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Date: Alcohol License Application Applicant Name Phone Number Applicant Home Address Business Name Business Phone Number Business Address Mailing Address (If different from business address above) Email Address LICENSE TYPE: PLEASE SELECT FROM THE FOLLOWING OPTIONS Pouring (Consumed on Premises): Retail Package: □Change of Managers: $100 □Beer $500 □Beer: $500 □Distilled Spirits $1,500 □Wine $400 □Wine: $400 □Sunday Sales $300 □Distilled Spirits: $5,000 FIRST TIME APPLICANT: INVESTIGATION FEE PAID AT CITY POLICE DEPT Public Safety Building, Police Department: 195 Cassville Rd □New Applicant Fingerprint Background Check: $50.00 ORI #:GA923310Z □Contact Person Fingerprint Background Check: $50.00 -a contact person is necessary if the applicant does not live in Bartow County. Please designate an affiliated individual to be the contact person who is a resident in Bartow County and/or an employee if applicable. Contact Person: Name Phone Number Home Address Wholesale Distributor: □Beer: $100 □Wine: $200 □Distilled Spirits: $100 P.O. Box 1390 10 North Public Square Cartersville, GA. 30120 Phone: [PHONE REDACTED] www.cityofcartersville.org ---PAGE BREAK--- 2 ESTABLISHMENT DETAILS: -Have you had or do you currently have an alcohol license at another location? □ Yes □ No If yes, where? -Have you ever had an alcohol violation? □Yes □ No If yes, where and when? -Do you intend to have live entertainment? □Yes □ No If yes, what type, and when? Describe. BUILDING AND LOCATION REQUIREMENTS: ATTACHMENTS NEEDED □ □n/a Please attach evidence of building ownership/lease agreement to this application. □ □n/a If this establishment is new construction or being remodeled the City requires detailed plans of the building in which the business will be located and outside premises. □ □n/a If this establishment has never sold alcohol before please provide a scale drawing of the location of the proposed premises showing the distance to the nearest type of building and/or property lines of types of property referred to in the “Distance Requirements” section of Ordinance No. 81-05; or a certificate of a registered surveyor that such location complies with the “Distance Requirements” of said Ordinance. Inspections: Signatures Required The following inspections are required prior to being scheduled for an ACB Meeting. ∙ Building Inspections: Call to schedule an inspection [PHONE REDACTED] 10 N. Public Sq APPROVAL: DATE: ∙ Fire Department Inspectors: Call to schedule an inspection [PHONE REDACTED] 195 Cassville RD APPROVAL: DATE: Maximum Capacity: seats P.O. Box 1390 10 North Public Square Cartersville, GA. 30120 Phone: [PHONE REDACTED] www.cityofcartersville.org ---PAGE BREAK--- 3 Ownership Information BUSINESS AFFILIATION: Select the title that most accurately reflects your affiliation with the business. □Owner □Manager □Employee □Other: BUSINESS OWNERSHIP: Stock Ticker Symbol: Name of individual or entity that owns/operates business: Legal structure of ownership entity (e.g. sole proprietor, corporation, LLC, partnership) List names and ownership percentages of anyone owning 30% or more of the business: % % % ∙Please describe your professional experience and background: P.O. Box 1390 10 North Public Square Cartersville, GA. 30120 Phone: [PHONE REDACTED] www.cityofcartersville.org ---PAGE BREAK--- 4 EMPLOYEE TRAINING REQUIREMENTS Please provide information regarding how you ensure employees are properly trained to abide by State Laws and City Ordinances. Please feel free to attach any training material used you would like to share with the Alcohol Control Board. 1. Description of training program? 2. How often is training required, and how does the employee pass a training program? 3. Penalty for selling alcohol to minor by employer to employee. 4. Procedures required to check identification and to make sales. 5. How do you ensure all servers are wearing their City issued server’s badge? (Pouring License) P.O. Box 1390 10 North Public Square Cartersville, GA. 30120 Phone: [PHONE REDACTED] www.cityofcartersville.org ---PAGE BREAK--- 5 Applicant Affidavit: Please check all of the following to state you understand and will comply. □I hereby acknowledge that I have received a copy of Ordinance No. 81-05 of the City of Cartersville, Georgia and that I understand its provisions. □I will, in fact, be responsible for the business for which I am applying for a license, and am not acting on behalf of someone else for the purposes of avoiding the provisions of Ordinance No. 81-05 of the City of Cartersville. □I realize that the giving of false information on this application may lead to penalties including the suspension or revocation of the license for which I am applying. □I have never been convicted under any Federal, State, or local law for a criminal offense involving alcoholic beverages/gambling/or any felony involving moral turpitude in the past 10 years. □I will agree to comply with and insist on compliance with all Federal, State, and local laws and ordinances by employees and customers alike. □I have not had an alcohol license revoked, for cause such as a violation of regulations or improper operation, within ten years next preceding this application, any license issued to me by the City of Cartersville, the State of Georgia, or any other state, to sell alcoholic beverages of any kind. □I understand each employee involved in the serving of beer/wine/distilled spirits must be fingerprinted and checked by the Cartersville Police Department. A server’s permit must be obtained. □I will make an immediate report to the City of Cartersville of any changes pertaining to ownership of the business, license