State Form 50184 – Fill Out and Use This PDF

STEP 1. PERMITTEE INFORMATION

Name of permittee (as it appears on your Indiana Alcoholic Beverage Permit)						DBA			Permit Number
Address (number and street, city, state, ZIP code)									Expiration date (month, day, year)
Printed name of contact person for permit						Fax Number			Emergency contact telephone number
						(	)		(	)
Printed name of contact person of event				Employee permit number					Emergency contact telephone number
									(	)
STEP 2. EVENT INFORMATION (A SEPARATE REQUEST MUST BE SUBMITTED FOR EACH EVENT)
Beginning			Ending
Day _____________ Date ______________			Day ______________ Date ________________					To include Sunday		Does not include Sunday
Times of catered function:	AM				AM		Sunday event times (if applicable )		AM	AM
Start ________________	PM	End ___________________			PM		Start ________________		PM	End ___________________ PM

Type or description of event

Exact address of event (number and street, city, state, ZIP code)

STEP 3. FLOOR PLAN (SEE STEP 4, #2 )

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 enclosure, 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.

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.

	FOR DISTRICT USE ONLY
District number	Date issued (month, day, year)

Reviewed by (must be signed by district lieutenant or sergeant)

ApprovedDenied