Fill - Free fillable CHECK-OFF LIST FOR ALCOHOLIC BEVERAGE LICENSE ( ) PDF form

City of Chamblee

City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

CHECK-OFF LIST FOR ALCOHOLIC BEVERAGE LICENSE

ALL APPLICANTS:

( ) APPLICANT WORKSHEET

( ) APPLICATION – All blanks must be completed, signed, and notarized.

( ) LIST OF OWNERS – For businesses not publicly traded: A list of business owners including their names, city and state of

their residential and work addresses, and ownership percentages for every owner. For publicly traded businesses: A list

of corporate officers including their names, city and state of their residential and work addresses and corporate titles.

( ) HOURS –Operating hours information [for restaurants, see 6-142(b)(2)].

( ) REVIEW OF ALCOHOL ORDINANCE and the following notes:

1. It is advisable that applicants of any business, liquor, beer and/or wine licenses make no expenditures, sign

no contracts or obligate themselves in any manner without first making themselves aware of all

requirements for State and City Code compliance.

2. Handling permit requirement.

( ) PERSONNEL STATEMENTS – Required of the primary applicant and of each additional applicant on the Applicant

Worksheet (defined in City Code Sec. 6-1). Original pictures are required on each form.

( ) S.A.V.E. AFFIDAVIT – Required with each Personnel Statement. Must be notarized and a copy (front and back) of

approved document attached.

( ) PRIVATE EMPLOYER AFFIDAVIT – Must be notarized – please make sure you complete parts that apply to your

business – 10 or fewer employees OR 11 or more employees

( ) REGISTERED AGENT FORM – Registered agent must reside in DeKalb County.

( ) AFFIDAVIT OF PERSON HAVING KNOWLEDGE OF REGISTERED AGENT RESIDENCE – Must be notarized.

( ) LEGAL SURVEY – Scale drawing showing business location and completion of enclosed SURVEYOR’S CERTIFICATE (Sec 6-46(d)).

( ) FLOOR PLAN DRAWING – Restaurants seeking to be licensed for consumption on premises must provide a diagram in

accordance with 6-142(b)(1). Retail package sales of wine and malt beverages must meet the requirements stated in

City Code Sec 6-121.

( ) STATEMENT OF FLOOR AREA – Restaurants must meet requirements stated in City Code Sec 6-142(a)(2).

( ) PAYMENT – Prorated on number of remaining months in calendar year; any portion of a month is counted as a full month.

( ) OCCUPATIONAL TAX CERTIFICATE APPLICATION – Submitted to the City Clerk’s Office with required documents.

( ) FINGERPRINTS – Register with G.A.P.S. Wait for approval, via email, from G.A.P.S. to go to the fingerprinting location.

NOTE: This will occur after submitted the application with each applicant personnel statement and SAVE affidavit.

( ) STATE ALCOHOL LICENSE

APPLICANTS FOR CONSUMPTION-ON PREMISES LICENSE:

( ) COPY OF MENU

( ) LIST OF EMPLOYEES

( ) LIST OF WHOLESALE DISTRIBUTORS – Cannot purchase and re-sell alcohol from retail establishment (i.e. Sam’s,

Costco, B.J.’s, Tower, etc.).

( ) AFFIDAVIT – ALCOHOL AND FOOD SALES (if open prior to applying for alcohol license)

( ) BUSINESS SEEKING TO OPERATE AFTER 12:30 AM MUST PROVIDE:

( ) Safety plan as set forth in City Code Sec. 6

-155.

( ) Promotional information (print advertisements, social media info). See City Code Section 6-142(b)(3)(b) & (b)(3)(c).

ADDITIONAL INFORMATION FOR WHOLESALER ONLY APPLICANTS:

( ) PERFORMANCE BOND

( ) LIST OF EMPLOYEES

Note: An applicant shall supplement the information provided in its application in writing by certified mail, return receipt

requested, to the city clerk within ten (10) working days of a change of circumstances which would render the information

originally submitted inaccurate or incomplete. (See City Code Sec. 6-44(c)).

