Fillable City of South Fulton Alcohol Beverage License Application (City of South Fulton)

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City of South Fulton Alcohol Beverage License Application (City of South Fulton)

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City of South Fulton
Alcohol Beverage License Application
and Information Packet
Revised 07/1/20
South Fulton Police Department
License and Permit Unit
5539 Old National Highway
College Park, GA 30349
470-809-7372
pdlicenses@cityofsouthfultonga.gov
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
2
APPLICATION INSTRUCTION SHEET
Incomplete or partial applications will not be accepted.
Please answer all questions on application legibly and appropriately in black/blue ink or typed. If a question does not apply to you, write “N/A”
in the space provided.
The personal history statement must be completed by the owner/licensee/agent and corporate officers or major stakeholders of the
business/organization with 20% or more of interest in business. Each person completing the personal history statement will pay the non-
refundable fingerprint fee is $55.00 per individual. Upon submission of a completed application you will be scheduled to get your fingerprints
completed. Please do NOT show up to get fingerprints without an appointment.
If you are a corporation or LLC, copies of your certificate of incorporation/corporate charter/by laws, properly signed by the Secretary of State
and the registered agent(s) for the corporation.
Application must be accompanied by a Federal Clearance Letter verifying the applicant/agent/licensee has no federal indictments or pending charges.
The Federal Clearance Letter may be obtained from the Federal District Court (see the Clerk of Court) Richard B. Russell Building, 75 Ted Turner
Drive, Atlanta, GA 30303. There is a cost of $31.00 for the Clearance Letter - per name.
Application must be accompanied by a Certificate of Residency verifying Applicant/Agent/Licensee is a resident of the thirteen Metropolitan
counties (Cherokee, Clayton, Cobb, Coweta, Dekalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry, Paulding and Rockdale). Applicants
may take the enclosed certificate of residency form to the Probate Court of the county in which they reside to have the form signed by clerk of
court.
Application must be accompanied by Proof of Citizenship by secure and verifiable document as outlined in O.C.G.A. § 50-36-2 (i.e. in the form
of government issued photo ID) and applicant must complete the enclosed Citizenship Affidavit for Public Benefits and E-Verify Affidavit.
Application must be accompanied by Survey of location prepared by a Registered Survey noting the distances per City Ordinance Sec. 16-
4001. The survey must be of the proposed premises depicting the distance requirements as specified on the alcoholic beverage application
(question #5). The survey must also state how the property was measured (from what point of the premises to what point of the measured
location and the direction of measurement).
Application must be accompanied by a copy of your City of South Fulton current occupational tax certificate. Applicants may submit a
copy a temporary occupational tax certificate however, a permanent occupational tax certificate must be received before your alcohol license
application will be submitted for council for approval.
Application must be accompanied by a copy of a signed deed, lease, sublease, rental agreement, etc., authorizing applicant’s use of location.
All applicants must disclose financial investments pertaining to the business operation. Financials include bank statements for the six months
prior to filing application.
As part of the application process, the police department will arrange for the following inspections to be approved by the following entities: Fire,
Health, School Board, Zoning and Code Enforcement. Applications will not be submitted to council for approval until all required inspections
are completed.
Application must be accompanied by a drawing of the alcohol license premises including the customer service area (if restaurant, club, bar,
etc.), to include measurements of total square footage of service area. Note: additional fees may apply for additional bar areas based upon
layout of location.
As part of the application process, the police department will arrange for the advertisement of the public hearing regarding your application. The
applicant is responsible for the advertisement fee of $505. (see fee page for cost)
The City’s Alcoholic Beverage Ordinance Sec.16-2017, requires alcohol awareness training to be completed by
Applicant, Agent, Licensee
and all employees who dispenses, sells, serves, takes orders or mixes beverages. See Ordinance for further or website at
https://www.cityofsouthfultonga.gov/2882/Alcohol-Awareness-Training
If there are any questions concerning the completion of the application, please call the South Fulton Police License and Permit Unit for assistance at
470-809-7372 or pdlicenses@cityofsouthfultonga.gov.
Upon completing your application, you may submit it for review along with all required documents to the license and permit unit at
pdlicenses@cityofsouthfultonga.gov . Once the application has been reviewed and all necessary documents are approved, an investigator will
contact the applicant to schedule an appointment for the formal filing of the original application and supporting documents.
