HomeMy Public PortalAbout030_FoTT_404Butler_20110415 12IbA )(
CITY OF TYBEE ISLAND
ALCOHOL LICENSE APPLICATION
1
Application is hereby made for a license to do business within the Gty of Tybee Island as a dealer in alcoholic ` * m ,
beverages as indicated below:
LICENSE CLASSIFICATION I FEE I CHECK Notice: The applicant
Retail Beer/Wine — Package Sales Only, Consumption on Premises Prohibited $ 350 for a license shall be a
Retail Beer/Wine — Sale by Drink for Consumption on Premises Only 575 citizen of the United
States, a resident of
Retail Liquor — Sale by Package Only, Consumption on Premises Prohibited 850 Chatham County, and
Retail Liquor — Sale by Drink for Consumption on Premises Only 1,250 owner of the business
Retail Liquor — Sale by Package & Drink both in One Building under One Ownership 2,000 or if a corporation,
Sunday Sales of Alcoholic Beverages 150 1 partnership or other
Wholesale Beer 765 legal entity is the
Wholesale Liquor 1,500 owner, a substantial
Wholesale Wine 150 1 and major stockholder
Distiller, Brewer, or Manufacturer of Alcoholic Beverages 300 / or the applicant may be
Special Event — Public or Private Property - Beer, Wine (no current license) per event 50 Nt/ the manager of the
Special Event — Public or Private Property - Beer, Wine (no current license) 3 days 100 business charged with
Special Event — Public or Private Property - Beer, Wine (holding current license) per event 10 the regular operation of
Special Event — Business Property — Beer, Wine, Liquor (no current license) per event 50 said business on the
Special Event — Business Property — Beer, Wine, Liquor (no current license) 3 days 100 1 premises for which the
Special Event — Business Property — Beer, Wine, Liquor (holding current license) per event 10 I license is issued.
I Business Name Fri ell,/ Sk a' - i D -�'l .Lh ' T k , / t 'r
Location
Mailing Address p R Ox, a 3 z/ 1---14 1TC-e a !Si . (-,a R) ., I f I
Phone ( 1 _ - I Email 11,1 I VLl RTPAr � 1 l 1 C . GCS
1 N and Home Addresses of Owners, Partners or Corporate Officers with Ten Percent (10 %) Interest n Business
Names (attach additional pages if necessary) I Date of Birth I Home Addresses I City, State, Zip I Social Security #
SA ea1-1 JON Es I iiiitohd G CAAi&K( I SAv 6A 3� lo �, S l g d. S tl
JA rv� s41_1 --k7 1 4)4 Vc . Box W-9 Fri:11364 N 3;3AA , ,4(0. C 1 6
1 O 128 1 1
Is business incorporated? State of Incorporation Date Incorporated 1` — 7 O 1
Names of landlord of the business location (\J / Address _ Phone
n 4
What other business is conducted at this location? / f `J /A •
Has application been made for required State and Federal L icenses? K I
Has applicant, any person connected with, or any person having an interest in this business:
o ever been convicted of any violation of law other than for a traffic violation? L' 0
o ever served time in prison or other correctional institution? h 1 1)
o ever had an alcohol beverage license suspended or revoked at any time in any location? N.) f
(if answer is yes, give details) r y �
If this application is for RENEWAL of an existing license, enter License Number of existing license N / A
If business is an eating establishment, are SUNDAY sales of alcoholic beverages contemplated? Ni 1 A If yes, submit additional affidavit.
ALL OF THE FOREGOING INFORMATION IS HEREBY GIVEN AND ALL OF THE FOREGOING STATEMENTS ARE HEREBY MADE ON OATH
WILLFULLY, KNOWIINXTEr AND ABSOLUTELY, AND THE SAME IS AND ARE HEREBY SWORN TO ME TO BE TRUE UNDER PENALTY OF LAW.
