Temporary Beer And Wine Permit Application {35494}

BEER / WINE AUTHORITY / TYPE 118 State Form 35494 (R8 / 11-15) Approved by State Board of Accounts, 2015 Send, deliver, or mail to: DISTRICT 1 52422 County Road 17 Bristol, IN 46507 Telephone: (574) 264-9480 DISTRICT 2 1353 South Governors Drive Columbia City, IN 46725 Telephone: (260) 244-4285 DISTRICT 3 279 West 300 North Crawfordsville, IN 47933 Telephone: (765) 362-8815 DISTRICT 4 651 S. Commerce Dr. Seymour, IN 47274 Telephone: (812) 523-8314 DISTRICT 5 3650 South US Hwy 41 Vincennes, IN 47591 Telephone: (812) 882-1292 DISTRICT 6 6400 East 30th Street Indianapolis, IN 46219 Telephone: (317) 541-4100 INSTRUCTIONS: 1. Applicant must complete all requested information. 2. Please type or print clearly. 3. Submit application and payment to the local excise district office. STEP 1. GENERAL INFORMATION Name of applicant applying for permit (organization, club, corporation, individual) Address of applicant (number and street, city, state, and ZIP code) Name of person making application Printed name of contact person of event Fax number TM Permit number (issued by ATC) E-mail address Emergency contact telephone number ( ) ( ( ) ) Emergency contact telephone number STEP 2. EVENT INFORMATION Beginning day Beginning date (month, day, year) Ending day Ending date (month, day, year) Time of event Start time Type or description of event AM PM End time AM PM Exact address of event (number and street, city, state, and ZIP code) STEP 3. FLOOR PLAN (See Step 4, Number 2) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com STEP 4. ACKNOWLEDGEMENT In order to qualify for this authority to serve beer and wine, the following guidelines must be met: There must be a well defined premises, i.e. building, tent, enclosure, or fenced-in or designated area. You must have a defined floor plan or diagram. This is to be drawn on Page 1, Step 3 of this application. If minors are to be present, you must have a defined separation between the bar area and family area. (Must be on floor plan.) 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 shall sign the authority. 5. ANY and ALL persons dispensing or accepting payment for alcoholic beverages MUST POSSESS a valid ATC employee permit. 6. The event must meet applicable Indiana State Board of Health requirements, particularly with regard to restroom facilities. 7. If the event is held in a town park, you must have approval from the town board. 8. Legal Hours of dispensing alcoholic beverages: (Prevailing time) Monday through Saturday -- 7 AM to 3 AM the following day Sunday -- 7 AM to 3 AM the following day 9. Applicant must file with the district office at which the event will be held at least five (5) days prior to the event. 10. The authority 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 the authority during the event. 1. 2. STEP 5. COMMUNITY CLEARANCE 1. Signature of Sheriff of county, or Chief of Police, or Town Marshall of jurisdiction where the event will be held 2. Signature of the mayor (if the event is held in Fort Wayne) Date signed (month, day, year) Date signed (month, day, year) Note: Please post your approved request in a conspicuous place where the alcoholic beverages are being dispensed at the location. If for any reason this request is denied, you may be notified either in person or by telephone. 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 and will abide by the rules and guidelines.) Date signed (month, day, year) FOR DISTRICT USE ONLY District number Reviewed by Excise Police District Representative Date issued (month, day, year) Approved Denied 1. ALL EVENTS ARE $50.00 PER DAY. BUSINESS CHECKS OR MONEY ORDERS ARE ACCEPTED MADE OUT TO THE INDIANA ALCOHOL AND TOBACCO COMMISSION. 2. SERVING PAST MIDNIGHT, NO LATER THAN 3 AM, IS ONE (1) DAY. 3. NO RAIN CHECKS ON ANY OF THE ABOVE EVENTS. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com