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
3
ALCOHOL LICENSE FEE SCHEDULE
The following alcohol license fees are hereby established and shall be payable by check, money
order, or debit/credit card, as applicable, at the time of filing the application:
Administrative Fees:
Alcohol License Application Fee ............................................................ 300.00
All other Application Fees .................................................................... $150.00
Background / Fingerprint Fee ............. ……………………………………$55.00
Advertising Fee…… ............................................................................. $505.00
Fire Inspection Fee ................................. …………………………………$75.00
LICENSE FEES:
Retail Consumption on Premises
Liquor ................................................................................... …………$3200.00
Beer .............................................................................................. ……$650.00
Wine ............................................................................ .................... …$650.00
Add’ Bar/Lounges…………………………….………… ............... ……$1000.00
BYOB Wine ................................................................. ........................ $125.00
Wine & Malt Tasting (No Distilled Spirits)…………… . .............. ………$50.00
Note: Premises offering sale by the drink require an additional fee (16-2003) for the
operation of each lounge, separate restaurant (with separate bar), or other place for
consumption on the premises located within the same building covered by the initial
license and under the same ownership. In addition to the initial license fee, an annual
fee of $1000.00 will be charged for each additional bar.
Special Permit Fees
Non-Profit Special Event, Beer, Wine & Distilled Spirits/Liquor ............. $50.00
For-Profit Special Event Beer & Wine ........................... ..................... $125.00
For-Profit Special Event Distilled Spirits / Liquor .......... ...................... $125.00
Annual Off Premises Catering License ......................... ...................... $200.00
Off Premises Per Event Catering Permit ...................... ........................ $50.00
Retail Package
Distilled Spirits /Liquor .................................................. ................... $3000.00
Beer ............................................................................. ...................... $400.00
Wine .............................................................................. ...................... $400.00
Temporary Alcohol License Fee
Distilled Spirits /Liquor (Sale/Consumption on Premises) ................... $500.00
Beer and wine (Sale/Consumption on Premises) ........ ....................... $250.00
Beer and Wine (Retail Package) ................................. ...................... $250.00
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
4
Wholesale:
Distilled Spirits / Liquor ...................................................................... $3500.00
Beer .............................................................................. ...................... $500.00
Wine ............................................................................... .................... $500.00
Location Outside of City ................................................. ..................... $100.00
Manufacturer (Distillery):
Distilled Spirits/ Liquor .................................................. ................... $4000.00
Beer ............................................................................... .................... $500.00
Wine ............................................................................... ..................... $500.00
Microbrewery
.............................................................. .................... $2000.00
Growler
........................................................................ .................... $2000.00
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
5
PERSONAL STATEMENT
INSTRUCTIONS: This personal statement must be executed, under oath, by every person having any ownership or profit-sharing
interest in or managing any place of business applying for a license from the City of South Fulton to sell or deal in alcoholic beverages.
Each question must be fully answered. If the space provided is not enough, answer the question on a separate sheet and indicate in the
space provided that such separate sheet is attached.
Applicant Name in FULL (Please Print)
Home Address:
Business Address:
Place of Birth Date of Birth: Age: _________
(City, State, Country) (Day, Month, Year)
Race: Height: Weight: Eye Color:
U.S. Citizen______ By Birth___________
Hair Color: __________Social Security Number:_____________________Driver License Number:
_________________
State Issued by: _________
Have you been convicted of any law? Federal:
Foreign Country:
State Law:
and/or
City Ordinance: if so, explain:
List names and addresses of employers for the past three (3) years:
Single_______ Married_________ Widowed ________ Divorced ________ Separated _______
(If married, divorced or widowed, complete the below requested information on spouse).
____________________________________________ ______________________________
Full name of spouse / (Maiden Name) DOB
__________________________________________________________________________________________________________
I, the undersigned, do solemnly swear and attest, subject to criminal penalties for false swearing, that the information provided in this Personal
Statement and in any and all documents provided in support of this application are true and accurate. I further understand that any false statements
provided by me or my representatives as part of this application, beyond any legal penalties, will result in the denial of the subject application.
___________________________________________ _________________________________________ ___________________________
Applicant’s Printed Name Applicant’s Signature Date of Application
I hereby certify that ______________________________________signed her/his name to the foregoing application stating to me that he/she knew
and understood all statements and information contained therein and, under oath actually administered by me, has sworn that said statements and
information are true and correct.
This ____________________ day of __________________________, 20____ .
Notary Public Signature: ________________________________________________ (AFFIX SEAL)
Notary Printed Name: __________________________________________________
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CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
6
RESIDENCE DETERMINATION FORM
Certificate of Residence
For Retail Package Distilled Spirts Applicants Only
State of Georgia, County
I, Judge of the probate Court, for ________________________
County, Georgia, hereby certify that is now and has been a Bona Fide Resident
of the state of Georgia for one year, and in the county of for one year immediately
preceding the date of this affidavit, based upon the affidavit of applicant, and the evidence submitted therewith.
In Witness Whereof, I have hereunto set my hand and affixed the seal of said Probate Court this day of
, 20 .
