Alcoholic Beverage License Information & Checklist (Except Wholesaler) (Revised 02-27-19) Page 1 of 2
ALCOHOLIC BEVERAGE LICENSE
INFORMATION & CHECKLIST FOR ATTACHMENTS
**Important** Please read all information before beginning your application!
STATE LICENSE REQUIRED ***A state license must be obtained before any alcoholic beverage can be served or
sold in Gwinnett County (this includes Alcoholic Beverage Manufacturers). The state license is obtained after
the county license. For more information on the state license process, please contact the Georgia Department
of Revenue at (877) 423-6711.
Before any Gwinnett County alcohol license can be issued, you must contact the following departments for
your inspections:
1. Gwinnett County Fire Marshal (all applications) at (678) 518-4800
2. Health Department (if alcohol is to be consumed on the premises) at (770) 963-5132
3. Department of Agriculture (if retail package only) at (770) 535-5955
Please Note
: You must schedule an appointment, in advance, to apply for your alcoholic beverage license. To
schedule an appointment to apply, please contact Gwinnett County License & Revenue at (678) 377-4100.
All information listed on the checklist on the next page is required in order to submit your application. We are
unable to accept incomplete applications.
When filling out and submitting the application, please keep in mind the following:
Read each question carefully, and answer the questions exactly as requested. If a question does not
apply to you, write “N/A” in the space provided.
No white-out is accepted on the application forms. If you make a mistake, draw a single line through it,
write the correct response and initial the change.
Complete the application using blue or black ink or type it on a computer.
Provide all documents in the order they are listed on the checklist.
All signatures must be original (no stamps/copies)
All documents requesting a notary signature at the bottom must be signed in front of a notary public
and be notarized.
All application & license fees are due at time of application and are non-refundable.
Payment must be submitted only in the form of a certified/official/cashier’s check. No personal checks
or money orders.
If you have any questions regarding whether or not alcohol is allowed at your location or other zoning
related questions, please contact Zoning at (678) 518-6000.
Processing time for approval of applications is four (4) to six (6) weeks. You will be contacted once
your license is ready for pickup.
Aft
er you submit your application to Gwinnett County License & Revenue, each person submitting a Statement
of Personal History will need to be fingerprinted. You will be advised by License & Revenue when and where to
obtain fingerprinting
Alcoholic Beverage License Information & Checklist (Except Wholesaler) (Revised 02-27-19) Page 2 of 2
PRIMARY CHECKLIST FOR ATTACHMENTS
For All Alcohol License Types (Except Wholesaler)
Application Form
Statement of Personal History Form for each Sole Owner, Partner, Member, Officer, Director, Majority
Stockholder (Private Corporations), and General Manager WITH A CLEAR, CURRENT,
FRONT AND
BACK COPY OF IDENTIFICATION DOCUMENT ATTACHED TO THE LAST PAGE
For U.S. Citizens: Driver’s License or State issued Photo Identification
For Permanent Residents: Permanent Resident Card
Registered Agent Consent Form with copy of registered agent’s driver’s license attached REGISTERED
AGENT MUST BE A GWINNETT COUNTY RESIDENT, WITH THEIR CURRENT HOME ADDRESS
PRINTED ON THEIR DRIVER’S LICENSE.
Copy of Georgia Secretary of State documents for LLCs & Corporations (Certificate & Articles) or
Partnership Agreement for Partnerships
Site plan (or proposed plan & specifications & building permit if not yet built)
Detailed floor plan, drawn to scale
Copy of Certificate of Occupancy (from Gwinnett County Building Plan Review & Fire Marshal)
Acknowledgement of Transferability Form
License fee and investigative and administrative fee (certified/official/cashier’s check only)
ADDITIONAL REQUIREMENTS
If the applicant is a franchise, provide everything from the Primary Checklist and:
Signed franchise agreement or contract
I
f this is a change in ownership, provide everything from the Primary Checklist and:
Signed sale/purchase agreement
If you are applying for distilled spirits consumption, provide everything from the Primary Checklist
and:
Projected purchases/projected gross sales
If the location has never had an alcohol license issued, provide everything from the Primary
Checklist and:
Certified report of survey from Registered Land Surveyor or Professional Engineer
Certified scale drawing showing location and distance to closest school buildings, daycares who offer
kindergarten programs, educational buildings, school grounds, colleges and/or any church buildings
If the location is a bona fide eating establishment, provide everything from the Primary Checklist
and:
Copy of menu(s)
If the location is a bona fide private club, provide everything from the Primary Checklist and:
Minutes of annual meeting setting salaries for members, officers, agents or employees
Alcoholic Beverage License Application (Revised 02/27/19) Page 1 of 6
GWINNETT COUNTY DEPARTMENT OF PLANNING & DEVELOPMENT
LICENSING AND REVENUE SECTION
ALCOHOL BEVERAGE UNIT
P. O. BOX 1045 (678) 377-4100 446 W. CROGAN ST., STE 130
LAWRENCEVILLE, GA 30046 LAWRENCEVILLE, GA 30046
(MAILING) (LOCATION)
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE
Instructions: This statement must be typed or neatly printed in blue or black ink and executed (notarized) under oath.
