Fill - Free fillable Privilege License Application (City of Gulfport Mississippi) PDF form

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PRIVILEGE

LICENSE

APPLICATION

Ver. 12/2018

Customer ID __________

Business ID ___________

License # ____________

(Check one) Individual 

Partnership  Corporation  LLC 

☐ NEW BUSINESS ☐ EXISTING BUSINESS/CHANGE OF ADDRESS

BUSINESS OWNER INFORMATION Date________________

BUSINESS OWNER NAME

ADDRESS:________________________________________________________________________

Street City State Zip

HOME PHONE NO :(______) _________________ BUSINESS PHONE _____________________

FAX # _________________________ ADDITIONAL TELEPHONE #’S ______________________

MAILING ADDRESS, IF DIFFERENT, ________________________________________________

EMAIL ADDRESS ______________________________ WEB SITE _________________________

SSN/FID ______________________________________ STATE ID _________________________

***COPY OF OWNER’S OR AUTHORIZED AGENT’S STATE ISSUED I.D. MUST BE ATTACHED***

TRADE NAME (DBA):_________________________________________________________

LOCATION: _____________________________________________ GULFPORT, MS 3950 ____

HOME BASED _______ YES ______ NO (IF YES AND YOU OWN HOME, SKIP)

WHAT WAS IN THIS LOCATION BEFORE YOUR BUSINESS, IF KNOWN? ________________

IS YOUR BUSINESS LOCATION IN A MALL, SHOPPING CENTER OR OFFICE COMPLEX?

_____ YES _____ NO

IF, YES, WHAT IS THE NAME OF THE COMPLEX?

__________________________________________________________________________________

ARE YOU LEASING THIS LOCATION? ____ IF YES, WHEN DOES YOUR LEASE END? _____

NAME AND ADDRESS OF LANDLORD ______________________________________________

__________________________________________________________________________________

I HEREBY CERTIFY THAT ALL INFORMATION GIVEN ON THIS APPLICATION (AND

IN ANY REQUEST FOR ADDITIONAL INFORMATION) FOR THE PURPOSE OF

SECURING A PRIVILEGE LICENSE, AND DETERMINING THE AMOUNT DUE, IS TRUE

AND CORRECT.

APPLICANT MUST SIGN HERE: ___________________________________________________

PRINT NAME HERE: _____________________________________________________________

IF PARTNERSHIP OR CORPORATION, GIVE OFFICIAL TITLE OF PERSON MAKING APPLICATION

AFFIDAVIT

SUBSCRIBED AND SWORN TO BEFORE ME, THIS THE ____________________________________ DAY OF ________________________________________

OFFICIAL TITLE

OFFICE USE ONLY

APPROVAL TO ISSUE PRIVILEGE LICENSE BY PLANNING AND BUILDING REPRESENTATIVES

NAME OF BUSINESS ____________________________________________________________________DATE _________________________________________

LOCATION OF BUSINESS _______________________________________________________________ZONING DISTRICT ______________________________

APPROVED FOR: ______ PERMANENT TEMPORARY FOR _______________ DAYS PRIVILEGE LICENSE ENDING _______/______/_______

FOR CONDUCTING THE BUSINESS OF: __________________________________________________________________________________________________

RESTRICTIONS, IF ANY ___________________________________________________________________________BY __________________________________

COMMENTS _____________________________________________________________________________________ BY __________________________________

APPROVED BY:

PLANNING DIVISION ____________________________________________ PLEASE PRINT NAME__________________________________________________

BUILDING CODE SERVICES ______________________________________ PLEASE PRINT NAME _________________________________________________

LICENSE ISSUED BY:

URBAN DEVELOPMENT BUILDING CODE SERVICES DEPARTMENT ______________________________________________________________________

***STAFF APPROVAL OF THIS APPLICATION EXPIRES AFTER 60 DAYS IF A PRIVILEGE LICENSE IS NOT ISSUED***

BUSINESS INFORMATION

TYPE OF BUSINESS:_______________________

DO YOU SELL BEER? ______________________

DO YOU SELL TOBACCO?___________________

DO YOU SELL OR SERVE FOOD?

__________________________________________

(If yes, additional documents required- see

instructions)

IF THE BUSINESS YOU ARE CONDUCTING IS

A SERVICE TYPE BUSINESS, HOW MANY

FULL-TIME EMPLOYEES DO YOU HAVE?