Judge of the Probate Court
County, Georgia
******************************************************************************************
Certificate of Residence
For All Other Alcoholic Beverage License Applicants
State of Georgia, County
I, Judge of the probate Court, for _________________________
County, Georgia, hereby certify that is now and has been a Bona Fide Resident of
the state of Georgia in the county of based upon the affidavit of applicant and the
evidence submitted therewith. In Witness Whereof, I have hereunto set my hand and affixed the seal of said
Probate Court this day of , 20 .
Judge of the Probate Court
County, Georgia
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
7
Save Affidavit
Affidavit Verifying Status for City Public Benefit
Pursuant to O.C.G.A. § 50-36-1(e)(2)
By executing this affidavit under oath, as an applicant for a(n) ____alcohol license____________________
[type of public benefit], as referenced in O.C.G.A. § 50-36-1, from City of South Fulton_ [name of
government entity], the undersigned applicant verifies one of the following with respect to my application for a
public benefit:
1)
I am a United States citizen.
2)
I am a legal permanent resident of the United States.
3)
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.
My alien number issued by the Department of Homeland Security or other
federal immigration agency is ____________________________.
The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has
provided at least one secure and verifiable document, as required by O.C.G.A.
§ 50-36-1(e)(1), with this affidavit.
The secure and verifiable document provided with this affidavit can best be classified as:
_____________________________________________________________________________.
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
________________________________________
Printed Name of Applicant
SUBSCRIBED AND SWORN BEFORE
ME ON THE
_____ DAY OF __________________, 20___
NOTARY PUBLIC
My Commission Expires:
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CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
8
E-Verify Affidavit
Private Employer Affidavit Pursuant to O.C.G.A. § 36-60-6(d)
By executing this affidavit under oath, the undersigned private employer verifies one of the following
with respect to its application for a business license, occupational tax certificate, or other document
required to operate a business as referenced in O.C.G.A. § 36-60-6(d):
Section 1.
Please check only one:
(A)
On January 1
st
of the below signed year, the individual, firm, or
corporation employed more than ten (10) employees.
(B) On January 1
st
of the below signed year, the individual, firm, or
corporation employed ten (10) or fewer employees.
*** If the employer selected Section1(A), please fill out Section 2 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. The
undersigned private employer also attests that its federal work authorization user identification
number and date of authorization are as follows:
Name of Private Employer
Federal Work Authorization User Identification Number
Date of Authorization
------------------------------------------------------------------------------------------------------------------------
I hereby declare under penalty of perjury that the foregoing is true and correct. Executed on this day
______ of ______________________, 20 in _________________________(city), ______(state).
Signature of Authorized Officer or Agent
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE DAY OF , 20 .
NOTARY PUBLIC
My Commission Expires:
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CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
9
REGISTERED AGENT DESIGNEE FORM
All licensed establishments that are corporations and limited liability companies must have and continuously maintain in
a “Registered Agent” upon whom any process, notice, or demand required or permitted by law or under the City of South
Fulton Alcoholic Beverage Code to be served upon the licensee or owner. The registered agent designee must submit to a
fingerprint criminal background check and complete the personal statement form. The registered agent must be a resident
of Fulton County, Georgia. The registered agent must obtain the certificate of residency enclosed.
Name: _______________________________________________________________________________
(Full Printed Name No Initials)
Sex: _______________ Race: ___________________ Date of Birth: ___________________
Home Address: ________________________________________________________________________
City: _______________________________ State: _________ Zip: _____________________
Phone# _________________________
Business Address: _____________________________________________________________________
City: ________________________________ State: _________ Zip: _______________________
Phone# ________________________
I hereby certify that I agree to serve as the “registered agent” on behalf of
___________________________________________________________________________a business located at
_______________________________________________________________________, City of South Fulton, Georgia.
As registered agent, I agree to accept any process, notice or demand required or permitted by law or under the Alcoholic
Beverage Code of the City of South Fulton, Georgia, to be served upon the licensee or owner. I understand that such
service upon me will serve as legal notice upon the licensee or owner and that it is my responsibility to forward such
service to the owner or licensee.
__________________________________________________________
SIGNATURE OF APPLICANT DATE
________________________________________________________________________
PRINTED NAME OF APPLICANT
SWORN TO AND SUBSCRIBED
BEFORE ME THIS
________________________D
AY OF _____________________ 20 _________
_____________________________________________________________________________________________________
NOTARY PUBLIC SIGNATURE
_____________________________________________________________________________________________________
NOTARY PUBLIC PRINTED NAME
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CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Revised: 07/1/2020
10
All applications must be typed or printed in black/Blue ink. Each question must be completely and correctly answered. If
the space provided is not sufficient, attach additional sheets. Applications must be signed, dated, notarized and filed with
the South Fulton Police Department. All required supporting documents must be attached.