Applicant Sign re Date - r
�,-.• Approval Signature Date
1 City Manager 1 I
Sworn to a subscribed before thi .� / � ' day of9/21 � I I zoning 1 1 . .1
rJ I Police I' l7.v
Nf1 9 /
City Council I
Notary blic B ONNit J . 1gr O
MOWN Public, Chatham County, dA
My O0mnilsolon Explree November 27, 2011
Fr/idttke 14-)c-li
Affidavit Verifying Status
4 for City Public Benefit Application
By executing this affidavit under oath, as an applicant for a City of Tybee Island, Georgia, Business License or Occupation Tax
Certificate, Alcohol License, Taxi Permit, Contract, or other public benefit as referenced in O.C.G.A. Section 50-36-1, I am
stating the following with respect to my application of a City of Tybee Island:
• Business License or Occupational Tax Certificate,
.--------
• ' Alcohol License
(circle all that apply)
• Taxi Permit,
• Contract
• Other public benefit
for (printed name of natural person applying on behalf of
individual, business, corporation, partnership, or other private entity).
1) I am a United States citizen.
OR
2) I am a legal permanent resident 18 years of age or older or I am an otherwise qualified alien or non-immigrant
under the Federal Immigration and Nationality Act, 18 years of age or older and lawfully present in the United
States. *
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 Code Section 16-10-20 of the
...:...
Official Code of Georgia.
( -4ignatrie of Applicant
9 -' 1/
Date
5 d (J)NE
Printed Name
* Alien Registration Number for Non-citizens
SUBSCRIBED AND SW0 BEFORE ME ON THIS
THE JS DAY OF -t...0-024 . 20 11
0 BONNIE J. HIER8
Notary Public 1.Y0/1/ 4 41;e-2--) myNcatuzzobnocE,xcohmasthwaomvecmor2,7%,
jt Lei t _, a d-z, 11
My Commission Expires:
Note: O.C.G.A. § 50-36-1(e)(2) requires that aliens under the federal Immigration and Nationality Act, Title 8 U.S.C., as
amended, provide their alien registration number. Because legal permanent residents are included in the federal definition of
"alien", legal permanent residents must also provide their alien registration number. Qualified aliens that do not have an alien
registration number may supply another identifying number below:
The CONSENT FORM is required for ALL alcohol license applications.
CONSENT FORM
I HEREBY AUTHORIZE THE TYBEE ISLAND POLICE DEPARTMENT TO REQUEST ANY CRIMINAL BACKGROUND HISTORY RECORD
INFORMATION PERTAINING TO ME WHICH MAY BE IN THE FILES OF ANY STATE OR LOCAL CRIMINAL JUSTICE AGENCY. BE IT FURTHER
UNDERSTOOD THAT THE PURPOSE OF OBTAINING THIS INFORMATION IS TO SATISFY THE REQUIREMENTS SET FORTH BY THE MAYOR
AND COUNCIL OF THE CITY OF TYBEE ISLAND, REGARDING AN ALCOHOL BEVERAGE LICENSE APPLICATION.
FULL NAME (PRINT) SD: / RACE / DATE OF BIRTH
Ld rw3 _
ADDRESS • v Rm' NUMBER
1)
CITY, STATE, ZIP -i1RE / DATE
The ACKNOWLEDGEMENT is required for all LIQUOR BY THE DRINK alcohol license applications.
ACKNOWLEDGEMENT
I declare knowled• - .nd understanding of Municipal Code Section 58 -80: There is levied an excise tax on the sale
of distilled spin 4 e drink in the amount of three percent of the charge to the public for the beverage.
SIGNATURE Dr E
The AFFIDAVIT is required if SUNDAY SALES of alcohol for consumption on premises are contemplated.
Food and beverage sales records prepared by a CPA are require-. to be rnshed to the City ul .n request.
STATE OF GEORGIA
COUNTY OF CHATHAM
CITY OF TYBEE ISLAND
AFFIDAVIT
I, , do hereby make this affidavit to be part of my application for an
alcohol beverage license in the City of Tybee Island to sell distilled spirits, malt beverages and /or wine for the
consumption on the premises in my eating establishment on Sunday. Said establishment is located at
Tybee Island, Georgia.
I am the of the establishment known as
I hereby further state that at least filly percent (50 %) of the total annual gross food and beverage sales are
derived from the sale of prepared meals or food.
SIGNATURE DATE
AL
Approved 4 Senied IMO M Chief of Police
I ` ill Date
/ 4
o 4 � , l0/
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