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HomeMy Public PortalAbout040_FoTT_30Meddin_20110416 s-)-ro P 0 A4 4-41,- - 11 CITY OF TYBEE ISLAND y ALCOHOL LICENSE APPLICATION Application is hereby made for a license to do business within the Gty of Tybee Island as a dealer in alcoholic " "• * ' beverages as indicated below: LICENSE CLASSIFICATION I FEE CHECK Notice: The applicant Retail Beer/Wine - Package Sales Only, Consumption on Premises Prohibited $ 350 I for a license shall be a citizen of the United Retail Beer /Wine - Sale by Drink for Consumption on Premises Only 575 I States, a resident of Retail Liquor - Sale by Package Only, Consumption on Premises Prohibited 850 1 Chatham County, and Retail Liquor - Sale by Drink for Consumption on Premises Only 1,250 I 1 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 I legal entity is the Wholesale Liquor 1,500 I owner, a substantial Wholesale Wine 150 I and major stockholder Distiller, Brewer, or Manufacturer of Alcoholic Beverages 300 1 or the applicant may be Special Event - Public or Private Property - Beer, Wine (no current license) per event 50 V 1 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 1 the regular operation of Special Event - Business Property - Beer, Wine, Liquor (no current license) per event 50 1 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 1 license is issued. Business Name Fri / ii ii s C)4 ' 1 4'(.Ph -1 `t IA Q ! ! Location o f �)f>I N DR-- �L.,i' h , t . ) , A 1 3 a e Mai ling AaG,pl 1 _ , s I' O .X v)3S1 , ill be- (6 ) . e. ,K) i 2) Phone 3 � X - �� .� — I I Email 4._ h -1 IA o fa.t'lAr' L. I if_t∎ Names and Home Addresses of Owners, Partners or Corporate Officers' with Ten Percent (10 %) Interest in Business I Names (attach additional pages if necessary) I Date of Birth I Home Addresses I City, State, Zip I Social Security # 1 5b e-14 N ()OmPs I a II, - 3101 5 (t4.1thev -i,, lei 1 SOU , 611 31ti-lc) I I, Ipi AA,P3K IL-LL -We . Ig q-4- - I 1 OFtl r_erS k �) It � =f Al /' 31 i1x ,-9Q 6 ,<Z )- 3 J© Is business incorporated? y Ls State of Incorporation 6A Date Incorporated 1 1 ---- 61 Names of landlord of the business location I`) 1 A Address Phone What other business is conducted at this location? / K) /t Has application been made for required State and Federal Licenses? lk; 1 tik 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? N rj o ever served time in prison or other correctional institution? K) rl o ever had an alcohol beverage license suspended or revoked at any time in any location? K.Z'.) (if answer is yes, give details) If this application is for RENEWAL of an existing license, enter License Number of existing license N) e i If business is an eating establishment, are SUNDAY sales of alcoholic beverages contemplated? 1Q/ 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, KNOWIN Q ABSOLUTELY, AND THE SAME IS AND ARE HEREBY SWORN TO ME TO BE TRUE UNDER PENALTY OF LAW. Applicant Sign Date - / U - 1 1 Approval Signature Date I City Manager I I Sworn to and subscri before me this g day ode C9 / / I Zoning kl/) f Police I K J / IAVAI-'201I t l e _ Notary Public !� BO NI ��'$ Q I ►��tary Pu61)tj mat o Cou ty, 0 My CcmtittiD BOA November 27, 2011 U2-OIL( +/1,-/f 2 • 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 0.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, .< ----------7-- L Licensn_ (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) 1 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 sh. •e guilty of a violation of Code Section 16-10-20 of the Official Code of Georgia. , iip .. signature of Applicant - ac - 1/ Date 3 J oNES Printed Name * Alien Registration Number for Non-citizens SUBSCRIBED AND SWOR1 BEFORE ME ON TI THE / i DAY OF 7 , 20 / I BONNi AIRS , my commrstio . at tounty, GA 27, 2011 - Notary Public ) 344AtAL, q; ).....-02.,(7-1 Notary Public; My Commission Expires: 11...1:TYte '-..) c2-- / Note: 0. 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/ e .