Each question must be fully answered. If space provided is not sufficient, answer on a separate sheet and indicate the
question that is being answered.
1. TYPE OF LICENSE (CHECK ONE): NEW AMENDMENT
2. ADMINISTRATIVE AND INVESTIGATIVE FEE: $500.00 - ALL APPLICANTS
3. TYPE OF BUSINESS:
Bona Fide Eating Establishment Convenience Store
Hotel/Motel Brew Pub
Wholesale Other
Super Market Explain: _____________________________
Will Live Entertainment Be Offered? YES NO
If Yes, Explain: ______________________________________________________________
___________________________________________________________________________
4. TYPE OF LICENSE AND FEES: PAYMENT BY CERTIFIED FUNDS ONLY!
FEES ARE ONE HALF AFTER JULY 1
ST
(EXCEPT ADMIN/INVESTIGATIVE FEE)
(Check All That Apply)
RETAIL PACKAGE:
Beer $600 Wine $600 Beer & Wine $1,200 Beer & Wine Sunday Sales $500
Beer Sunday Sales $250 Wine Sunday Sales $250
RETAIL CONSUMPTION ON PREMISES:
Beer $600 Wine $600
Beer & Wine $1,200 Beer & Wine Sunday Sales $500
Beer Sunday Sales $250 Wine Sunday Sales $250
Brew Pub $750 Distilled Spirits $4,500
Distilled Spirits Sunday Sales $1,000 Patio Sales (no fee)
Additional Fixed Bars $750 (each bar) Movable Bars $250 (each bar)
Hotel/Motel In-Room Service
(Beer & Wine Only) $250
Alcoholic Beverage License Application (Revised 02/27/19) Page 2 of 6
TYPE OF LICENSE AND FEES CONTINUED:
WHOLESALE DISTRIBUTOR:
Based Within Gwinnett County
Beer $750 Wine $750 Beer & Wine $1,500
Distilled Spirits $2,000
Based Outside Gwinnett County
Beer, Wine and/or Distilled Spirits $500
NON-PROFIT PRIVATE CLUB:
Beer $150 Wine $150 Beer & Wine $300
Beer Sunday Sales $35 Wine Sunday Sales $35
Beer & Wine Sunday Sales $70 Distilled Spirits $1,000
Distilled Spirits Sunday Sales $200 Patio Sales (no fee)
Temporary License (Non-Profit Civic Organization Only)
$25 Per Day, Maximum 10 Days Per Calendar Year
5. BUSINESS:
Applicant Name (Corporation/LLC): _____________________________________
Business Name (DBA):
_______________________________________________
Location: __
Street Number Street Name (NO P.O. BOXES)
City State Zip Code Phone Number
Mailing Address: ___
Street Number Street Name
City State Zip Code Phone Number
6. OWNER:
Full Name:
Social Security #
Mailing Address:
Street Number Street Name
City State Zip Code Phone Number
Alcoholic Beverage License Application (Revised 02/27/19) Page 3 of 6
7. REGISTERED AGENT: (MUST BE A RESIDENT OF GWINNETT COUNTY!)
Full Name:
Social Security #
Home Address: ______________________________________________________
Street Number Street Name (NO P.O. BOXES)
City State Zip Code Phone Number
8. TYPE OF OWNERSHIP:
Sole Owner Partnership
Private Held Corporation Public Held Corporation
Public Held Corporation Subject to S.E.C. Regulations
Limited Liability Company
9. FOR PARTNERSHIP:
Date the Partnership was formed:___________________________________
List all Partners:
Name Social G-General Interest
Security L-Limited Investment Participation
Number S-Silent $ %
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
10. FOR CORPORATION:
Corporation Name:________________________________________________
Date of Incorporation:_____________________________________________
State Corporation was formed in:___________________________________
Name of Parent Corporation (if applicable):________________________
Number of Shares of Capital Stock Authorized:______________________
Number of Shares of Outstanding Stock:_____________________________
For corporations, list officers, directors and/or principal shareholders with 20% or more of the
stock:
Name Social Security # Position Interest %
_
_
_
Is the corporation owned by a parent corporation or held by a holding company?
YES NO If yes, explain: ________________________________________
0%
0%
0%
Alcoholic Beverage License Application (Revised 02/27/19) Page 4 of 6
11. FOR LIMITED LIABILITY COMPANY, L.L.C.:
Name of L.L.C.:_______________________________________________________
Date of organization:_______________________________________________
Name of Managing Member:____________________________________________
List any member or other legal entity owning twenty percent (20%) or more of the L.L.C.:
Name Social Security # Interest %
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
12. FOR PRIVATE CLUBS:
Date of organization under the laws of the State of Georgia:
_________________________________________________________________________
State the total number of regular dues paying members:_____________
Is any member, officer, agent, or employee compensated directly or indirectly from the profits
of the sale of distilled spirits beyond a fixed salary as established by its members at any
annual meeting or by its governing board out of the general revenue of the club?
YES NO If yes, explain: __________________________________________
_________________________________________________________________________
List officers, directors and/or principal shareholders with 20% or more of the stock:
Nam
e Social Security # Position
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
13. FINANCING:
Bank to be used by business:_______________________________________
Bank branch to be used:____________________________________________
State total amount of capital that is or will be invested in the business by any party or
parties:__________________________________
State total amount of funds invested by the owner(s):______________
State total amount of funds invested by parties other than the
owner(s):__________________________________________________________
Is any capital borrowed? YES NOIf yes, provide:
Name
of Lender Date Amount Interest rate
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
0%
0%
0%
Alcoholic Beverage License Application (Revised 02/27/19) Page 5 of 6
14. GENERAL INFORMATION:
Has owner and/or individual partner, shareholder, director or officer any financial interest in
any manufacturer or wholesale of alcoholic beverage?
YES NO
Has owner and/or individual partner, shareholder, director, or officer received any financial aid
or assistance from any manufacturer of alcoholic beverages?
YES NO
If answer is “Yes” to either of immediate foregoing, explain:
___________________________________________________________________
___________________________________________________________________
Show hereunder any and all persons, corporations, partnerships, or associations (other than
persons stated herein as owner(s), directors, or officers) who have received or will receive, as
a result of your operation under the requested license, any financial gain or payment derived
from any interest or income from the operation. Financial gain or payment shall include
payment or gain from any interest in the land, fixtures, building, stock and any other asset of
the proposed operation under the license. In the event any corporation is listed as receiving an
interest or income from this operation, show the names of the officers and directors of said
corporation together with the names of the principal stockholders.
Name Name of Business
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List all other businesses engaged in the sale of alcoholic beverages that you the owner, or any
individual, partner, shareholder, officer or director is interested in, employed by or associated
with in any way whatsoever, or have been interested in, employed by, or associated with in the
past.
Name Name of Business Interest%
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Alcoholic Beverage License Application (Revised 02/27/19) Page 6 of 6
ALCOHOLIC
BEVERAGE
LICENSE
DECLARATION
I, , DO SOLEMNLY SWEAR, SUBJECT TO THE PENALTIES
OF FALSE SWEARING, THAT THE STATEMENTS AND ANSWERS MADE BY ME
AS THE APPLICANT IN THE FOREGOING ALCOHOLIC BEVERAGE LICENSE
APPLICATION ARE TRUE AND CORRECT.
