Blind Pig PermitAlcoholic Beverage Control
I 09 SW 9th Street, 5th Floor
PO Box 3506
Topeka KS 66601-3506
Phone:785-296-7015
Fax: 785-296-7185
Kdor _ abc.email@ks.gov
www.ksrevenue.gov/abc.html
REQUEST FOR TEMPORARY EXTENSION OF PREMISE APPROVAL
Licensee Information
Business OBA Name License Number
Mike & Denise Ward Partnership 10014084301
Business Location Street Address City Zip Code
2501 Market Place, Suite A Salina 67401
Contact Phone Person Phone Number Email Address
Denise Ward 785-826-0337 denise.ward49@gmail.com
Event Date(s} Event Start Time(s} Event End Time(s)
06/04/2022 11:00am 1:00am
Temporary Extension Information
Check all that apply:
0 I am extending onto unlicensed or unpermtted premises
Is the area of the extension under the control of the licensee? 0 Yes O No
I have attached written permission from the owner or city/county. O Yes DNo
D I am extending onto a temporarily permitted premises.
What is the event name?
D I am extending onto any of the following areas: public streets, alleys, roads, sidewalks or highways.
D I have attached the ordinance or resolution approved by the local governing body._ OYes O No
Diagram: Draw a complete diagram of the premises for which you are seeking approval or attach your drawing. The
diagram must indicate the current premise and the temporary extension area. Architectural drawings will n2t be accepted.
Check one: ODiagram drawn below 0 8Y:z" X 11" drawing attached on supplimental page
ABC-816 (Rev. 07/19)
Page 2 of 3
: ~ --. . .. -
' . .'"": -·.
Alcoholic Beverage Control
109 SW 9th Street, 5th Floor
POBox3506
Topeka KS 66601-3506
Phone:785-296-7015
Fax: 785-296-7185
Kdor _ abc.email@ks.gov
www.ksrevenue.gov/abc.html
Zoning: CERTIFICATE OF CITY, TOWNSHIP OR COUNTY CLERK
1HEReevceRTIFYTHATTHEPREM1sesAT 2.Sol MAY"\::'~+ P\a.ce. Se.l ; "'a Ks c,1'10 l IS:
Location Street Address City Zip
(Check one box in each section below)
CITY LIMITS: Di!' Inside the incorporated city limits D Outside the city limits
County
~ City Clerk · 0 Township Clerk 0 County Clerk
DATE 4#/u. PHONE {785')=n9-£7ll .
D I understand that I must maintain a copy of the approved diagram on the licensed premise and it must be available for
immediate i spection upon request.
ormation contained in this document a true, accurate and complete disclosure of information.
rd.
Date
ABC Office Use Only
0 DIAGRAM APPROVED AS SUBMITTED Signature of ABC Official Date
0 DIAGRAM DENIED
Reason Denied:
ABC-816 (Rev. 07/19)
Page 3 of 3