Application For New Or Transfer Permit {51189}

APPLICATION FOR NEW OR TRANSFER PERMIT State Form 51189 (R4 / 11-14) Approved by State Board of Accounts, 2014 FOR OFFICE USE ONLY Date received (mm/dd/yy) Permit number INSTRUCTIONS: 1. Type or print legibly. 2. Submit in duplicate. Include payment. 3. Mail to the address at the end of this application form. 4. If there is no opening for this applied permit or there is an omission, this application will be returned. Permit type Quota check * Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. Jurisdiction Checked by STEP 1: GENERAL INFORMATION This permit type will allow you to sell: Beer Wine Liquor This permit type is for: On-premise consumption (Retailer) Off-premise consumption (Dealer) Other (Specify) ___________________________________ Type of application: New application Transfer owner Transfer location Base fee receipt number Please briefly describe your business that qualifies you for this permit type. This ownership entity is: (Check one) Sole Owner Simple Partnership Corporation Business entity making this application Doing business as (DBA) Location where alcoholic beverages will be dispensed (number and street) City / Town Certification number of Indiana retail merchant State Home telephone number (include area code) Permit number (Required for transfers.) Balance due Limited Partnership Limited Liability Partnership Limited Liability Company Municipality Club Association Club Corporation Telephone number of business Refund Catering receipt number ( ) Telephone number of premise Balance due Refund ( ) ZIP code E-mail address ( 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. 4. If no, please name the unincorporated community which has been known by that name for more than ten (10) 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? If no mail receptacle at this location or you wish to have your correspondence sent to another address: Name Address (number and street, city, state, and ZIP code) General Questions Part 2 Yes No Date reviewed (mm/dd/yy) Hearing date of Local Board Yes No Commission approved Permit issued Date of expiration (mm/dd/yy) Yes Yes Yes Yes Yes Yes No Permit released No Remarks No No No No 1. Do you understand that you must apply for a Federal Identification number? 2. Do you understand that you must apply for a Federal Stamp from the Bureau of Alcohol, Tobacco, and Firearms (BATF)? 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? 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? Yes No Page 1 of 6 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 sixty percent (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 (excluding all carryout and catering sales) 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 question: 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 sixty percent (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.) 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? Is the applicant a retailer corporation with forty-one percent (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. Yes Yes Yes No No No Initial ______________ 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: Is at least sixty percent (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.) Yes No 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. Is the applicant a retailer limited partnership, limited liability company or limited liability partnership applying with forty-one percent (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.) Yes No I here