Applicant
Signature
Date
Signed
State of Georgia
County of ___________
Personally appeared before me________________________(applicant)
on __________________(Date) who proved to me on the basis of satisfactory
evidence to be:
______Personally Known
Or
______Produced Identification
Type of ID_________________________________
SEAL
Statement of Personal History (Revised 02-27-19) Page 1 of 6
GWINNETT COUNTY DEPARTMENT OF PLANNING & DEVELOPMENT
LICENSING AND REVENUE SECTION
ALCOHOL BEVERAGE UNIT
P. O. BOX 1045 (678) 377-4100 446 W. CROGAN ST., STE 130
LAWRENCEVILLE, GA 30046 LAWRENCEVILLE, GA 30046
(MAILING) (LOCATION)
STATEMENT OF PERSONAL HISTORY
Instructions: This statement must be typed or neatly printed in blue or black ink and executed
(notarized) under oath. Each question must be fully answered. If space provided is not sufficient,
answer on a separate sheet and indicate the question that is being answered.
1. NAME: ____________________________________________________________________________
Last First Middle
RESIDENCE: _______________________________________________________________________
Street Number Street Name (NO P.O. BOXES)
____________________________________________________________________________________
City State Zip Code Telephone Number
2. CHECK:
Sole Owner/Proprietor Partner: General Limited Silent
Director Principal Stockholder (20% or more)
Registered Agent Officer: _______________________
Manager Employee: _____________________
3. CORPORATION / LLC NAME: ________________________________________________________
BUSINESS NAME (DBA): ____________________________________________________________
LOCATION: ________________________________________________________________________
Street Number Street Name (NO P.O. BOXES)
____________________________________________________________________________________
City State Zip Code Telephone Number
4. STATE THE PERCENTAGE OF OWNERSHIP OR INTEREST IN THIS BUSINESS:
____________________________________________________________________________________
5. DATE OF BIRTH: _____________________ PLACE OF BIRTH: ________________________
SSN: ______________________ SEX: MALE FEMALE RACE: _________________
COLOR OF HAIR: ________________________ COLOR OF EYES: _________________________
0%
Statement of Personal History (Revised 02-27-19) Page 2 of 6
6. U.S. CITIZEN PERMANENT RESIDENT LIST ALIEN NUMBER: _________________
7. SINGLE MARRIED WIDOWED DIVORCED SEPARATED
IF MARRIED OR SEPARATED, COMPLETE ALL INFORMATION LISTED BELOW:
FULL NAME OF SPOUSE: ________________________________ SSN#: _____________________
MAIDEN NAME: ___________________________ PLACE OF BIRTH: ______________________
DATE OF BIRTH: _________________ NAME AND ADDRESS OF SPOUSE’S EMPLOYER:
___________________________________________________________________________________
8. STATE ANY OTHER NAMES WHICH YOU HAVE USED (MAIDEN NAME, NAMES BY FORMER
MARRIAGES, FORMER NAMES CHANGED LEGALLY OR OTHERWISE, ALIASES, NICKNAMES, ETC.
SPECIFY WHICH, SHOW DATES, ETC.):
____________________________
___________________________________________________________________________________
___________________________________________________________________________________
9. GIVE NAME AND ADDRESS OF ALL CHILDREN AND STEPCHILDREN (REGARDLESS OF AGE):
FULL NAME ADDRESS AGE PLACE OF BIRTH
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
10. EMPLOYMENT RECORD FOR THE PAST TEN (10) YEARS (INCLUDING PRESENT) IF THERE WERE
PERIODS YOU WERE UNEMPLOYED OR A STUDENT, LIST THE DATES AND WRITE “UNEMPLOYED” OR
“STUDENT”. (LIST THE MOST RECENT EXPERIENCE FIRST):
From To Occupation & Salary Employer Reason for
Year Year Duties Performed Received (Business Name) Leaving
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Statement of Personal History (Revised 02-27-19) Page 3 of 6
13. RESIDENCES FOR THE PAST TEN (10) YEARS (THROUGH PRESENT). (LIST THE CURRENT RECENT
FIRST):
From Year To Year Street City State Zip Code
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
14. DO YOU HAVE ANY FINANCIAL INTEREST, OR ARE YOU EMPLOYED IN ANY OTHER WHOLESALE OR
RETAIL BUSINESS ENGAGED IN DISTILLING, BOTTLING, RECTIFYING OR SELLING ALCOHOLIC
BEVERAGES?