City of Chamblee

City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

APPLICANTS WORKSHEET

STEP ONE: List those who have an influential interest in the establishment. Complete all columns in this step, except for Column 2.

Influential interest means the actual power to control or influence the operation, management, or policies of an establishment

or legal entity which operates the establishment. An individual is deemed to have an “influential interest” if he or she:

(1) is the on-site general manager of the establishment,

(2) owns a financial interest of ten percent or more of a legal entity operating the establishment, or

(3) holds an office (e.g., president, vice president, secretary, treasurer, managing member, managing director, etc.) in a

legal entity which operates the establishment. (City Code Sec. 6-1, see “Influential interest”)

STEP TWO: In Column 2, write “P” to indicate the Primary Applicant for this application.

Primary applicant means the individual with an influential interest in the establishment who is primarily responsible for

alcoholic beverage matters for the establishment applying for an alcoholic beverage license. (City Code Sec. 6-1, see “Applicant”)

STEP THREE: In Column 2, write “A” to indicate the Additional Applicant(s) for this application.

Additional applicant means any other individual with an influential interest in the establishment who lives or has an office in any

of the following Georgia counties: Cherokee, Clayton, Cobb, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry,

Newton, and Rockdale. (City Code Sec. 6-1, see “Applicant”)

STEP FOUR: The Primary Applicant and each Additional Applicant must complete a Personnel Statement, complete a SAVE affidavit, and

provide his/her fingerprints for a criminal background check. (City Code Sec. 6-44(a), (c).)

Name (First Middle Last)

Column 2

Residence

Office (where person works)

City

State

County

City

State

County

Check here _____ and use extra pages, if necessary, to list and provide information for other individuals with an influential interest in the establishment.

The above is accurate and true as of the date of submission of the application/renewal with the City of Chamblee.

_________________________________________________________________________________ ___________________________

Primary Applicant Signature Date

_________________________________________________________________________________

Primary Applicant Printed Name

Business Name & DBA: _________________________________________________________________________________

Cit f Ch bl Cit H lCit f Ch bl Cit H l

City of Chamblee

City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

CITY OF CHAMBLEE PRIVILEGE LICENSE APPLICATION

INSTRU

CTIONS: Every question must be fully and correctly answered. If space provided is not sufficient, answer the question on a separate sheet and indicate

in the space provided that a separate sheet is attached. When completed, it must be dated, signed, and verified, under oath by the primary applicant and

filed with the City Clerk, 5468 Peachtree Road, Chamblee, GA 30341, together with all supporting papers and Cash, Money Order, Cashiers or Certified Check

for the exact fees. If license requirements are satisfied, the license will issue to the primary applicant, business, and other applicants listed in the application.

Check on

e: ( ) New Location ( ) New Licensee ( ) New Ownership ( ) Other Changes (Specify): _______________________________________________

TYPE OF BU

SINESS Check one:

( ) Package Store ( ) Grocery Store ( ) Restaurant ( ) Convenience Store ( ) Country Club

( ) Art Shop ( ) Performing Arts Facility ( ) Manufacturer ( ) Other (specify): _____________________________________________________

TYPE OF LI

CENSE: ( ) Retail/Package ( ) Wholesaler ( ) Consumption on Premises ( ) Manufacturer

Annual Fee Monthly Fee *Months Fee Due

(1) Liquor/Beer/Wine $5,000 $416.67 x _______ =

(2) Beer/Wine $2,500 $208.34 x _______ =

(3) Beer Only $1,250 $104.17 x _______ =

(4) Wine Only $1,250 $104.17 x _______ =

(5) ** Sunday Sales $1,700 $141.67 x _______ =

(6) Art Shop $ 500 $ 41.67 x _______ =

(7) Performing Arts Facility $1,000 $ 83.33 x _______ =

(8) Manufacturer $ 500 $ 41.67 x _______ =

(9) Wholesaler $ 750 $ 62.50 x _______ =

Administrative and Investigation Fee =

Fingerprinting Fee =

Total Due =

$______________________

$200.00

Paid online via GAPS

$______________________

*LICENSES ARE ISSUED ONLY FOR NUMBER OF MONTHS REMAINING IN CALENDAR YEAR. ANY PARTIAL MONTHS SHALL BE COUNTED AS A FULL MONTH.

