03-26-12 Council Agenda & Packet

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""FOIL EXISTING BUSINESSES ONLY" PAqulred for the following permits:Type 208(except golf courses);All retail permit with less than 90%ownership by Indiana residents;Retail permits with limited bar/ f*im"y room sepan Lion. Date of beginning repot(month,day,year) Date of ending report(month,day,year) Gross food sales(excluding all carryout and catering sales) Gross alcoholic beverage sales Total grass food and beverage sales id Y SOLE OWNER I PARTNERSHIP PERMIT: if applying as a sofa 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. (PLEASEATTACH COPY OF'CERTIFICATE OFEWSTENCE'FROM THE INDIANA SECRETARY OF STATE) If applying as a corporation for any type permit,answer the following questions: ❑Yes ONO Is at least 60%of the outstanding common stock owned by persons who have been continuous and bona aide residents of this State for Ave(5)years? (For exceptions,see IC 7,1-3-21-6.) ❑Yes ONO 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? (!f the answeris 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 I LLP PERMIT:(PLEASE ATTACH COPY OF CERTIFICATE OF E)OSTENCE'FROM THE INDIANA SECRETARY OF STATE) If applying as a limited partnership,limited liability company,or frosted 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 7.1-3-21-8.) If a limited partnership,fimited 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 Ilmited liability partnership applying with 41%or more of the ownership interest held by out of state residents? (If the answeris 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 Iwo 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 fetter 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 cha ed with any duty or function in the enforcement of this title? ❑Yes [:]No Have any individuals with an Interest in this application held a pemiit 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 yea prior to this application fora permit? unless the application was deniued by reason of 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 sate 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 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 Iiy a ®Yes ❑No 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?