YES NO
IF YES, GIVE NAMES, LOCATIONS AND AMOUNT OF INTEREST IN EACH:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
15. HAVE YOU EVER HAD ANY FINANCIAL INTEREST IN AN ALCOHOLIC BEVERAGE BUSINESS, WHICH
WAS DENIED A LICENSE?
YES NO
IF YES, GIVE DETAILS: _____________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
16. HAS ANY ALCOHOLIC BEVERAGE BUSINESS IN WHICH YOU HOLD, OR HAVE HELD, ANY FINANCIAL
INTEREST OF, OR EMPLOYED, OR HAVE BEEN EMPLOYED, EVER BEEN CITED FOR ANY VIOLATIONS
OF THE RULES AND REGULATIONS OF THE STATE REVENUE COMMISSIONER RELATING TO THE
SALE AND DISTRIBUTION OF ALCOHOLIC BEVERAGES?
YES NO
IF YES, GIVE DETAILS: _____________________________________________________________
____________________________________________________________________________________
17. IF DURING THE PAST TEN YEARS YOU HAVE BOUGHT OR SOLD ANY BUSINESS ASSOCIATED WITH
ALCOHOL?
YES NO
IF YES, GIVE DETAILS (DATE, LICENSE NUMBER, PERSONS AND CONSIDERATIONS INVOLVED):
_______________________________________________________________________
____________________________________________________________________________________
18. HAVE YOU EVER BEEN DENIED BOND BY A COMMERCIAL SECURITY COMPANY?
YES NO
IF YES, GIVE DETAILS: _____________________________________________________________
____________________________________________________________________________________
Statement of Personal History (Revised 02-27-19) Page 4 of 6
19. ARE YOU A REGISTERED VOTER? YES NO
IF YES, LIST STATE _________________________ AND COUNTY __________________________
20. HAVE YOU EVER BEEN ARRESTED, OR HELD BY FEDERAL, STATE OR OTHER LAW-ENFORCEMENT
AUTHORITIES, FOR ANY VIOLATION OF ANY FEDERAL LAW, STATE LAW, COUNTY OR MUNICIPAL
LAW, REGULATION OR ORDINANCES? (Do not include traffic violations. All other charges must be
included even if they were dismissed. Give reason charged or held, date, place where charged and
disposition. If no arrest, write “NO ARREST”. After last arrest is listed, please write “NO OTHER
ARRESTS”):
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. _______________________________________________________________________
21. HAVE YOU HAD ANY LICENSE UNDER THE REGULATORY POWERS OF GWINNETT COUNTY DENIED,
SUSPENDED OR REVOKED WITHIN TWO (2) YEARS PRIOR TO THE FILING OF THIS APPLICATION?
YES
NO
IF YES, GIVE DETAILS: _____________________________________________________________
____________________________________________________________________________________
22. ATTACH PASSPORT STYLE (FRONT VIEW) PHOTO TAKEN WITHIN THE PAST YEAR:
(ATTACH PHOTO HERE)
Statement of Personal History (Revised 02-27-19) Page 5 of 6
NOTE: BEFORE SIGNING THIS STATEMENT, CHECK ALL ANSWERS AND
EXPLANATIONS TO SEE THAT YOU HAVE ANSWERED ALL QUESTIONS FULLY AND
CORRECTLY. THIS STATEMENT IS TO BE EXECUTED UNDER OATH AND SUBJECT TO
THE PENALTIES OF FALSE SWEARING, AND IT INCLUDES ALL ATTACHMENTS
SUBMITTED HEREWITH.
STATEMENT OF
PERSONAL
HISTORY
DECLARATION
I, __________________________________________________, DO SOLEMLY SWEAR, SUBJECT
TO THE PENALTIES OF FALSE SWEARING, THAT THE STATEMENT AND ANSWERS
MADE BY ME AS THE APPLICANT IN THE FORGOING PERSONAL STATEMENT ARE
TRUE AND CORRECT. FURTHER, AS PART OF THE PROCESS RESULTING FROM MY
APPLICATION FOR BACKGROUND INVESTIGATION, FOR AN ALCOHOLIC BEVERAGE
LICENSE, I HEREBY AUTHORIZE PERSONNEL OF THE GWINNETT COUNTY POLICE
DEPARTMENT TO RECEIVE, VERIFY, AND DISSEMINATE ANY CRIMINAL HISTORY
INFORMATION WHICH MAY BE IN THE FILES OF ANY LOCAL, STATE, OR FEDERAL
CRIMINAL JUSTICE AGENCY FOR INVESTIGATIVE PURPOSES, DENIAL, OR APPEALS.
