interest in this application of sound mind, good moral character, and good repute in the community in which they reside? Yes No Are any individuals with an interest in this application a law enforcement officer, or an officer of a municipal corporation, or government subdivision, or of this state charged with any duty or function in the enforcement of this title? Yes No Have any individuals with an interest in this application held a permit under this title and has the permit been revoked within one year prior to the date of this application? Yes No Have any individuals with an interest in this application made an application for a permit of any type which has been denied less than one year prior to this application for a permit? (unless the application was denied by reason of a procedural or technical defect ) Yes No Do any individuals with an interest in this application hold any other permit of any kind connected with the sale of alcoholic beverages, or do they have any interest in any such permit directly or indirectly, through ownership of stock or otherwise? If yes, list permit numbers below: Permit numbers Yes No Are you indebted to a person or an officer or agent of that person, who holds a brewer's permit or wholesale permit, for a debt, secured by a lien, mortgage, or otherwise upon the premises for which the beer retailers permit is to be applicable or upon any of the property or fixtures in the premises, or used, or to be used in connection with the premises? American LegalNet, Inc. www.FormsWorkFlow.com STEP 4. AFFIDAVIT OF OWNERSHIP Complete Name Social Security Number Date of Birth (month, day, year) Citizen of US Yes No Address (number and street, city, state, and ZIP code) Nature of interest Percent of ownership Sole Owner Corporate President Stockholder Partner Corporate Secretary Club Officer Complete Name Social Security Number Date of Birth (month, day, year) Citizen of US Yes No Address (number and street, city, state, and ZIP code) Nature of interest Percent of ownership Sole Owner Corporate President Stockholder Partner Corporate Secretary Club Officer Complete Name Social Security Number Date of Birth (month, day, year) Citizen of US Yes No Address (number and street, city, state, and ZIP code) Nature of interest Percent of ownership Sole Owner Corporate President Stockholder Partner Corporate Secretary Club Officer Complete Name Social Security Number Date of Birth (month, day, year) Citizen of US Yes No Address (number and street, city, state, and ZIP code) Nature of interest Percent of ownership Sole Owner Corporate President Stockholder Partner Corporate Secretary Club Officer If you need more space, please attach additional sheets. STEP 5. PERMIT TYPE SPECIFIC QUESTIONS You must meet specific requirements to hold certain types of permits. Please answer only the following questions that are applicable to your permit application. LIQUOR RETAILER Yes No Is the proposed permit premise located in an incorporated city having a population of less than 5,000? Yes No If the answer is yes, have you attached to the application the enabling ordinance from the city consenting to the issuance of liquor retailer's permits? CATERING HALL Yes No Are you applying for a special three-way catering hall permit that will allow you to sell alcoholic beverages for on-premise consumption only on a premise that is used only for private catered events and has accommodations for at least 250 individuals? CLUBS Social Club Fraternal Club If you are applying for a club permit, please check the appropriate box. Yes No If a social club, does your association or organization meet the general requirements of IC 7.1-3-20-1? Yes No If your club permit premise is outside the corporate limits, do you meet the requirements of IC 7.1-3-20-3? No If you are applying as a hotel, do you meet the general requirements of IC 7.1-3-20-18? HOTEL Yes HISTORIC DISTRICT If you are applying for historic district permit, is the restaurant located in a facility that is on the National Register of Historic Places Yes No or is it located within the boundaries of a historic district established by ordinance? If yes, you must submit the appropriate verification. AIRPORT, REDEVELOPMENT, RIVERFRONT, RAILWAY STATION, CULTURAL CENTER Yes No If you are applying for a permit authorized by IC 7.1-3-20-16, do you meet the requirements for the designated permit? Specify the type of permit you are applying for: ______________________________________. NOTE: If you are applying for a municipal riverfront development permit, you must also submit a letter indicating that the statutory requirements have been met and the mayor's approval of the permit. American LegalNet, Inc. www.FormsWorkFlow.com STEP 5. PERMIT TYPE SPECIFIC QUESTIONS CONTINUED DRUG STORE Yes No If you are the proprietor of a drug store, do you hold a valid permit issued by the State Board of Pharmacy? NOTE: You must designate on your floor plan the pharmacy area that has been submitted and approved by the State Board of Pharmacy. Pharmacy Permit Number Issuance Date Expiration Date RIVERBOAT Yes No Are you applying for a riverboat / excursion permit and do you currently hold a valid riverboat owner's license issued by the Indiana Gaming Commission? Riverboat Owner's License Number Yes No Issuance Date Expiration Date Are you applying for an adjacent landsite permit? HORSE TRACK Yes No Are you applying for a horse track permit and do you currently hold a valid recognized meeting permit issued by the Indiana Gaming Commission? Recognized Meeting Permit Number Yes No Issuance Date Expiration Date Are you applying for a satellite permit? Satellite Facility License Issuance