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ALCOHOLIC BEVERAGE LICENSE INFORMATION & CHECKLIST FOR ATTACHMENTS

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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

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

(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: ________________________________________

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 NO – If yes, provide:

Name

of Lender Date Amount Interest rate

_______________________________________________________________________________

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

______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: _________________________

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

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

______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.

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.

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 $ _________________________

lendar Year

of 20 _______ Projection $ _________________________

Pro

jected Gross Sales of Mixed Drinks

Balance of Calendar

Year of 20 _______ Projection $ _________________________

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.

______________________________________________________________________________

my opinion, the distances listed above are true and correct.

Signature of Georgia Registered Land Surveyor/Engineer

Date Surveyed

Professional License Number

SEAL

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

(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

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): _____________________

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

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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ALCOHOLIC BEVERAGE LICENSE INFORMATION & CHECKLIST FOR ATTACHMENTS

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Completed 2 September 2020

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