3167 Main St Duluth, GA 30096 770-476-3434 www.duluthga.net 04/2020 1

City of Duluth 2020 Alcohol License Renewal

Application Please type or print legibly. Each question must be answered fully. The statements and answers contained within this application are furnished to the City of Duluth under oath and subject to the penalties of false swearing.

Alcohol License #: Occupational Tax #: Licensee Name: Business Name: Street Address: Duluth, GA Email address: Phone: Cell phone:

TYPE OF BUSINESS IN CITY OF DULUTH FOR 2020: (check the business type that applies)

Eating Establishment (Restaurant) Brew Pub Hotel/Motel Tavern Package/ Liquor Store Art Shop Super Market/Grocery Performing Arts Facility Convenience Store/Gas Station Growler Wholesaler Brewer Other

TYPE OF LICENSE/FEES: (check all that apply)

A. Retail Package (Consumption off premises) B. Retail (Consumption on premises)

Package Store (Liquor) $5,000 Beer and Wine $1,000 Beer or Wine Only $500 Wholesaler $ 5,000

C. Supplemental Licenses D. Stand-Alone Licenses (flat fee)(Requires additional license & fee under A or B)

Annual Catering License (Liquor) $150 Annual Catering License (Beer/Wine) $100 Indoor Commercial Rec. (Liquor) $750 Indoor Commercial Rec. (Beer/Wine) $500 Golf Course (Liquor/Beer/Wine/) $150 Wine Tasting Room (Pkg Store) $100 Open areas $50 Brew Pub $250

For Licenses Under Categories B-D: Does your establishment have the following?

Patio Sales: Yes No If yes, see Section 3-266 City of Duluth Code of Ordinance

Live Entertainment: Yes No If yes, explain:

TOTAL LICENSE FEE DUE (addition of A-D) $________ Due by 6-1-2020

Liquor/Beer/Wine $3,500 Beer and Wine $1,000 Beer only $500 Wine only $500 Tavern (Liquor/Beer/Wine) $4,000 Tavern (Beer/Wine) $1,250 Brewer $5,000

Performing Arts Facility $200 Deli/Food Market (Pkg beer/wine) $150 Ancillary (Beer/Wine) $200 Gift Shop (Beer/Wine) $100 Art Shop (Beer/Wine) $250 Special Events Facility $1,500 Grocery Store Tasting (Beer/Wine) $200

3167 Main St Duluth, GA 30096 770-476-3434 www.duluthga.net 04/2020 2

OWNER INFORMATION

Alcohol License #:

Owner Information: Please complete for each owner of the business for those owning 10% or more. Personal history also required for each.

Owner Name (1): Driver License #:

Street Address:

City: State: Zip Code:

Cell Phone: Email Address:

Owner Name (2): Driver License #:

Street Address:

City: State: Zip Code:

Cell Phone: Email Address:

Owner Name (3): Driver License #:

Street Address:

City: State: Zip Code:

Cell Phone: Email Address:

Owner Name (4): Driver License #:

Street Address:

City: State: Zip Code:

Cell Phone: Email Address:

3167 Main St Duluth, GA 30096 770-476-3434 www.duluthga.net 04/2020 3

MANAGER INFORMATION

Alcohol License #:

Manager Information: Please complete for each manager of the business. Personal history also required for each.

Manager Name (1): Driver License #:

Street Address:

City: State: Zip Code:

Cell Phone: Email Address:

Manager Name (2): Driver License #:

Street Address:

City: State: Zip Code:

Cell Phone: Email Address:

Manager Name (3): Driver License #:

Street Address:

City: State: Zip Code:

Cell Phone: Email Address:

Manager Name (4): Driver License #:

Street Address:

City: State: Zip Code:

Cell Phone: Email Address:

TAX ADVICE ACCOUNTING AND FINANCIAL ADVISORY

Name of CPA or Financial Advisor:

Street Address: City: State: Zip:

Email: Phone Number: Fax Number: Mailing Address: (if different) City: State: Zip:

3167 Main St Duluth, GA 30096 770-476-3434 www.duluthga.net 04/2020 4

PERSONAL HISTORY STATEMENT

Alcohol License #:

Instructions: Make additional copies of this form for each owner and manager of the business. This application must be typed or printed legibly and executed under oath. Each question must be answered fully. If the space provided is not sufficient, please answer on a separate sheet and indicate in the space provided that a separate sheet is attached.

Business Name:

Name: (Last, First, Middle)

Home Address: City: State: Zip:

Cell Phone: Email: Gender:

Race: Hair Color: Eye Color:

Date of Birth: Place of Birth:

Social Security #:

Relationship To This Business:

Owner: Percentage Ownership: Manager:

A copy of verifiable identification must be provided at the time of application. Copy of driver’s license or state photo identification card.