holder, contact person, ownership of building, or any change in the information as stated in this application for license. □I do not owe any debts to the City of Cartersville. □I am at least 21 years of age. I, hereby, expressly authorize the City of Cartersville Police Department to conduct an investigation of my background, for any time they deem necessary. □I acknowledge that I have received a copy and read the Non-Criminal Justice Applicant’s Privacy Rights and the Privacy Act Statement. □I have read and understand the information and compliance requirements set forth to complete this application and potentially obtain an Alcohol License. I HEREBY CERTIFY THAT THIS APPLICATION HAS BEEN COMPLETED CORRECTLY AND TRUTHFULLY. Applicant Signature Sworn to and subscribed before me this day of , 20_ . Notary Public P.O. Box 1390 10 North Public Square Cartersville, GA. 30120 Phone: [PHONE REDACTED] www.cityofcartersville.org ---PAGE BREAK--- 6 Applicant AFFIDAVIT VERIFYING STATUS FOR CITY OF CARTERSVILLE BENEFIT APPLICATION By executing this affidavit under oath, as an applicant for a City of Cartersville, Georgia Occupation Tax Certificate, Alcohol License or other public benefits as referenced in O.C.G.A. Section 50-36-1, I am stating the following with respect to my application for a City of Cartersville, Georgia Occupational Tax Certificate, Alcohol License or other public benefit (circle one) for [Name of natural person applying on behalf of individual, business, corporation, partnership, or other private entity] [Name of business, corporation, partnership] 1) I am a United States citizen 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. Signature of Applicant: Date Printed Name: SUBSCRIBED AND SWORN BEFORE ME ON THIS THE * DAY OF , 20 Alien Registration number for non-citizens Notary Public 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: P.O. Box 1390 10 North Public Square Cartersville, GA. 30120 Phone: [PHONE REDACTED] www.cityofcartersville.org ---PAGE BREAK--- 7 Contact Person (if necessary) AFFIDAVIT VERIFYING STATUS FOR CITY OF CARTERSVILLE BENEFIT APPLICATION By executing this affidavit under oath, as an applicant for a City of Cartersville, Georgia Occupation Tax Certificate, Alcohol License or other public benefits as referenced in O.C.G.A. Section 50-36-1, I am stating the following with respect to my application for a City of Cartersville, Georgia Occupational Tax Certificate, Alcohol License or other public benefit (circle one) for [Name of natural person applying on behalf of individual, business, corporation, partnership, or other private entity] [Name of business, corporation, partnership] 1) I am a United States citizen 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. Signature of Applicant: Date Printed Name: SUBSCRIBED AND SWORN BEFORE ME ON THIS THE * DAY OF , 20 Alien Registration number for non-citizens Notary Public 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: P.O. Box 1390 10 North Public Square Cartersville, GA. 30120 Phone: [PHONE REDACTED] www.cityofcartersville.org ---PAGE BREAK--- NON-CRIMINAL JUSTICE APPLICANT’S PRIVACY RIGHTS As an applicant who is the subject of a Georgia and Federal Bureau of Investigation (FBI) national fingerprint/biometric-based criminal history check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. All notices must be provided to you in writing. These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code Section 552a, and Title 28 Code of Federal Regulation (CFR), 50.12, among other authorities. • You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later) when you submit your fingerprints and associated personal information. This Privacy Act Statement must explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated information will be searched, shared or retained. • You must be advised in writing of the procedures for obtaining a change, correction, or update of your FBI criminal history record as set forth at 28 CFR 16.34. • You must be provided the opportunity to complete or challenge the accuracy of the information in your FBI criminal history record (if you have such a record). • If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on the information in the FBI criminal history record. • If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at history-summary-checks and You may find information regarding how to obtain a copy of your Georgia criminal history record on the GBI website: questions. • If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI by submitting a request via The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.) If the disputed arrest occurred in the State of Georgia, you may send your challenge directly to the GCIC. Contact information for the GCIC can be found at frequently-askedquestions. • You have the right to expect that officials receiving the results of the criminal history record check will use it only for the authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. ---PAGE BREAK--- Privacy Act Statement This privacy act statement is located on the back of the FD-258 fingerprint card. Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety. As of 02/04/2021 ---PAGE BREAK--- Applicant Privacy Rights Notification Signature Form Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure of obtaining a change, correction or updating an FBI identification record is set forth in Title 28, Code of Federal Regulations (CFR), 16.34. Procedures for obtaining a copy of the FBI criminal history record are set forth in 28 CFR 16.30 through 16.33 or review the FBI website. Signature Print Name Date P.O. Box 1390 10 North Public Square Cartersville, GA. 30120 Phone: [PHONE REDACTED] www.cityofcartersville.org