Type of License Applying For: (Check All That Apply)
☐ New License ☐ Change of Ownership ☐ New Location Other. Please Specify:___________________________
Please select the beverages to be sold: (Check All That Apply)
BEER WINE DISTILLED SPRITS/LIQUOR
Please select the category that best describes the business for which this application is being submitted.
☐ Retail Package Store ☐ Convenience Store ☐ BYOB (Wine only) ☐ Restaurant (3% for excise taxes)
☐ Growler ☐ Supermarket ☐ Microbrewery ☐ Gas / Drug / Dry Goods Store
☐ Importer ☐ Manufacturer ☐ Wholesale ☐ Public Entertainment Facility
☐ Hotel / Hotel Suites ☐ Night Club / Bar / Lounge ☐ Tasting (Wine/Malt)
(3% excise tax)
Other. Please Specify.
________________________________________________________________________________________
Activities Proposed for Premises (check all that apply)
Customer Dancing Live Entertainment Adult Entertainment
_________________________________________________________________________________________________________
If a Private Club: (1) Submit the salaries and other benefits received by each officer, trustee and employee; (2)
Attach A copy of 501(c) Internal Revenue Code tax exempt documentation; (3) Attach membership application
and copy of member list.
1. Is applicant: [ ] Sole Proprietorship [ ] Partnership [ ] Corporation [ ] LLC
2. Legal Name of Business:
Operating/Trade Name of Business
Has location had an alcohol license within the last 12 months? [ ] Yes [ ] No
3. Business Address: Council District:
(Street Address, City, State Zip)
4. Billing Address:
5. Proposed Location Zoned:
6. A. Distance from closest private residence in any direction: _______________
B. Distance from closest college campus or school ground: _______________
C. Distance from closest branch of any South Fulton Public library: _______________
D. Distance from closest church or place of worship: _______________
E. Distance from closest regular school bus stop as designated by
Fulton County Board of Education for pick-up or drop-off of
school children in transport to the public schools of City of South Fulton. _______________
Date Revised: 07/1/2020
11
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
1.
Full name of applicant (Company/Corporation)
2.
Full name of Licensee/Agent:
Licensee/Agent Social Security Number:
Date of Birth and Place of Birth:
Citizen of the USA? [ ] Yes [ ] No Alien Number:
Resident of Georgia? [ ] Yes [ ] No Years _______ County
________________________________
Home Address:
__________________________________________________________________________________________________
City State Zip Code
Telephone Number: Home: (_______)__________________Business: ( )
Email Address:
Hours said Licensee/Agent will actively be on the premise:
List duties of Licensee/Agent:
3.
Full Name of Spouse, Including Maiden Name:
Date of Birth and Place of Birth:
Hours Spouse on Premises:
4.
Licensee’s/Agent’s Business interest(s), occupation(s) and employment for the past ten (10) years
COMPANY
ADDRESS (CITY & STATE)
POSITION
DATES
5.
Does Licensee/Agent, or any Partner(s), Corporation Officer, Principle Shareholder(s), Trustee(s) or Spouse have,
within the preceding ten (10) years, any conviction for the violation of any federal, state or Local laws, Ordinances
or Regulations, or does said person have current proceeding for violation of any Federal, State or Local laws,
ordinances or regulations? [ ] Yes [ ] No
6.
For the purpose of this question, the term – conviction shall include an adjudication of guilt, a plea of guilty, a
plea of nolo contendere, the forfeiture of a bond or adjudication by pre-trial intervention.
PERSON CHARGED
DATE
OFFENSE
LOCATION
DISPOSITION
SECTION 2:
Date Revised: 07/1/2020
12
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
7.
Does Licensee/Agent or any member of the Partnership, Corporation or Stockholder currently hold an
Alcohol license (including a server permit)? [ ] Yes [ ] No
8.
Has Licensee/Agent or any member of the Partnership or Corporation or Stockholder ever applied for an Alcoholic
Beverage license (or work/server/pour permit) and been denied, suspended, or revoked? [ ] No [ ] Yes
If yes check which type [ ] denied [ ] suspended [ ] revoked
If yes, please check the appropriate status above and explain
9.
Full Name of Manager:
Social Security Number of Manager:
Date of Birth and Place of Birth:
Home Address:
Telephone Number: Home: ( ) Business: ( )
E-mail Address:
10.
Hours said manager will be on the premise:
11.
What is the manager’s business experience?
12.
Has the manager worked in this or a similar capacity? [ ] Yes [ ] No
If yes, explain:
13.
Applicant’s full name (Company/Corporation)
If a Corporation, Date of Incorporation: Taxpayer Id#
14.
