Fillable ALCOHOL BEVERAGE LICENSE REGISTRATION CHECKLIST Complete Application. Application (City of Pooler)

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ALCOHOL BEVERAGE LICENSE REGISTRATION CHECKLIST Complete Application. Application (City of Pooler)

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ALCOHOL BEVERAGE
LICENSE REGISTRATION
CHECKLIST
________________________________________________________________________________________________________________________
City of Pooler ● Customer Service/Finance Department ● 100 SW Highway 80, 2
nd
Floor ● Pooler, Georgia 31322 ● (912) 748-7261
www.pooler-ga.gov
✓ Complete Application. Application must be completed in its entirety. Please be sure form is notarized.
✓ Have application approved by the City of Pooler Building & Zoning Department. The Building & Zoning
Department is located on the second floor of City Hall. If approved, the Building & Zoning Department will
indicate the zoning classification and sign the application in the appropriate location.
✓ Attach the Private Employer Affidavit. Please be sure form is notarized. A blank form is attached for your
convenience.
✓ Attach the Affidavit Verifying Status for City Public Benefit Application. Please be sure form is notarized. A
blank form is attached for your convenience. See link for complete list of acceptable forms of identification –
https://law.ga.gov/immigration-reports.
✓ Attach a copy of at least one (1) secure and verifiable document (driver’s license, passport or I-551 permanent
resident card). See link for complete list of acceptable forms of identification – https://law.ga.gov/immigration-
reports.
✓ If applying for Sunday Sales, attach a copy of the Affidavit to Dispense Alcoholic Beverages on Sunday. Please be
sure form is notarized. A blank form is attached for your convenience.
✓ Applicant must submit fingerprints using the Georgia Applicant Processing Service (GAPS). Instructions for
fingerprinting are attached. Please provide GAPS receipt # :_________________ and date of
fingerprinting:_______________.
✓ Provide payment for license. In addition to the fee for the selected alcohol beverage license, there shall be a
$20 investigative fee for each application.
✓ If application is for an alcoholic beverage license of liquor/distilled spirits for sale by the drink, applicant
understands that they are to pay the alcohol beverage excise drink tax each month in accordance with Chapter
6, Article II of the Code of Ordinance of the City of Pooler. Tax forms and instructions for reporting are enclosed.
Please make additional copies for your use. Additional forms are available on our website – www.pooler-
ga.gov.
Once all the above items are complete, please return all documentation to the Customer Service window on the second
floor of City Hall. If all documentation has been completed properly and payment has been received, then the application
will be scheduled for the next available Council meeting for consideration by Mayor and Council. Council meetings are
held the 1
st
and 3
rd
Monday of each month.
APPLICATION FOR
ALCOHOLIC BEVERAGE
LICENSE
________________________________________________________________________________________________________________________
City of Pooler ● Customer Service/Finance Department ● 100 SW Highway 80, 2
nd
Floor ● Pooler, Georgia 31322 ● (912) 748-7261
www.pooler-ga.gov
1. TYPE OF ALCOHOL BEVERAGE LICENSE APPLIED FOR:
✓
TYPE OF LICENSE
FEE
Retail Wine& Beer or Other Malt Beverages
$460.00
Retail Liquor – Sale by Package Only
$750.00
Retail Liquor/Distilled Spirits – Sale by Drink Only (for consumption on Premises)
$1,500.00
Retail Liquor – Sale by Package & Drink
$2,000.00
Sunday Sales (Food Serving Establishments; Must Complete Additional Provided Affidavit)
$150.00
Wholesale Beer or Other Malt Beverages
$935.00
Wholesale Liquor
$1,500.00
Wholesale Wine
$150.00
TOTAL OF LICENSE FEES:
2. BUSINESS INFORMATION:
___________________________________________________________________________________________
Legal Name of Business (include any DBA)
___________________________________________________________________________________________
Physical Address of Business
___________________________________________________________________________________________
Business Telephone Number Projected Opening Date
___________________________________________________________________________________________
Operator’s/General Manager’s Name
___________________________________________________________________________________________
Operator’s/General Manager’s Home Address Telephone Number
3. APPLICANT’S INFORMATION:
___________________________________________________________________________________________
Applicant’s Name
___________________________________________________________________________________________
Applicant’s Home Address Telephone Number
4. OWNER’S INFORMATION:
Please list all owners who have an ownership interest of 10% or more in the business. Use additional paper if necessary.