__________________________________________

(See instructions for further information)

IF THE BUSINESS YOU ARE CONDUCTING IS

A SALES TYPE BUSINESS, HOW MUCH IS

YOUR INVENTORY?

$_________________________________________

(See instructions for further information)

IF BUSINESS IS A RENTAL CAR BUSINESS,

HOW MANY RENTAL CARS DO YOU HAVE?

_________________________________________

REQUEST FOR ADDITIONAL BUSINESS INFORMATION

In addition to the information you provided in the “Privilege License Application,” please accurately

and truthfully respond to the following:

Please state whether any item, substance, or product to be offered for sale or otherwise part of any

business transaction involving your business will be prohibited by Mississippi law.

YES NO

Please state whether any item, substance, or product to be offered for sale or otherwise part of any

business transaction involving your business will contain or consist of any amount of “THC”

(tetrahydrocannabinol).

YES NO

Please state whether you are aware of Miss. Code Ann. § 41-29-136, as amended, and its effects

regarding “CBD oil” and “CBD solutions.”

YES NO

Please state whether any item, substance, or product to be offered for sale or otherwise part of any

business transaction involving your business will violate Miss. Code Ann. § 41-29-136, as amended,

(also referred to as “Harper Grace’s Law”).

YES NO

Please state whether any item, substance, or product to be offered for sale or otherwise part of any

business transaction involving your business will contain or consist of any amount of a “controlled

substance,” as such is defined by Mississippi law (Miss. Code Ann. § 41-29-105, as amended).

YES NO

Please state whether any item, substance, or product to be offered for sale or otherwise part of any

business transaction involving your business will contain or consist of any amount of a substance,

product, or item prohibited by Miss. Code Ann. § 41-29-101, et seq. (Mississippi’s “Uniform

Controlled Substances Law”) or any other Mississippi law or will constitute “paraphernalia” (as

defined in Miss. Code Ann. § 41-29-105(v)) and prohibited by Mississippi law.

YES NO

APPLICANT MUST SIGN HERE: ____________________________________________________

PRINT NAME HERE: ______________________________________________________________

DATE:

SECTION I. To be filled in by applicant

SECTION II. STAFF USE ONLY.

Describe Your Business in

Detail Below:

APPLICANT INFORMATION

NAME OF

APPLICANT:_______________________________________________________

LAST FIRST

ADDRESS: ________________________________________________________

STREET

___________________________________________________________________

CITY STATE ZIPCODE

PHONE:(______)__________________ FAX.:(______)___________________

IF APPLICABLE, STATE WHERE NONCONFORMING USE DIFFERS FROM PROVISIONS OF THE CITY’S ZONING

ORDINANCE:

___________________________________________________________________________________________________

BASED UPON THE ACCURACY OF THE INFORMATION OF THE APPLICANT HEREIN, THE UNDERSIGNED CITY

BUILDING OFFICIAL/ PLANNING ADMINISTRATOR HEREBY STATES HIS OPINION AT THE TIME OF HIS OR HER

SIGNATURE THAT THE SPECIFIC INTENDED OR PROPOSED USE OF THE SUBJECT SITE, AS SET OUT BY THE

APPLICANT ABOVE, CONFORMS TO THE REQUIREMENTS OF THE CITY’S ZONING ORDINANCE AS PRESENTLY IN

EXISTENCE, PROVIDE COMPLIANCE IS MADE WITH ANY AND ALL CONDITIONS CITED OR OTHERWISE REQUIRED IN

THIS ORDINANCE AND/OR SET OUT OR DESCRIBED HEREIN. SIGNATURE OF CITY

BUILDING OFFICIAL/PLANNING ADMINISTRATOR: ______________________________________ DATE: ______________

THIS CERTIFICATE OF ZONING COMPLIANCE, IF PROPERLY AND ACCURATELY COMPLETED BY THE PARTIES AND

SIGNED BY THE CITY OF GULFPORT BUILDING OFFICIAL/PLANNING ADMINISTRATOR, AND WHILE SUBJECT TO

BEING SUBSEQUENTLY REVOKED, RESCINDED, AND/OR MODIFIED, IS ISSUED IN ACCORDANCE WITH SECTION

VIII(A)(2) OF THE CITY OF GULFPORT’S COMPREHENSIVE ZONING ORDINANCE AND ANY LIMITATIONS OR

RESTRICTIONS SET OUT THEREIN.