If a Corporation, indicate the following for all Officers, members of the Board of Directors, Trustees and principal
stockholders. If a Partnership, include all partners. (Complete all information requested for each person).
NAME
ADDRESS
DOB
SSN
POSITION
% INTEREST
If operating as a partnership, submit a copy of all partnership agreements. If corporation, attach a copy of all
Articles of Incorporation, By-laws and amendments thereto, minutes of any corporation meetings within the last
twelve (12) months.
Date Revised: 07/1/2020
13
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
15.
State the amount and source of funds that have or will be invested by each individual who has an interest in the
business. If a Corporation or Partnership, list each individual separately.
NAME
AMOUNT INVESTED
SOURCE OF FUNDS
DATES
16.
Bank accounts and assets in the name of licensee/agent and/or maintained by the licensee/agent, whether individual,
partnership or corporation. (Provide copies of account statements)
TYPE
BANK
CITY & STATE
LAST 6 OF
ACCOUNT#
AMOUNT
17.
Has Licensee/Agent, Spouse or any person having an interest in the business received, directly or indirectly, any
financial aid or assistance, to include land, fixtures, equipment, etc., from any manufacturer or wholesaler of
alcoholic beverages? [ ] Yes [ ] No If yes, please specify.
NAME
ADDRESS
AMOUNT/ITEM
DATE
18.
List any other individual(s) or firm(s) owning any interest in or receiving any funds from the operation of the business
or on the premises. This includes cigarette machines, game machines, billiard tables vendors, etc.
19.
List any financial interest or ownership which Licensee/Agent or any member of the partnership or
corporation or stockholder presently has in any other alcoholic beverage license in the state of Georgia.
NAME
NAME AND ADDRESS OF PREMISES
POSITION
% OF INTEREST
20.
List all assets which will be used or converted for use as an investment in the business and/or all sources of
funding used to capitalize and/or operate the Business.
Date Revised: 07/1/2020
14
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
21.
Do you own the property where the business is located? [ ] Yes [ ] No
If yes:
Date of Purchase Purchase Price
Name of Seller: ______________________________________________________________________________
22.
If property is rented/leased provide owner’s name and address:
Amount of rent/lease:
Monthly_________________ Annually _________________ Other (specify) _______________________
(Submit copy of signed lease agreement, deed, sublease, etc.)
23.
Has a license at this location ever been denied, suspended, or revoked? [ ] No [ ] Yes
[ ] denied, [ ] suspended or [ ] revoked
If yes, check the appropriate status above and explain:
_________________________________________________________________________________________________________________
24.
Is business located in a hotel or motel? [ ] Yes [ ] No
If yes, name of Hotel or Motel
25.
If the business is to be operated as a department inside of premises where another business is operating, give
details of the existing business.
_________________________________________________________________________________________________________________________
26.
What will be your business/operating hours?
27.
Where will your trash receptacle be located?
28.
What arrangements have you made for trash removal?
29.
How often will you clean your property?
30.
What is your plan for sanitation (clean water and sewage disposal) on the premises?
__________________________________________________________________________________________________________________________
31.
What is your plan for unlawful conduct on the premises?
___________________________________________________________________________________________________________________
32.
What is your plan for fire prevention on the premises?
___________________________________________________________________________________________________________________
33.
What type of security do you plan to have?
___________________________________________________________________________________________________________________
Date Revised: 07/1/2020
15
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
34.
Do you offer your employees training with respect to items covered by the alcohol code? [ ] Yes [ ] No
If yes, what type of training and how do you plan to prevent the selling to and consumption by underage
consumers of alcohol and tobacco products on your premises?
__________________________________________________________________________________________________________________________
35.
What type of buffering do you have, or will you provide to alleviate the effects of noise, lighting, odors, traffic or other
nuisances on surrounding properties?
__________________________________________________________________________________________________________________________
36.
What plans do you have to prevent un-permitted vending on your property?
__________________________________________________________________________________________________________________________
37.
Describe the traffic and pedestrian ingress and egress to/from the property and to/from any existing or proposed
structure on the property.
If you are applying for an on-premises alcoholic beverage consumption license, please complete questions 38-44.
If not, please skip ahead to question 45.
38.
Seating Capacity: [ ] Restaurant __________ [ ] Bar ______________ [ ] Other__________
[ ] Brewpub __________ [ ] Brewery ___________
[ ] Lounge _____________ [ ] Winery ____________
[ ] Private _____________ [ ] Nightclub__________
39.
Describe kitchen Facilities:
__________________________________________________________________________________________________________________________
List number of Employees: Cooks Waiters/Waitress Other employees
Alcohol Servers
40.
Is business air conditioned? [ ] Yes [ ] No
41.