Date Expiration Date BOAT (SEASONAL) Yes No If you are applying for a boat permit, do you engage in regular passenger service which makes regular runs in seasonal weather between established locations? BEER WHOLESALER Yes No Do you have available for investment capital and cash or property necessary and useful in your business, exclusively as a beer wholesaler, of at least $15,000 (exclusive of motor vehicles), and do you agree that you will, if the application is granted, actually make the investment and submit proof to the Commission before you engage in business as a beer wholesaler? Yes No I certify that the projected number of barrels of beer to be manufactured during the permit year will not exceed 20,000 barrels. (A barrel equals 31 gallons.) (Small Brewer) Yes No I certify that the projected number of barrels of beer to be manufactured during the permit year will exceed 20,000 barrels. (A barrel equals 31 gallons.) (Brewer) BREWER WINERY Check if you qualify and are applying for one of the following permits: Vintner (IC 7.1-3-12-1) Farm Winery (IC 7.1-3-12-3) Farm Winery Brandy Distiller (IC 7.1-3-7.5-2) BOND REQUIREMENTS The following applicants are required to file with this application the appropriate non-revocable surety bond, made payable to the State of Indiana. Check the appropriate bond amount if applicable: Brewer ($10,000) Distiller ($10,000) Liquor Wholesaler ($10,000) Rectifier ($15,000) Vintner (excludes farm winery) ($1,000) American LegalNet, Inc. www.FormsWorkFlow.com STEP 6. MANAGER'S QUESTIONAIRE Name of Manager (last, first, middle initial) ATC Employee permit number Social Security Number Expiration Date Age Sex Date of Birth Male Height Weight Female Home Address (number and street) City, state, zip Are you a citizen of the United States? Yes 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-reside nt e of this state, or is engaged in carrying on any phase of manufacture of, traffic in , or transportation of alcoholic beverages without a permit when one is required? Yes No Are you a State law enforcement officer, or a non-elected officer of a municipal corporation or government subdivision charged with any duty or funcion in the enforcement of Alcoholic Beverage Laws? Yes No Has your alcoholic beverage permit been revoked within one year prior to the date of this application for a permit? Yes No (Unless the application was denied by a reason of a procedural or technical defect.) Yes No 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 permit premise you are managing have a minimum annual gross food sales of at least $100,000? Yes No Do you hold a permit of any kind for the sale of alcoholic beverages in Indiana, or do you have any interest in any such permit, directly or indirectly, through ownership of stock or otherwise? If yes, explain below: Yes No Have you been convicted of a felony? If yes, attach places and dates of arrest, court of record, and conviction and attach relevant court record. Yes No Have you been convicted of a violation or the Indiana Alcoholic Beverage Laws, rules, regulations, or orders of the Commission? If yes, explain on a separate attachment. 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? Signatures of manager or agent(s) referred to in this schedule STEP 7. FLOOR PLAN INSTRUCTIONS: Yes No Applicant must submit four (4) drawings on letter size paper (8 1/2" x 11"). These drawings must show dimensions and identifications of any existing family room(s), seating arrangement(s), ballroom(s), service bar(s), dance floor area(s), kitchen area(s), restrooms, storage and office areas, exits, and alcoholic beverage display areas for all types of permits. Please sign and date each drawing. If a restaurant or a restaurant located in a hotel or motel, will anyone under the age of 21 be guests to the permit premise? If the answer to the above question is "yes," it should be understood that there must be COMPLETE SEPARATION of the barroom from the room or rooms where individuals under the age of 21 will be present. Yes No Are you requesting approval for limited separation? NOTE: ALL DRAWINGS MUST BE APPROVED BY THE COMMISSION BEFORE THE PERMIT IS ISSUED. WE RECOMMEND YOU RECEIVE APPROVAL BEFORE CONSTRUCTION BEGINS. CONTACT YOUR LOCAL EXCISE DISTRICT OFFICE. (Please attach all drawings to this application) American LegalNet, Inc. www.FormsWorkFlow.com STEP 8. AFFIRMATION OF APPLICANT Name of applicant (individual, corporation, partnership, LLC, LLP) I certify that this application was completed by myself or by the preparer identified herein. I certify that all information provided herein and on any attachments are true and correct. I UNDERSTAND THAT IT IS A FELONY 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 and title of applicant Signature Date (month, day, year) NOTE: The applicant MUST sign this application unless the proper Power of Attorney forms are attached to this application. STEP 9. SIGNATURE OF PREPARER (IF APPLICABLE) I certify that I have examined this application and the accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete. Signature of preparer Telephone number (including area code) Date (month, day, year) STEP 10. FEES Please remit business, certified checks, or money order - application will not be processed without payment One-way (beer only) = MAIL TO: $500 Two-way (beer & wine only) = $750 INDIANA ALCOHOL & TOBACCO COMMISSION Three-way (beer, wine, & liquor) = $1,000 302 W. Washington Street, Room E114 $250 Indianapolis, IN 46204 Except Fraternal Clubs = Catering = $150 Transfer of Permit= $250 Each transfer type (317) 232-2430 http:www.state.in.us/atc American LegalNet, Inc. www.FormsWorkFlow.com