Date:_________________ CITY OF GULFPORT

CERTIFICATE OF ZONING COMPLIANCE VER. 5/2018

PLEASE PRINT LEGIBLY

1410 24

Avenue, Gulfport, Mississippi 39501 (228) 868-5715

PLEASE READ AND FILL IN ALL INFORMATION THAT IS REQUESTED. FAILURE TO COMPLETE THIS APPLICATION MAY RESULT IN A DELAY IN ISSUING THE

CERTIFICATE. ***STAFF APPROVAL OF THIS APPLICATION EXPIRES AFTER 60 DAYS IF REQUIRED PERMITS OR LICENSES ARE NOT ISSUED***

PROPERTY INFORMATION

PHYSICAL ADDRESS/LOCATION OF SUBJECT SITE (“Subject Site”):

___________________________________________________________________

AD VALOREM TAX PARCEL # _______________________________________

IF METES AND BOUNDS ATTACH PHOTOCOPY OR DEED OR SURVEY WITH LEGAL

DESCRIPTION

APPLICANT’S CONNECTION WITH SUBJECT SITE (e.g., Owner, Lessee, etc.):

___________________________________________________________________

PROPOSED/INTENDED USE OF SUBJECT SITE. Use back, if needed:

___________________________________________________________________

PROPOSED/INTENDED HOURS OF OPERATION OF PROPOSED/INTENDED

USE OF SUBJECT SITE:

___________________________________________________________________

IF APPLICABLE, NUMBER OF DWELLING UNITS SUBJECT SITE IS

DESIGNED TO ACCOMMODATE: ______________________________

IF THIS IS FOR A HOME OCCUPATION, ARE THERE PROTECTIVE

COVENANTS THAT EXIST THAT PROHIBIT HOME OCCUPATIONS AT

THE PROPOSED LOCATION: (CIRCLE ONE) YES NO

IF A SITE PLAN WAS NOT FURNISHED WITH AN APPLICATION

FOR A BUILDING PERMIT SUBMITTED TO THE DEPARTMENT

OF URBAN DEVELOPMENT FOR THE CITY OF GULFPORT FOR

THE SUBJECT SITE, A SITE PLAN, IN DUPLICATE AND DRAWN

TO SCALE, SHOWING THE LOCATIONS AND DIMENSIONS OF

EXISTING AND PROPOSED STRUCTURES WITH SUPPORTING

OPEN FACILITIES, THE GROUND AREA TO BE PROVIDED AND

CONTINUOUSLY MAINTAINED FOR THE PROPOSED SUBJECT

SITE MUST BE ATTACHED TO THIS DOCUMENT. IS A SITE PLAN

ATTACHED? (CIRCLE ONE) YES NO

CERTIFICATION OF APPLICANT: I HEREBY CERTIFY, THAT I

HAVE READ THIS APPLICATION AND THAT ALL INFORMATION

CONTAINED HEREIN IS TRUE AND CORRECT, THAT I AGREE TO

COMPLY WITH ALL APPLICABLE CODES, ORDINANCES AND

STATE LAWS REGULATING BUILDING CONSTRUCTION. THAT I

AM THE OWNER OR AUTHORIZED INDIVIDUAL TO ACT AS THE

OWNER AGENT FOR THE HEREIN DESCRIBED WORK AND

THAT THE TOTAL CONTRACT OR VALIDATION IS:

DATE _____________________________________________________________

SIGNATURE OF APPLICANT:________________________________________

ZONING: ________ CONDITIONS OF APPROVAL:

_____________________________________________

IS THIS CERTIFICATE OF ZONING COMPLIANCE

LIMITED TO SIX (6) MONTHS OR LESS FROM DATE

OF SIGNATURE BELOW DURING ALTERATIONS OR

PARTIAL OCCUPANCY OF SUBJECT SITE PENDING

ITS COMPLETION? (CIRCLE ONE) YES NO

IF “YES,” STATE DURATION OF CERTIFICATE:

_________________________________

IF “YES,” LIST ANY CONDITIONS:

__________________________________________________

SEE REVERSE FOR ADDITIONAL DETAIL

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