LICENSE FEES ARE NOT REFUNDABLE.

**SUNDAY SALES PERMITS ARE ISSUED ONLY TO CONSUMPTION ON PREMISES ESTABLISHMENTS.

Primary Applicant (Must print legibly):

Full Name (Last, First, Middle Initial): ____________________________________________________________________________________________________

Phone Nu

mber: (______) ______ - ________ Date of Birth

(MM/DD/YYYY): ____ - ____ - ________ E-Mail: ________________________________________

Home Addr

ess

(Street, City, State, Zip Code): ______________________________________________________________________________________________

Business Information (Must print legibly):

Legal Name: _____________________________________________________________________________________________________________________

Doing Busine

ss As

(If applicable – This is the name that will appear on the business location door): _______________________________________________________

Location

(Street, Suite, City, State, Zip Code): ______________________________________________________________________________________________

Mailing

Address

(Street, City, State, Zip Code): ____________________________________________________________________________________________

Federal E

mployer Identification Number/SSN: ___________________________________ Georgia Sales Tax Number: ______________________________

Georgia W

ithholding Number: ________________________________________________ E-Mail: ______________________________________________

Is the business pu

blicly traded? ( ) Yes ( ) No Phone Number: (______) ______ - ________ Phone Fax: (______) ______ - ________

Type of B

usiness: ( ) Partnership or Association ( ) Sole Proprietor ( ) Corporation: Type of Corporation: ________ Place of Incorporation: _______

Owner(s)/Corporate Officer(s):

Name Corporate Title Residence City/State Work Address (street, city, state, zip code) % Interest

Use additional page if necessary with the same information if additional space for owner(s)/corporate officer(s) is needed.

For Office Use Only:

$__________ Finger Printing Fee $__________ Investigation Fee $__________ License Fee $__________ Total Paid __________ Check Number __________ Date Sent to PD

City of Chamblee

City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

CITY OF CHAMBLEE PRIVILEGE LICENSE APPLICATION (Continued)

Day(s) & Time(s) of Operations: Does this establishment seek to remain open any time after 12:30 am?

Yes No

Monday: ____________________________________ Tuesday: ____________________________________

Wednesday: _________________________________ Thursday: ____________________________________

Friday: ______________________________________ Saturday: ____________________________________

Sunday: _____________________________________

If a restaurant, does the establishment serve the prepared meals described on its menu every hour that it is open?

Yes

Not applicable (because the establishment is not a restaurant)

If NO, EXPLAIN: _______________________________________________________________________________________________

NOTE: Before signing this application, check all answers and explanations to see that you have answered all questions fully and correctly. This

application is to be executed under oath and subject to the penalties of false swearing and it includes all attached sheets submitted

herewith. Licensee understands that any license issued pursuant to this application is conditioned upon the truth of the answers and

statements made herein and that any false answers and statements herein shall constitute cause for the suspension or revocation of any

license issued pursuant to this application.

I, _____________________________________________________, do solemnly swear, subject to the penalties of false swearing, that

the statements and answers made by me as the primary applicant in the foregoing application are true and correct. Furthermore, I affirm

that the City of Chamblee may request an audit, at any time at the businesses expense to verify any information provided. I affirm that I

have read the City of Chamblee Alcohol Ordinance. In making the above representation under oath, I understand that any person who

knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of violation of

O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal state.

_______________________________________________________

Primary Applicant Signature (Full name in ink)

I hereby certify that ______________________________________________ State of Georgia ___________________________ County

Full name of Primary Applicant

signed his name to the foregoing after stating to me that he knew and understood all statements and answers made therein, and, under

oath actually administered by me, has sworn that said statements and answers are true.