Will you have live entertainment? [ ] Yes [ ] No
42.
What percentage of revenues do you expect to come from food sales? from alcohol?
43.
What is the total square footage of the licensed premises?
44.
How many parking spaces are you required to have?
Does the location have on-site parking? [ ] Yes [ ] No How many spaces?
If no or if parking is insufficient, what arrangements have you made for parking?
____________________________________________________________________________________________
Date Revised: 07/1/2020
16
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
If you are applying for a package liquor license, please complete questions 45-47.
If not, please skip ahead to question 48.
45.
Do you propose to operate this store solely as a package liquor store? [ ] Yes [ ] No
46.
Does the Licensee/Agent, Spouse, or any other owner(s), partner(s) or stockholders have an interest in other
retail liquor stores? [ ] Yes [ ] No
NAME
NAME & LOCATION OF BUSINESS
POSITION
% INTEREST
47.
Do you or your spouse or any partner or stockholder have any financial interest in any wholesale liquor
business?
[ ] Yes [ ] No
If yes, give details: ___________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If you are applying for a retail beer and or wine license, please complete questions 48-50.
If not, please skip ahead to next page.
48.
Are you (the applicant) or any member of your family, the owner, lessor or sub-lessor of any real estate which
is occupied by a retail package (liquor) store? [ ] Yes [ ] No
If yes, list locations, information as to any lease or rental agreement, amount of rent received, and to whom.
LOCATION
LEASE/RENTAL
AGREEMENT INFORMATION
AMOUNT OF RENT
LESSOR
Date Revised: 07/1/2020
17
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
49.
Are you or any member of your family the Executor, Administrator, Beneficiary or Heir of any estate having any
interest in retail package (liquor) store? [ ] Yes [ ] No
If yes, list location(s), amount of interest and your relationship with the estate:
LOCATION(S)
% INTEREST
YOUR RELATIONSHIP TO ESTATE
50.
Are you or any member of your family the beneficiary or trustee of any trust fund having any interest in a retail
package (liquor) store? [ ] Yes [ ] No
If yes, give your position, the name of the trust and the amount of income that you receive.
POSITION
NAME OF TRUST
INCOME RECEIVED
Date Revised: 07/1/2020
18
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
CERTIFICATION
I have received a copy of the City of South Fulton Alcoholic Beverage Ordinances and I have read it and agree to adhere to all
applicable City of South Fulton Ordinances, Georgia state laws and regulations governing the operation of establishments that
serve and/or sell alcoholic beverages? [ ] yes [ ] no
I understand it is the responsibility of the applicant/licensee/agent to ensure that all licenses to sell alcoholic beverages are
renewed no later than December 15th of each year or I will have to apply for a new alcohol license. [ ] yes. [ ] no
I understand that a state license must be obtained before any alcoholic beverage can be served or sold in the City of South, (this
includes Alcoholic Beverage Manufacturers). I further understand that the state license is obtained after the city license is
obtained and I am responsible for contacting the Georgia Department of Revenue to obtain a state alcohol license.
[ ] yes. [ ] no
I understand that I am required to pay alcohol excise tax in accordance with City of South Fulton Ordinance, Title 16 Alcoholic
Beverages, and failure to pay excises taxes imposed by this ordinance will be grounds for suspension or revocation of my alcohol
license. [ ] yes. [ ] no
I, the undersigned, do solemnly swear and attest, subject to criminal penalties for false swearing, that the information provided in
this Application for Alcoholic Beverage Sales and Service and in any and all documents provided in support of this application
are true and accurate. I further understand that any false statements provided by me or my representatives as part of this
application, beyond any legal penalties, will result in the denial of the subject application.
_______________________________________________________________________________________
SIGNATURE OF APPLICANT DATE
__________________________________________________________________________
PRINTED NAME OF APPLCIANT
~For Notary~
I hereby certify that ________________________________ signed her/his name to the foregoing application
stating to me the he/she knew and understood all statements and information contained therein and, under oath
actually administered by me, has sworn that said statements and information are true and correct.
SWORN TO AND SUBSCRIBED
BEFORE ME THIS
________________________D
AY OF _____________________ 20 _________
_____________________________________________________________________________________________________
NOTARY PUBLIC SIGNATURE
_____________________________________________________________________________________________________
NOTARY PUBLIC PRINTED NAME
Date Revised: 07/1/2020
19
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
APPLICANT PRIVACY RIGHTS
As an applicant that is the subject of a Georgia only or a Georgia and Federal Bureau of Investigation (FBI) national
fingerprint/biometric-based criminal history record check for a non-criminal justice purpose (such as an
application for a job or license, immigration or naturalization, security clearance, or adoption), you have certain
rights which are discussed below.
