APPLICATION FOR ON PREMISES CONSUMPTION – HOTEL, MOTEL, OR RESTAURANT PERMIT
City of Fayetteville, 113 West Mountain, Fayetteville, AR 72701
Regulated by Title XI, Chapter 111 of the City of Fayetteville Code of Ordinances
Type of On Premises Consumption Permit: ___ Hotel ___ Motel ___ Restaurant
Please print or type the following:
Business
Applicant
Name:
(Must be person listed on State Permit)
Address:
City, State Zip:
Phone:
Mailing Address: Date of Birth:
*ALL INFORMATION MUST BE FILLED OUT
Driver’s License #:
BEFORE APPLICATION WILL BE PROCESSED.
Permit fee – Hotel or Motel (enclose check payable to City of Fayetteville):
A. Capacity of fewer than one hundred (100) rooms. $ 250.00
B. Capacity of one hundred (100) or more rooms. $ 500.00
Capacity
Amount due $
Permit fee – Restaurant (enclose check payable to City of Fayetteville):
A. Seating capacity of less than one hundred (100). $ 250.00
B. Seating capacity of one hundred (100) or more. $ 500.00
Seating Capacity
Amount due $
If this is a new establishment, I do hereby swear and affirm that the location of the business for which this permit is sought is not
within 200 yards of any church or school building, if said business is a retail establishment for the sale of alcoholic beverages for
consumption off the premises; or is not within 300 feet of any church or school building for any other business for which a City
of Fayetteville alcoholic beverage permit is required. Affidavit
– The below signed applicant, being 21 years of age or older, after
first being duly sworn, states that all above information is true and accurate to the best of his or her knowledge and belief.
Applicant’s signature
(Must be person listed on State Permit)
Subscribed and sworn before me this day of , 20
Notary Public
(Seal)
My commission expires
A COPY OF YOUR CURRENT STATE PERMIT MUST ACCOMPANY THIS APPLICATION