This _____________ day of _____________________________ 20____

(SEAL)

_______________________________________________________

Notary Public

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

PERSONNEL STATEMENT

Instructions: A personnel statement must be executed under oath, by the Primary Applicant and by each Additional Applicant (see

definitions in City Code Section 6-1) applying for an alcoholic beverage license. Each question must be fully answered. If space

provided is not sufficient, answer the question on a separate sheet and indicate in the space provided that a separate sheet is

attached. A personnel statement for all the above persons must be submitted with each license application.

1. Full Name ___________________________________________________________________________________________________

2. Full name and address of business of which this personnel statement is a part:

____________________________________________________________________________________________________________

3. Position of applicant in business:_________________________________________________________________________________

4. State ownership or interest, if any, in this business:____________________________________________________________________

5. Do you have any financial interest, or are you employed in any wholesale or retail business engaged in distilling, bottling, rectifying or

selling alcoholic beverages? _____________________________________________________________________________________

If yes, give names and locations and amount of interest in each:_________________________________________________________

____________________________________________________________________________________________________________

6. Have you ever had any financial interest in an alcoholic beverage business which was denied a license? _________________________

If so, give details: ______________________________________________________________________________________________

Has any alcoholic beverage business in which you hold, or have held, any financial interest, or are employed, or have been employed,

ever been cited for any violation of the rules and regulations of the State Revenue Commissioner relating to the sale and distribution

of alcoholic beverages? ____________ If so, give details: ______________________________________________________________

____________________________________________________________________________________________________________

8. If during the past ten years you have bought and sold any alcoholic beverage business, give details (date, license number, persons

and considerations involved). ____________________________________________________________________________________

____________________________________________________________________________________________________________

9. Have you ever been denied bond by a commercial security company? ____________ If so, give details: _________________________

____________________________________________________________________________________________________________

10. Other names used by applicant: Maiden name, names by former marriages, former names changed legally or otherwise, aliases,

nicknames, etc. Specify which, and show dates used:________________________________________________________________

___________________________________________________________________________________________________________

11. Home address ________________________________________________________ Home Phone_______ - _______ - __________

Business address _____________________________________________________ Business Phone______ - ________ - ________

12. Date of Birth ____/____/_______

13. Single ________ Married ________ Widowed ________ Divorced ________ Separated ________

14. If married or separated, complete the below requested information on spouse/partner:

Full name of spouse: _________________________________________________________________________________________

Birth Name: _________________________________________________________ Date of Birth: ______-_______-____________

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

(Attach Photo Here)

PERSONNEL STATEMENT (Continued)

15. Employment Record for the past ten years (Give most recent experience first):

Dates Employed (from/to)

Month Year Month Year

Occupation and Description

of Duties Performed

Salaries

Received

Employers Reason for Leaving

16. List of all of your residences for the past ten years (Give current/most recent residence first):

Dates

From To

Street City State

17. Have you ever been arrested, or held by Federal, State or other law-enforcement authorities, for any violation of federal law, state

law, county or municipal law, regulation or ordinances? (Do not include traffic violations. All of the charges must be included, even if

they were dismissed. Give reason charged or held, date, place where charged, disposition. If no arrest, write no arrest. After last arrest

is listed, please write no other arrest).

____________________________________________________________________________________________________________________________________________________

18. Attach photograph (front view) taken within the past year.

19. To complete this application, I will submit a complete set of my fingerprints, via G.A.P.S., for a

criminal background check.

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 attached sheets submitted herewith.

State of Georgia, ________________________________ County

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 personnel statement are true and correct.

____________________________________________________________________

Applicant’s Signature

I hereby certify that _________________________________ signed his/her name to the foregoing application stating to me that he/she knew and understood all

statements and answers made therein, and, under oath, actually administered by me, has sworn that said statements and answers are true and correct.

