Catering Authority Type 222 {50184}

CATERING AUTHORITY / TYPE 222 State Form 50184 (R / 11-15) Send, deliver, mail or fax to: District #1 52422 County Road 17 Bristol, IN 46507 Fax: (574) 264-9348 1353 South Governors Drive Columbia City, IN 46725 Fax: (260) 244-3830 279 W. 300 N. Crawfordsville, IN 47933 Fax (765) 362-8817 District #4 651 S. Commerce Dr. Seymour, IN 47274 Fax: (812) 522-5681 3650 S. US 41 Vincennes, IN 47591 Fax: (812) 882-1386 6400 E. 30th St. Indianapolis, IN 46219 Fax: (317) 541-4104 STATE EXCISE POLICE INSTRUCTIONS: 1. Applicant must complete all requested information. 2. Please type or print clearly. 3. Submit application to the local excise district office. District #2 District #5 District #3 District #6 STEP 1. PERMITTEE INFORMATION Name of permittee (As it appears on your Indiana Alcoholic Beverage Permit) Address (number and street, city, state, and ZIP code) Printed name of contact person for permit Printed name of contact person of event Fax number Doing Business As (DBA) Permit number Expiration date (month, day, year) Emergency contact telephone number ( Employee permit number ) ( ( ) ) Emergency contact telephone number STEP 2. EVENT INFORMATION (A SEPARATE REQUEST MUST BE SUBMITTED FOR EACH EVENT.) Beginning Day Date AM PM End Times of catered function: Start Type or description of event Ending Day Date AM PM Start To include Sunday AM PM Does not include Sunday AM PM Sunday event times (if applicable) End Exact address of event (number and street, city, state, and ZIP code) STEP 3. FLOOR PLAN (SEE STEP 4, #2.) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com STEP 4. ACKNOWLEDGEMENT The following are guidelines for the approval of an event catered by a supplemental caterers permit: 1. The exact address of the proposed catered event must be disclosed upon the application form. 2. A floor plan of the designated licensed premises must be submitted along with the application form. There must be a well-defined premises, i.e., a building, a tent, an enclousre, a fenced in area, or a roped off area.The exact area from which the alcoholic beverages shall be dispensed must be listed on the floor plan. Areas where minors will be present must be so designated on the plans. No minors shall be allowed within the area where alcoholic beverages are dispensed. (Complete Step 3.) 3. Consumption of alcoholic beverages shall take place on the licensed premises only. There shall be no carry-out privileges. 4. Each applicant shall designate an individual responsible for the event. Such person shall possess an employee's permit and shall be available to the Excise Police during the event. 5. An Excise Officer has the authority to revoke approval of a catered event before or during the event for good cause. 6. The event must meet applicable Department of Health sanitation requirements, particularly with regard to restroom facilities. 7. All applications should be received a full fifteen (15) days prior to the event. 8. If the catered event is open to the public, the applicant shall notify the local law enforcement agency responsible for the area in which the catered function will be held. The Excise Police may ask for proof of notification to local police which may be demonstrated by a copy of a letter, a "log" entry by the police department, or other means deemed as an appropriate authentication. 9. The wholesaler servicing a supplemental caterer may deliver the alcoholic beverages directly to the location of the catered event if the supplemental caterer has his letter of authority posted at that location. 10. A supplemental caterers permit is to be used for a specific off premises function or event and not for a permittee to use any adjoining or remote facilities to enlarge or enhance his own business enterprises. 11. Have you? Completed Step 3, a drawing of your proposed floor plans? Read and signed the catering guidelines? Is the event or function open to the public? If this event or function is open to the public, you must notify local law enforcement agencies of your intent to cater this event; have you done so? 1. Name of law enforcement agency notified Yes Yes Yes Yes (See #2, 3 above.) No (See #9 above.) 2. Name of law enforcement agency notified Note: Please post your approved request in a conspicuous place where the alcoholic beverages are being dispensed at the catered location. If for any reason this request is denied, you may be notified either in person or by phone, and you will be notified by registered mail. (IC 7.1-3-9.5-2) I swear or affirm under penalties of perjury that the information is true and accurate. Signature of permittee / agent (Your signature acknowledges that you have read the the rules and guidelines and that you agree to abide by those rules and guidelines.) Date (month, day, year) FOR DISTRICT USE ONLY District number Reviewed by (must be signed by district lieutenant or sergeant) Date issued (month, day, year) Approved Denied Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com