ADDITIONALLY,
AUTHORIZATION IS HEREBY GIVEN TO GWINNETT COUNTY TO
VERIFY, IN ANY MANNER IT DEEMS APPROPRIATE, ANY AND ALL ITEMS INDICATED
ON THIS STATEMENT.
Applicant
Signature
Date
Signed
State of Georgia
County of ___________
Personally appeared before me________________________(applicant)
on __________________(Date) who proved to me on the basis of satisfactory evidence to
be:
______Personally Known
Or
______Produced Identification
Type of ID_________________________________
SEAL
Registered Agent Consent Form (for Alcohol Licenses) Revised 02-27-2019 Page 1 of 1
GWINNETT COUNTY REGISTERED AGENT CONSENT FORM
FOR ALCOHOLIC BEVERAGE LICENSES
____________________________________________________________________________
Applicant (Corporation or LLC Name)
_______
_____________________________________________________________________
Trade Name (DBA)
_______
_____________________________________________________________________
Location Address
I, ______________________________, do hereby consent to serve as the Registered Agent for the licensee,
owners, officers, and/or directors and to perform all obligations of such agency under the Alcoholic
Beverage Ordinance of Gwinnett County. I understand the basic purpose is to have and continuously
maintain in the County a Registered Agent upon which any process, notice, or demand required or
permitted by law or under said Ordinance to be served upon the licensee or owner may be served.
I
understand that to serve as the Registered Agent, I must be a Gwinnett County resident and attach a
copy of my driver’s license, reflecting my current home address.
Si
gned, this ________ day of ______________________, 20______.
____________________________________
Signature of Agent
____________________________________
Printed Name of Agent
____________________________________
Agent’s Current Home Street Address
____________________________________
Agent’s City, State & Zip Code
____________________________________
Agent’s County of Residence
____________________________________
APPROVED BY: A
gent’s Phone Number
______________________________ ___________________________________
Signature of Sole Owner/Partner/ Printed Name of Sole Owner/Partner/
Member/Officer/Director Member/Officer/Director
*REQUIRED*
ATTACH A CLEAR COPY OF AGENT DRIVER’S
LICENSE OR STATE OF GEORGIA ISSUED PHOTO
ID CARD HERE
IDENTIFICATION DOCUMENT MUST REFLECT
THE CURRENT HOME ADDRESS
*REQUIRED*
Gwinnett County Alcoholic Beverage License Acknowledgment of Transferability (Revised 2-27-2019)
ACKNOWLEDGEMENT OF TRANSFERABILITY
Gwinnett County Alcoholic Beverage License
Pursuant to Section 6-13 of the Gwinnett County Alcoholic Beverage Ordinance,
alcoholic beverage license are not transferable and all alcoholic beverages
sales must cease once ownership is transferred.
I understand that a violation of Section 6-13 will result in revocation of the
license being used and a fine on the new ownership and the old ownership of
not less than three hundred dollars ($300.00) and/or thirty (30) days in jail. I
further understand that a license will not be issued to the old or new owner in
the county for one year from the date of violation.