Business Owner Name:
Business Owner’s Address:
Business Owner’s Telephone
Number:
APPLICATION FOR
ALCOHOLIC BEVERAGE
LICENSE
________________________________________________________________________________________________________________________
City of Pooler ● Customer Service/Finance Department ● 100 SW Highway 80, 2
nd
Floor ● Pooler, Georgia 31322 ● (912) 748-7261
www.pooler-ga.gov
5. BUSINESS DISCLOSURE:
1. Has applicant, owner, corporation, or any person connected with or having an interest in said business ever
previously or currently held/hold a license to sell wine, beer and/or distilled spirits/liquor? □ Yes □ No
2. If yes, were there any violations of any law, regulation or ordinance relating to such business? □ Yes □ No
3. Has applicant, owner or any person connected with or having an interest in said business:
(a) Ever been convicted of any criminal violation or city ordinance violation (other than a traffic citation)? □ Yes □ No
(b) Ever served time in prison or other correctional institution? □ Yes □ No
(c) Ever had an alcoholic beverage license suspended or revoked at any time in any locality: □ Yes □ No
NOTE: If the answer to any question in this section (5) is “yes” for the applicant or any person connected with or having an
interest in said business, describe circumstances in detail for each person. Please provide and attach a written explanation.
Before the undersigned attesting officer duly authorized to administer oaths, personally comes the applicant for a license to
conduct the sale of alcoholic beverages in the City of Pooler, says that the information given and the statements made in
this application are true, correct and complete under penalty of law.
Executed this ______________ day of __________________, 20_________.
___________________________________________
Applicant’s Signature
___________________________________________
Applicant’s Printed Name
SUBSCRIBED AND SWORN BEFORE ME ON
THIS _________ DAY OF ________________, 20_____.
____________________________________________
Notary Public/Seal
My Commission Expires: _______________________
NOTICE: The applicant for an alcoholic beverage license shall be the owner of the business. If this is a corporation, partnership or
other legal entity, the applicant must be a substantial and major stockholder or the applicant may be the General Manager charged
with the regular operation of said business on the premises for which the license is issued. Applicant for an alcoholic beverage license,
as well as every owner having 10% or more ownership, must submit to fingerprinting by using the GAPS system prior to submitting
the application. Instructions for fingerprinting are attached.
APPLICATION FOR
ALCOHOLIC BEVERAGE
LICENSE
________________________________________________________________________________________________________________________
City of Pooler ● Customer Service/Finance Department ● 100 SW Highway 80, 2
nd
Floor ● Pooler, Georgia 31322 ● (912) 748-7261
www.pooler-ga.gov
6. STAFF RECOMMENDATIONS – CITY OF POOLER USE ONLY
BUILDING & ZONING DEPARTMENT
The Building & Zoning Department has reviewed and examined the application. Based on the findings and the
requirements of the Zoning Ordinance of the City of Pooler, the application is therefore recommended for:
Zoning District:
Approval: □ Denial: □
Reviewed By:
Date:
Comments:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
POLICE DEPARTMENT
The Police Department have reviewed the application and the disclosures and criminal histories of the
applicant(s). Based on their findings and the requirements of the Code of Ordinances of the City of Pooler, the
application is therefore recommended for:
Reviewed by:
Date:
Approval:□
Denial: □
Comments:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________
7. COUNCIL APPROVAL:
Scheduled for City Council Meeting Date:__________________________________________________________
COUNCIL APPROVAL
Mayor’s Signature:
Date:
Approval: □ Denial: □
Comments:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PRIVATE EMPLOYER
AFFIDAVIT
PURSUANT TO
O.C.G.A. § 36-60-6(d)
________________________________________________________________________________________________________________________
City of Pooler ● Customer Service/Finance Department ● 100 SW Highway 80, 2
nd
Floor ● Pooler, Georgia 31322 ● (912) 748-7261
www.pooler-ga.gov
By executing this affidavit under oath, the undersigned private employer verifies one of the following with respect to its
application for an Alcohol License required to operate a business as referenced in O.C.G.A. § 36-60-6(d):
__________________________________________________________________________________________________
Name of Private Employer
Please check only one:
___________ On January 1
st
of the below-signed year, the individual, firm or corporation employed more than ten (10)
employees.
The employer has registered with and utilizes the federal work authorization program (E-Verify) in
accordance with the applicable provisions and deadlines established in O.C.G.A. § 36-60-6. The
undersigned private employer also attests that its federal work authorization (E-Verify) user
identification number and date of authorization are as follows:
_____________________________________________________________________________________
Federal Work Authorization (E-Verify) User Identification Number Date of Authorization
___________ On January 1
st
of the below-signed year, the individual, firm or corporation employed less than ten (10)
employees.
I hereby declare under penalty of perjury that the foregoing is true and correct. Executed this ________ day of
______________________, 20___________.
_____________________________________________
Signature of Authorized Officer or Agent
_____________________________________________
Printed Name of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME ON
THIS___________DAY OF _____________, 20_________.
_______________________________________________
NOTARY PUBLIC/SEAL
My Commission Expires: ___________________________
AFFIDAVIT VERIFYING
STATUS FOR CITY
PUBLIC BENEFIT APPLICATION
By executing this affidavit under oath, as an applicant for an Alcohol License (type of public benefit), as referenced in
O.C.G.A. § 50-36-1, from the City of Pooler, Georgia, the undersigned applicant verifies one of the following with respect
to my application for public benefit.
1.)___________ I am a United States citizen.
OR
2.)___________ I am a legal permanent resident.