This ____________ day of ________________________, 20_____. _____________________________________________ _________________________

Notary Public My Commission Expires

(Seal)

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

S.A.V.E AFFIDAVIT

Affidavit Verifying Residency Status of an Applicant as Required by the

Georgia Security and Immigration Compliance Act O.C.G.A. § 50-36-1(e)(2)

This form is required from both primary and additional applicants for ALL LICENSES/PERMITS by State Law

By executing this affidavit under oath, as an Applicant, as a City Vendor, or as a Recipient for other public benefit as referenced in

the Georgia Security and Immigration Compliance Act, (O.C.G.A. § 50-36-1), I am stating the following:

□ I am a United States citizen, or

(Must include a copy of either current State Driver’s License, Passport, Military ID, or other approved document*.)

□ I am a legal permanent resident of the United States**, or

(Must include a copy of your Permanent Resident Card or other approved document*.)

□ I am a 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**(Must include a copy your Employment

Authorization Card or other approved document*.)

**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.

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious,

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.

Executed in _____________________________________ (City), __________________(State).

Signature of Applicant Date

Printed Name of Applicant

SCRIBED AND SWORN BEFORE ME ON THIS THE _____ DAY OF ___________________, 20____.

NOTAR

Y PUBLIC

(Seal)

My Commission Expires

*A complete list of verifiable documents can be found on the City of Chamblee website under Occupational Tax Certificates or on

the Georgia Attorney General’s website (O.C.G.A. § 50-36-2).

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

Private Employer Affidavit Pursuant to O.C.G.A. §36-60-6(d)

By executing this affidavit under oath, as an applicant for an Alcohol License as referenced in O.C.G.A. §36-30-6(d), from the City of Chamblee, the

undersigned applicant representing the private employer known as

(Name of Business) verifies one of the following with respect to my application for the above mentioned document:

Section 1:

Choose ONE of the following:

a. On January 1

of the below signed year the individual, firm, or corporation employed more than ten (10) employees.

Complete Section 2 and 3 below.

b. On January 1

of the below signed year the individual, firm, or corporation employed ten (10) or fewer employees.

Complete Section 3 below.

Section 2:

The employer has registered with and utilizes the federal work authorization program in accordance with the applicable provisions and

deadlines established in O.C.G.A. §36-60-6(a). The undersigned private employer also attests that its federal work authorization user

identification number and date of authorization are as listed below:

Federal Work Authorization User Identification Number Date of Authorization

(This number is between 4-8 digits and does not include letters)

Section 3:

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or

fraudulent statement or representation in an affidavit shall be guilty of violation of O.C.G.A. § 16-10-20, and face criminal penalties allowed by

such statute.

Executed on the date of , 20 in

(city), (state)

Signature of Authorized Officer or Agent

Printed Name of and Title of Authorized Officer or Agent

SCRIBED AND SWORN BEFORE ME ON THIS DAY OF , 20

(Seal)

NOTARY PUBLIC

My Commission Expires:

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

REGISTERED AGENT FORM

______________________________________

BUSINESS NAME

______________________________________

BUSINESS LOCATION

______________________________________

CITY/STATE/ZIP

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 provisions of Ordinance #308 of the City

of Chamblee. (Every establishment holding an alcoholic beverage license in the City must have a registered agent and this

person must be a resident of DeKalb County).

This _____________day of _________________________, 20_______.

REGISTERED AGENT INFORMATION:

______________________________________________ ___________________________________________

Signature of Agent Agent Date of Birth (MM/DD/YYYY)

______________________________________________ ____________________________________________

Type or print name of Agent Agent E-Mail

______________________________________________

Agent’s Home Address

______________________________________________

Agent’s City, State, Zip Code

PRIMARY APPLICANT:

______________________________________________

Signature of Primary Applicant

______________________________________________

Type or print name of Primary Applicant

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

AFFIDAVIT OF PERSON HAVING KNOWLEDGE OF REGISTERED AGENTS RESIDENCE

STATE OF GEORGIA, _______________________________COUNTY:

Personally appeared before the undersigned Notary Public one ____________________________________________

(name of person having knowledge)

who says, under oath, that he/she is personally acquainted with ______________________________________________,

(name of Registered Agent)

and that he/she knows of his/her own knowledge that said registered agent has resided in the County of DeKalb, State of

Georgia, since 20_____, and is now a resident of said State and County, as of _______ day of __________, 20_____, and

resides at ____________________________________________________________________________.