_____________________________________________________
Applicant Name (LLC / Corporation Name)
_____________________________________________________
Business Name (Trade Name / DBA)
_____________________________________________________
Location Street Address
_____________________________________________________
Location City, State & Zip Code
_____________________________________________________
Printed Name of Sole Owner, Partner, Member, Officer, Director,
Majority Stockholder (Private Corporations), or General Manager
_____________________________________________________
Signature of Sole Owner, Partner, Member, Date
Officer, Director, Majority Stockholder
(Private Corporations), or General Manager
Gwinnett County Alcoholic Beverage License Projected Purchases / Gross Sales (Distilled Spirits) (Revised 02-27-2019)
PROJECTED PURCHASES & PROJECTED GROSS SALES
FOR DISTILLED SPIRITS CONSUMPTION
Gwinnett County Alcoholic Beverage License
_______________________________________________________________
Applicant Name (LLC / Corporation Name)
_______________________________________________________________
Business Name (Trade Name / DBA)
_______________________________________________________________
Location Street Address
_______________________________________________________________
Location City, State & Zip Code
Please provide the following projections for your establishment:
Projected Food Sales
Balance of Calendar
Year of 20 _______ Projection $ _________________________
Ca
lendar Year
of 20 _______ Projection $ _________________________
Pro
jected Gross Sales of Mixed Drinks
Balance of Calendar
Year of 20 _______ Projection $ _________________________
Ca
lendar Year
of 20 _______ Projection $ _________________________
Gwinnett County Certified Report of survey for Alcoholic Beverage License Revised (02-27-19)
CERTIFIED REPORT OF SURVEY
For Gwinnett County Alcoholic Beverage License
Applicant Name (LLC / Corporation Name): ______________________________________________
Business Name (Trade Name / DBA): ____________________________________________________
Com
plete Location Address
: ___________________________________________________________
The undersigned has examined the subject location and has made measurements to determine the
compliance or non-compliance with distance requirement pursuant to the Alcoholic Beverage Ordinance of
Gwinnett County. The undersigned understands and applied the following criteria in making said
determinations:
1. Church Distance requirement applies to any church building. (100 yards minimum)
2. Schools Distance requirement applies to any school grounds, educational grounds, day care
grounds (offering kindergarten instruction), or college campus. The school grounds or
educational grounds or a college campus shall apply only to state, county, city, or church
school grounds and to such grounds at such other schools in which are taught subjects
commonly taught in the common schools and colleges of this State. Campus shall be
defined as grounds used for educational purposes and the space adjoining such
buildings necessary and convenient, and habitually used for educational purposes. (200
yards minimum)
Distance shall be measured by the most direct route of travel on the ground and shall be measured:
from the main entrance of the establishment from which alcoholic beverages are sold or offered for sale
in a straight line, regardless of obstructions, to the nearest public sidewalk, walkway, street, road or
highway
along such public sidewalk, walkway, street road or highway by the nearest route
to the main entrance of the church building, or to the nearest portion of the school grounds
*IF
ADDITIONAL SPACE IS REQUIRED, ATTACH ADDITIONAL COPIES OF THIS FORM*
________________ yards to any church building. Give name and location.
Note: Attach a scale drawing if within 200 yards of the proposed alcohol establishment.
______________________________________________________________________________
________________ yards to any school grounds. Give name and location.
Note: Attach a scale drawing if within 300 yards of the proposed alcohol establishment.
______________________________________________________________________________
In
my opinion, the distances listed above are true and correct.
Signature of Georgia Registered Land Surveyor/Engineer
Date Surveyed
Professional License Number
SEAL
1
FOR OFFICE USE ONLY
ACCOUNT #
________________
CERTIFICATE #
____________________________
AMOUNT PAID:
$___________________
CASH CHECK _______ CARD ____
gwinnettcounty
Department of Planning and Development
Initial Business / Occupation Tax Application
Gwinnett County Licensing and Revenue
446 West Crogan Street, Suite 130
Lawrenceville, GA 30046
(678) 377-4100
This application and all required affidavits/forms must be submitted to the Licensing & Revenue Office in person.