US Citizen: Legal Permanent Resident: Qualified Alien or Non-Immigrant:

Have you ever been arrested or held by federal, state or other law-enforcement authorities for violation of any federal law, state law, county or municipal law, regulations or ordinances? (Do not include traffic violations, all other charges must be included even if they were dismissed.)

If yes, give reason charged or held, date, place where charged and disposition. (If no arrest, please write “no arrest.” After last arrest is listed, please write “no other arrest.”)

CERTIFICATION OF PERSONAL HISTORY AND AUTHORIZATION FOR BACKGROUND CHECK

Note: Before signing this statement, ensure all questions are answered fully and correctly. This statement is to be executed under oath and is subject to the penalties of false swearing. “I authorize the City of Duluth to receive any criminal history record information pertaining to me, which may be in the files of any federal, state, and/or city criminal justice agency in Georgia.”

I, ________________________________________________ , do solemnly swear that the statements and answers made by me as the applicant in the foregoing personal history statement are true and correct.

Applicant Printed Name Applicant Signature Date

Yes No

3167 Main St Duluth, GA 30096 770-476-3434 www.duluthga.net 04/2020 5

REGISTERED AGENT

All licensed establishments must have and continuously maintain a “Registered Agent.” This is an individual who upon any process, notice or demand required or permitted by law or under the City of Duluth Alcohol Beverage Code can be served upon for the licensee or owner. This person must be a Georgia resident and agree to act in this capacity for the business.

Name:

Gender: Race: Date of Birth:

Home Address: City: State: Zip:

Phone Number: Email:

I hereby certify that I am a resident of the State of Georgia, and agree to serve as “registered agent”

on behalf of __________________________________________________________________ (business name), a business

located at __________________________________________________________________ Duluth, 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 Duluth, 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 Registered Agent

Date

Sworn To and Subscribed Before Me

This ___________ Day of _____________ ___________ , 20 _____ .

Notary Public Signature My Commission Expires

NOTE: Attach a copy of driver’s license and proof of residency, i.e.; phone or utility bill that reflects the current address listed by the Registered Agent.

3167 Main St Duluth, GA 30096 770-476-3434 www.duluthga.net 04/2020 6

LIST OF EMPLOYEES FOR ALCOHOL-LICENSED BUSINESS (NON-MANAGERS)

Business Name: Alcohol License #:

Employee Name: Title:

Date of Birth: Phone:

Alcohol Permit #: Permit Expires:

Employee Name: Title:

Date of Birth: Phone:

Alcohol Permit #: Permit Expires:

Employee Name: Title:

Date of Birth: Phone:

Alcohol Permit #: Permit Expires:

Employee Name: Title:

Date of Birth: Phone:

Alcohol Permit #: Permit Expires:

Employee Name: Title:

Date of Birth: Phone:

Alcohol Permit #: Permit Expires:

Employee Name: Title:

Date of Birth: Phone:

Alcohol Permit #: Permit Expires:

Employee Name: Title:

Date of Birth: Phone:

Alcohol Permit #: Permit Expires:

Employee Name: Title:

Date of Birth: Phone:

Alcohol Permit #: Permit Expires:

3167 Main St Duluth, GA 30096 770-476-3434 www.duluthga.net 04/2020 7

ALCOHOL LICENSE RENEWAL CHECKLIST

Alcohol License #:

Questions? Alcohol Officer: alcohol@duluthga.net Office: 770-497-5286 or visit www.duluthga.net/alcohol

1) Complete and review the renewal application and have notarized. City Hall has notaries available.2) Verify 2020 Occupational Tax Certificate renewal has been received and posted at business

location.3) Include complete Personal History Statements for all owners and managers.4) Provide a copy of the current driver’s license or photo identification card for owners and managers.5) Include required verification for the Registered Agent.6) Provide copy of current, unexpired State of Georgia Alcohol Beverage License.7) Submit complete list of employees and verify permit status.8) Submit copy of alcohol menu.

RENEWAL APPLICATION AFFIDAVIT

This is to certify that no change has taken place with respect to the operation of the named business affecting its ownership as stated in the previous application. I certify and affirm that I have read the City of Duluth Alcohol Beverage Ordinance (Chapter 3) and that I am in accordance with the ordinance. The answers to all questions in the previous applications about the above named business are correct and remain unchanged. Additionally I certify to compliance to the City of Duluth and the State of Georgia laws governing the above named business. All sections of the application have been answered fully and correctly.

Applicant Name Applicant Signature

This Day Of , 20 __ _____ .

Notary Public Signature My Commission Expires