(address of registered agent for past year)

_______________________________________

Affiant

Sworn to and subscribed before me, this _______ day of _____________________, 20______.

__________________________________________

Notary Public (Seal)

City of Chamblee

City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

REPORT OF SURVEY FOR ALCOHOLIC BEVERAGE LICENSE

DATE: _____________________

TO: CITY CLERK, CITY OF CHAMBLEE

PRIMARY APPLICANT: ___________________________________________________________________________________

BUSINESS & DBA (if applicable) NAME: _____________________________________________________________________

BUSINESS ADDRESS: ____________________________________________________________________________________

THE UNDERSIGNED HAS EXAMINED THE SUBJECT LOCATION AND HAS MADE MEASUREMENTS TO DETERMINE

THE COMPLIANCE OR NON-COMPLIANCE WITH DISTANCE REQUIREMENTS IN ACCORDACE WITH CITY CODE § 6-46:

200 YARDS MINIMUM

1. _______________ yards to the _______________________________________________________________________________

(school building, school ground, and college campus, this includes kindergarten or churches which have schools or kindergartens)

located at

_________________________________________________________________________________________________________

100 YARDS MINIMUM

1. _______________ yards to the ______________________________________________________________________________

(church or other place used primarily for religious service) located at

________________________________________________________________________________________________________

2. _______________ yards to the ______________________________________________________________________________

(alcoholic treatment center owned and operated by this state or any council or municipal government therein) located at

_________________________________________________________________________________________________________

3. _______________ yards to the ______________________________________________________________________________

(parcel of land located in a residential zoning district*) located at

_________________________________________________________________________________________________________

AFTER READING CITY OF CHAMBLEE CODE § 6-46, IN MY OPINION, THE PREMISES INDICATED ABOVE MEET THE DISTANCE

REQUIREMENTS FOR LICENSING.

NOTE:

SURVEY SHOWING DISTANCE TO THE

USE ABOVE MUST BE ATTACHED. _______________________________________________

GEORGIA REGISTERED LAND SURVEYOR

_______________________________________________

SURVEYOR NO.

(SEAL)

STATEMENT OF FLOOR AREA

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

Name of Business & DBA

(if applicable): _____________________________________________________

Business Location Address: ______________________________________________________________

Street City State Zip Code

The total square footage of floor area occupied by the establishment is: _________________

The total square footage of floor area accessible to patrons is: _________________

The total square footage of floor area devoted to tables and seating for patron dining is: _________________

RESTAURANTS: A copy of the floor plan in accordance with city code section 6-142(a) is attached.

RETAIL of package sales of wine and malt beverages must meet the requirements stated in city code

section 6-121.

I, , certify subject to the penalties for false swearing, that the

foregoing is true and correct.

____________________________________ ______________________________________

Primary Applicant Printed Name Primary Applicant Signature

Signed and sworn to before me on this _____ day of _________________________, 20_____

________________________________________________________

Notary Signature and Seal

My commission expires: ________________________

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

List of Employees and Wholesale Distributors

List the name of your employees below:

1._____________________________________ 14._____________________________________

2._____________________________________ 15._____________________________________

3._____________________________________ 16._____________________________________

4._____________________________________ 17._____________________________________

5._____________________________________ 18.____________________________________

6.____________________________________ 19.____________________________________

7.____________________________________ 20.____________________________________

8.____________________________________ 21.____________________________________

9.____________________________________ 22.____________________________________

10.____________________________________ 23.____________________________________

11.____________________________________ 24.____________________________________

12.____________________________________ 25.____________________________________

13.____________________________________ 26.____________________________________

List the name of your distributors below:

1.______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

4.______________________________________________________________________

5.______________________________________________________________________

6.______________________________________________________________________

7.______________________________________________________________________

8.______________________________________________________________________

AFFIDAVIT - ALCOHOL AND FOOD SALES

(Consumption on the Premises Alcoholic Beverage License Application)

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

This form is required for all consumption-on premises alcoholic beverage license applications (see city code section 6-4(c)(1))

Instructions for the Alcohol and Food Sales Affidavit:

Column A: “Total Monthly Revenue” – Total monthly revenue of the establishment.