• You must be provided written notification that your fingerprints/biometrics will be used to check the
criminal history records maintained by the Georgia Crime Information Center (GCIC) and the FBI, when a
federal record check is so authorized.
• If your fingerprints/biometrics are used to conduct a FBI national criminal history check, you are provided
a copy of the Privacy Act Statement that would normally appear on the FBI fingerprint card.
• If you have a criminal history record, the agency making a determination of your suitability for the job,
license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the
information in the record.
• The agency must advise you of the procedures for changing, correcting, or updating your criminal history
record as set forth in Title 28, Code of Federal Regulations (CFR), Section 16.34.
• If you have a Georgia or FBI criminal history record, you should be afforded a reasonable amount of time
to correct or complete the record (or decline to do so) before the agency denies you the job, license or
other benefit based on information in the criminal history record.
• In the event an adverse employment or licensing decision is made, you must be informed of all information
pertinent to that decision to include the contents of the record and the effect the record had upon the
decision. Failure to provide all such information to the person subject to the adverse decision shall be a
misdemeanor [O.C.G.A. § 35-3-34(b) and §35-3-35(b)].
You have the right to expect the agency receiving the results of the criminal history record check will use it only
for authorized purposes and will not retain or disseminate it in violation of state and/or federal statute, regulation
or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy
Compact Council.
If the employment/licensing agency policy permits, the agency may provide you with a copy of your Georgia or
FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a
copy of the record, information regarding how to obtain a copy of your Georgia, FBI or other state criminal history
may be obtained at the GBI website (http://gbi.georgia.gov/obtaining-criminal-history-record-information).
If you decide to challenge the accuracy or completeness of your Georgia or FBI criminal history record, you should
send your challenge to the agency that contributed the questioned information. Alternatively, you may send your
challenge directly to GCIC provided the disputed arrest occurred in Georgia. Instructions to dispute the accuracy
of your criminal history can be obtained at the GBI website (http://gbi.georgia.gov/obtaining-criminal-history-
record-information).
2018-05 Attachment A
Date Revised: 07/1/2020
20
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
PRIVACY ACT STATEMENT
Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally
authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include
Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations.
Providing your fingerprints and associated information is voluntary; however, failure to do so may affect
completion or approval of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be
predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may
be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of
comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its
successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the
employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated
information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may
continue to be compared against other fingerprints submitted to or retained by NGI.
Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and
associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your
consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable
Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI
system and the FBI’s Blanket Routine Uses. Routine Uses include, but are not limited to, disclosures to: employing,
governmental or authorized non-governmental agencies responsible for employment, contracting, licensing,
security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies;
criminal justice agencies; and agencies responsible for national security or public safety.
2018-05 Attachment B
Date Revised: 07/1/2020
21
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
TITLE 28 CFR 16.30 THROUGH 16.34
§ 16.30 Purpose and Scope
This subpart contains the regulations of the Federal Bureau of Investigation (FBI) concerning procedures to be
followed when the subject of an identification record requests production of that record to review it or to obtain
a change, correction, or updating of that record.
§ 16.31 — Definition of identification record An FBI identification record, often referred to as a “rap sheet,” is a
listing of certain information taken from fingerprint submissions retained by the FBI in connection with arrests
and, in some instances, includes information taken from fingerprints submitted in connection with federal
employment, naturalization, or military service. The identification record includes the name of the agency or
institution that submitted the fingerprints to the FBI. If the fingerprints concern a criminal offense, the
identification record includes the date of arrest or the date the individual was received by the agency submitting
the fingerprints, the arrest charge, and the disposition of the arrest if known to the FBI. All arrest data included in
an identification record are obtained from fingerprint submissions, disposition reports, and other reports
submitted by agencies having criminal justice responsibilities. Therefore, the FBI Criminal Justice Information
Services Division is not the source of the arrest data reflected on an identification record.
§ 16.32 — Procedure to obtain an identification record
The subject of an identification record may obtain a copy thereof by submitting a written request via the U.S.
mails directly to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer
Hollow Road, Clarksburg, WV 26306. Such request must be accompanied by satisfactory proof of identity, which
shall consist of name, date and place of birth and a set of rolled-inked fingerprint impressions placed upon
fingerprint cards or forms commonly utilized for applicant or law enforcement purposes by law enforcement
agencies.
§ 16.33 — Fee for production of identification record
Each written request for production of an identification record must be accompanied by a fee of $18 in the form
of a certified check or money order, payable to the Treasury of the United States. This fee is established pursuant
to the provisions of 31 U.S.C. 9701 and is based upon the clerical time beyond the first quarter hour to be spent
in searching for, identifying, and reproducing each identification record requested as specified in § 16.10. Any
request for waiver of the fee shall accompany the original request for the identification record and shall include a
claim and proof of indigency. Subject to applicable laws, regulations, and directions of the Attorney General of
the United States, the Director of the FBI may from time to time determine and establish a revised fee amount to
be assessed under this authority. Notice relating to revised fee amounts shall be published in the Federal Register.