OR
3.)___________ I am qualified alien or non-immigrant under the Federal Immigration and Nationality Act with
an alien number issued by the Department of Homeland Security or other federal immigration agency.
If you chose #2 or #3, my alien number issued by the Department of Homeland Security or other federal
immigration agency is:
_________________________________________________________________________________________.
The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one
secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.
The secure and verifiable document provided with this affidavit can be best classified as:
________________________________________________________________________________________________.
In making the above representation under oath, I understand that any person who knowingly and willfully makes a false,
fictious or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20 and
face criminal penalties as allowed by such criminal statute.
_____________________________________________
Signature of Applicant Date
_____________________________________________
Printed Name of Applicant
_____________________________________________
Name of Business
SUBSCRIBED AND SWORN BEFORE ME ON THIS _________ DAY OF ________________, 20_____.
____________________________________________
Notary Public/Seal
My Commission Expires: _______________________
_______________________________________________________________________________________________________________________
_ City of Pooler ● Customer Service/Finance Department ● 100 SW Highway 80, 2
nd
Floor ● Pooler, Georgia 31322 ● (912) 748-7261
www.pooler-ga.gov
AFFIDAVIT TO DISPENSE
ALCOHOLIC BEVERAGES
ON SUNDAY
________________________________________________________________________________________________________________________
City of Pooler ● Customer Service/Finance Department ● 100 SW Highway 80, 2
nd
Floor ● Pooler, Georgia 31322 ● (912) 748-7261
www.pooler-ga.gov
The City of Pooler permits eating establishments (restaurants) holding a license to dispense alcoholic beverages for consumption on
the premises under certain conditions.
To be authorized to dispense alcoholic beverages for consumption on Sunday, your establishment must:
(1.) Be licensed by the City of Pooler to sell alcoholic beverages by the drink for consumption on the premises; and
(2.) Be an eating establishment whose primary business is the sale of prepared meals; and
(3.) Derive at least 50 percent of its total annual gross food and beverage sales from the sale of prepared meals or food; and
(4.) Have its primary floor area specifically designed, set aside, set up and operating to serve meals and food on the premises
and shall have a fully-equipped commercial kitchen to include an appropriate stove, refrigerator, food preparation area,
sink and other items required by the county health department and city inspections department for the preparation of
food; and
(5.) Have a printed or posted menu from which selections of prepared meals can be made; and
(6.) Provide full food service to the public during its entire operating hours, including Sunday; and
(7.) Complete the below affidavit and submit along with the required Sunday Sales permit fee of $150.00.
__________________________________________________________________________________________________
Name of Business
__________________________________________________________________________________________________
Location Telephone Number
I certify that the establishment named above: (1) is a bona fide public eating establishment which will actually and regularly prepare
and serve food on the premises; (2) fully intends to derive at least 50% of its total annual gross food and beverage sales from the
sale of prepared meals or food; and (3) will provide full food service along with a printed or posted menu to the public during
operating hours. Further, I understand that I must submit a certified affidavit from my certified public accountant (CPA) or
registered public accountant (RPA) upon my request for renewal each year if Sunday Sales of alcoholic beverages is to be continued.
Executed this _______________ day of _____________________, 20________.
_______________________________________
Signature
_______________________________________
Printed Name
SUBSCRIBED AND SWORN BEFORE ME ON
THIS _________ DAY OF ________________, 20_____.
____________________________________________
Notary Public/Seal
My Commission Expires: _______________________
INSTRUCTIONS FOR REGISTERING FOR FINGERPRINTING:
1. Go the the following webpage:
http://cogentid.com
2. Select ‘Georgia’.
3. Select ‘Applicant Registration’.
4. Select ‘City/County Government and Law Enforcement Agencies (CCGC)’.
5. Select ‘Alcohol and Liquor License’.
6. Read the ‘Non-Criminal Justice Applicant’s Privacy Rights’ and ‘Privacy Act Statement’. Once
read, check the box beside ‘I have read and accepted these items’. Then select ‘Continue’.
7. Fill in the information. Please use GA922965Z in the ‘Reviewing Agency ID’ field.
DO NOT CHECK
THIS BOX!
GA923329Z
8. For the ‘Reason’, select ‘Alcohol/Liquor Licensee’.
9. Once information is entered, select ‘Continue’.
10. Verify information and select ‘Submit’.
11. Enter payment information.
12. Print receipt and take with you to have fingerprinting done.
13. Fingerprints are done at City of Tifton City Hall located at 130 1
st
Street East,
Tifton, Georgia. They are open Monday – Friday from 8 am to 4:30 pm. Please
bring your registration number and ID with you.
To find a fingerprinting location, visit http://cogentid.com, then select Georgia. On the
left hand side of the screen, the first selection is 'Find a Fingerprint Location'. When
this is selected, you can find a location nearest you for fingerprinting.
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ALCOHOL BEVERAGE LICENSE REGISTRATION CHECKLIST Complete Application. Application (City of Pooler)

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Completed 4 August 2020

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