Column B: “Total revenue from food & nonalcoholic beverages” – Revenue derived from the sale of food prepared and consumed on premises and nonalcoholic

beverages consumed on the premises.

Column C: “Percentage of total revenue from food & non-alcoholic beverages” – This percentage is Column A (Total Monthly Revenue) divided by Column B (Total

revenue from food & non-alcoholic beverages).

Column D: “Total revenue from charges to enter or remain on premises” – Use this column to report the revenue derived from charges to enter or remain on the

premises.

Column E: “Total revenue from alcoholic beverages” – Use this column to report the revenue from the sale of alcoholic (wine, malt and distilled) beverages

combined.

Column F-H: “Total revenue from (fill in blank) (category > 10%)” – Use these columns to report revenue from any other category that exceeds ten percent (10%) of

the monthly revenue not accounted for in a columns B, D or E. For example, “carry-out” food orders, merchandise sales, parking, tobacco, hookah, etc.

If additional space is needed add monthly information on a separate form. Write the category reported on the lines provided.

Column I: “Total revenue for categories that do not individually exceed 10%” – Use this column to report any other combined revenue derived from categories that

individually do not exceed 10% of monthly revenue. For example, “carry-out” food orders, merchandise sales, parking, tobacco, hookah, etc.

Establishments licensed as a restaurant who desire to remain open to the public after 12:30 a.m. must provide a sworn statement (affidavit) from a

certified public

accountant (CPA), which reports the information required in subsection 6-4(c)(1) of the city code for each of the last 12 months (also see city code section 6-

142(b)(3)(d)).

AFFIDAVIT - ALCOHOL AND FOOD SALES

(Consumption on the Premises Alcoholic Beverage License Application)

City of Chamblee City Hall

5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov

Name of Applicant Business: 12 month period:

month/year - month/year

Applicant Business Address:

Street City State Zip Code

This affidavit must be completed and signed under oath in accordance with City Code section 6-4(c)(1) (and by a CPA if 6-142(b)(3)(d) applies). The following must be

provided for the last twelve months. If the business has not been open that long, state the start date: _____________________.

A B C D E F G H I

Month/Year

(MM/YYYY)

Total monthly

revenue

Total revenue

from food & non-

alcoholic

beverages

Percentage of total

revenue from food

& nonalcoholic

beverages

Total revenue

from charges to

enter or remain

on premises

Total revenue

from alcoholic

beverages

Total revenue

from

_______________

(category > 10%)

Total revenue

from

_______________

(category > 10%)

Total revenue

from

_______________

(category > 10%)

Total revenue for

categories that do

not individually

exceed 10%

10.

11.

12.

I, , certify subject to the penalties for false swearing, that the foregoing is true and correct.

____________________________________ ______________________________________ ______________________

Printed Name Signature (if a CPA, CPA License No.)

Signed and sworn to before me on this _____ day of _________________________, 20_____

________________________________________________________

Notary Signature and Seal

My commission expires: ________________________

Food must be prepared and consumed on premises

Write the category reported on the lines provided (e.g., merchandise sales, parking, tobacco, etc.)

Fill Online, Printable, Fillable, Blank CHECK-OFF LIST FOR ALCOHOLIC BEVERAGE LICENSE ( ) Form

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Fillable CHECK-OFF LIST FOR ALCOHOLIC BEVERAGE LICENSE ( )

Fill Online, Printable, Fillable, Blank CHECK-OFF LIST FOR ALCOHOLIC BEVERAGE LICENSE ( ) Form

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