§ 16.34 — Procedure to obtain change, correction or updating of identification records
If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in
any respect and wishes changes, corrections or updating of the alleged deficiency, he/she should make application
directly to the agency which contributed the questioned 2018-05 Attachment C information. The subject of a
record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the
FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road,
Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting
that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from
the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in
accordance with the information supplied by that agency.
2018-05 Attachment C
Date Revised: 07/1/2020
22
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Criminal History Record Information Consent/Inquiry Form
ALCOHOL LICENSE
I hereby authorize City of South Fulton Police Department to conduct an inquiry for the purpose of eligibility of my alcohol
license as listed below and receive any Georgia and/or national criminal history record information as authorized by state
and federal law.
Full Name (print)
Any other name used (i.e.
maiden name)
Place of Birth
Home Address
Name of Business
Address of Business
Gender
Race
Date of Birth
Social Security Number
□ I, ______________________________________________________, give consent to the above-named entity to perform
periodic criminal history background checks for the duration of my tenure as agent, licensee, or member of this
establishment listed above.
□ I, ______________________________________________________, confirm that I have received a copy of the Privacy
Act Statement, Applicant’s Privacy Rights and Title 28 CFR 16.30 through 16.34. I further confirm, that I have read and
understand these guidelines.
________________________________________ _____________
Signature Date
Date of Inquiry:___________ Time of Inquiry:___________ Operator’s Initials:___________
Purpose Code Used: (check all that apply)
E- Employment
J- Civilian Criminal Justice Employment (State & III Info Received)
W- Working with Children
Z- Sworn Criminal Justice Employment (State & III Info Received)
The inquiry resulted in the following: (check all that apply)
No Criminal Record Available
Criminal Record (Attached/Released)
No NCIC/GCIC Warrant
Possible NCIC/GCIC Warrant (List Wanting Agency Below)
Wanting Agency Name: _______________________________________________________________________________
Wanting Agency Telephone Number:_____________________________________________________________________
___________________________________________________________________________ ___________________
Print Agency Designee Name and Title Date
_________________________________________________________
Agency Designee Signature
Date Revised: 07/1/2020
23
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
PRIMARY CHECKLIST FOR ATTACHMENTS
For All Alcohol License Types
Application Form
Personal Statement Form for each Sole Owner, Partner, Member, Officer, Director, Majority Stockholder (Private
Corporations), and Manager (with 20% interest in business) with a clear, current, front and back copy of identification
document.
For U.S. citizens: driver’s license or state issued photo identification
For permanent residents: permanent resident card
Citizenship Affidavit for Public Benefits
E-Verify Affidavit
Copy of 6 months financials
Registered agent designee form with copy of registered agent’s driver’s license attached registered agent must be a
Fulton County resident, and complete the certificate of residency form.
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)
Certified report of survey from registered land surveyor – or – professional engineer indicating distance requirements
as outlined in City of South Fulton Title 16 Alcoholic Beverage Ordinance.
Certified scale drawing showing location and distance to closest school buildings, educational buildings, school
grounds, colleges and/or any church buildings
detailed floor plan, drawn to scale
Copy of occupational tax certificate from City of South Fulton
Criminal History Record Information Consent/Inquiry Form for each Sole Owner, Partner, Member, Officer,
Director, Majority Stockholder (Private Corporations), and Manager (with 20% interest in business).
Copy of Alcohol Awareness Certificate
(Note: Fees will be accessed and an invoice provided to applicant, please do not write checks or cashier checks until
you receive an invoice with requisite fees.)
Additional Requirements
If the applicant is a franchise, provide everything from the Primary Checklist and:
Signed franchise agreement or contract.
If this is a change in ownership, provide everything from the Primary Checklist and:
Signed sale/purchase agreement .
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:
Proof of membership in the form of a list showing paid active members, copy of minutes from prior year’s annual meetings,
and listing of salaries for members, officers, agents or employees.
Date Revised: 07/1/2020
24
CITY OF SOUTH FULTON APPLICATION FOR ALCOHOL BEVERAGE LICENSE
Date Application Received ________________________________________________________
(This Section Must Be Date and Time Stamped)
_________________________________________________________________________________________________
Print Investigator Name Receiving Application
_________________________________________________________________________________________________
Signature of Investigator
FOR POLICE LICENSE & PERMIT UNIT USE ONLY
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City of South Fulton Alcohol Beverage License Application (City of South Fulton)

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