1. TYPE OF OWNERSHIP: (Check One)
Sole Proprietorship Partnership Corporation Limited Liability Company (LLC)
2. BUSINESS: (Check One) HOME BASED COMMERCIAL BASED
(a) Tradename/DBA Name: __________________________________________________________
(b) Business Location: ______________________________________________________________
Address (including Suite/Unit #) (No P.O. Box or Virtual Office)
______________________________________________________________________________
City State
Zip Code Business Phone
(c) Mailing Name: __________________________________________________________________
(d) Mailing Address: ________________________________________________________________
Address (including Suite/Unit #) or P.O. Box
______________________________________________________________________________
City State
Zip Code
3. APPLICANT (NAME OF SOLE OWNER / PARTNER / OFFICER OF CORP / MEMBER OF LLC):
(a) Full Name: ____________________________________________________________________
(b) Mailing Address: ________________________________________________________________
Address or P.O. Box
______________________________________________________________________________
City State
Zip Code Phone
2
4. LOCAL BUSINESS CONTACT PERSON: (for commercial located businesses only)
(a) Full Name: ____________________________________________________________________
MUST BE A GEORGIA RESIDENT
(b) Home Address: _________________________________________________________________
Address (No P.O. Box or Commercial Address)
______________________________________________________________________________
City State Zip Code Phone
5. LEGAL ENTITY (CORPORATION / LIMITED LIABILITY COMPANY / LIMITED PARTNERSHIP):
(a) Complete Legal Entity Name: ______________________________________________________
(b) Date of Formation with the Georgia Secretary of State (MM-DD-YYYY): _____________________
(c) List All Officers / Members / Partners by Name and Position:
Complete Name Position
1: _________________________________________________ ___________________________
2: _________________________________________________ ___________________________
3: _________________________________________________ ___________________________
Attach sheet if additional space is required
6. PARTNERSHIPS NOT FILED WITH THE SECRETARY OF STATE: Date Formed: ___________
MM-DD-YYYY
(a) List Partners:
1. ______________________________________ ___________________________
Full Name % of Ownership
Hom
e Address: ________________________________________________________________________
Address (No P.O. Box or Virtual Office)
___________________________
___________________________________________
City State Zip Code Phone
2. _______________________________________ ____________________________
Full Name % of Ownership
Hom
e Address: ________________________________________________________________________
Address (No P.O. Box or Virtual Office)
___________________________________
___________________________________
City State Zip Code Phone
0%
0%
3
7. FEDERAL TAX ID # _______________________ OR LAST FOUR DIGITS OF THE SS#
FOR THE SOLE OWNER / OFFICER / PARTNER / SOLE MEMBER ____________________
8. DATE BUSINESS WILL OPEN/OPENED AT THIS LOCATION (MM-DD-YYYY): _____________
9. DESCRIBE LINE OF WORK: ______________________________________________________
10. NAICS CODE (6 DIGITS): ______________________ Visit https://www.naics.com/search to
identify code
11. PROJECTED GROSS REVENUE FROM CUSTOMERS IN GEORGIA: $____________________
12. NUMBER OF EMPLOYEES AT THIS LOCATION (INCLUDE OWNER AS ONE): _____________
13. * GEORGIA SALES AND USE TAX ACCOUNT NUMBER (9 DIGITS): _____________________
14. EMAIL ADDRESS (REQUIRED-ANNUAL RENEWALS ARE ONLINE ONLY):
_______________________________________________@_______________.com
I CERTIFY THE ABOVE INFORMATION IS TRUE AND CORRECT AND CONTAINS NO FALSE OR
FRAUDULENT INFORMATION. IN ADDITION, I UNDERSTAND MY BUSINESS LOCATION MUST CONFORM
TO ALL GWINNETT COUNTY ORDINANCES, RULES AND REGULATIONS. FURTHERMORE, I UNDERSTAND
NON-COMPLIANCE WITH ANY GWINNETT COUNTY ORDINANCE, RULE OR REGULATION WILL RESULT IN
NON-RENEWAL OF THE BUSINESS / OCCUPATION CERTIFICATE FOR THIS BUSINESS.
Printed Name: ___________________________________ Title: ______________________________
Sole Owner/President/CEO/Managing Member/Majority Partner
Signature: _______________________________________________ Date: _____________________
Sole Owner/President/CEO/Managing Member/Majority Partner (Original Signature)
Check List for Attachments (Provide Copies)
(All businesses) If this business is a LLC, Corporation or Limited Partnership, provide a copy of the GA
Secretary of State Certificate of Organization / Incorporation and Articles listing all officers and agents
(All businesses) If your profession / occupation is required to obtain a state license, health permit, or
any other regulatory approval from any state, federal or professional licensing board, provide a copy of
the current license / certification
(All businesses) Original notarized E-Verify Private Employer of Compliance Affidavit
(All businesses) Original notarized U.S. Citizen / Qualified Alien Affidavit along with a front and back
copy of your secure and verifiable identification document
(Commercial based businesses) Fire & Building Certificate of Occupancy reflecting your
DBA/Tradename
(Home based businesses) State of GA issued Driver’s License/Photo ID showing current home
address, which must match location address on Page 1
* Contact the Georgia Department of Revenue (Georgia Tax Center) to determine if required for this business type
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