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Form # 3 Revised 1-1-12 Page 1 of 4 DAWSON COUNTY PLANNING AND DEVELOPMENT ALCOHOL LICENSING Locating & Mailing Address: 25 JUSTICE WAY, SUITE 2322 Phone: [PHONE REDACTED] x 42335 Dawsonville, GA 30534 PREMISE AND STRUCTURE FORM INSTRUCTION: THIS STATEMENT MUST BE TYPEWRITTEN OR PRINTED AND EXECUTED UNDER OATH. EACH QUESTION MUST BE FULLY ANSWERED. IF SPACE PROVIDED IS NOT SUFFICIENT, ANSWER ON A SEPARATE SHEET AND INDICATE IN THE SPACE PROVIDED THAT A SEPARATE SHEET IS ATTACHED. 1. TYPE OF BUSINESS: EATING ESTABLISHMENT INDOOR COMMERCIAL RECREATION ESTABLISHMENT CONVENIENCE STORE SUPER MARKET PACKAGE LIQUOR STORE HOTEL OR MOTEL OTHER (DESCRIBE) 2. TRADE NAME OF BUSINESS: LOCATION: Street Number Street Name City State Zip Code Phone Number Land Lot Map & Parcel Number 3. IS THIS LOCATION WITHIN A COMMERCIAL ZONING DISTRICT? yes no PROOF OF ZONING IS REQUIRED FROM PLANNING AND DEVELOPMENT For package liquor stores, is this zoned Commercial Highway Business (C-HB) or Commercial Planned Comprehensive Development (CPCD) as required by the ordinance? PROOF OF C-HB or CPCD ZONING IS REQUIRED FROM PLANNING AND DEVELOPMENT. 4. DOES THE COMPLETED BUILDING OR THE PROPOSED BUILDING COMPLY WITH ORDINANCES OF DAWSON COUNTY, REGULATIONS OF THE STATE REVENUE COMMISSIONER, AND THE LAWS OF THE STATE OF GEORGIA? IF NO, EXPLAIN NON-COMPLIANCE AND PROPOSED METHODS TO RECTIFY SAME: ---PAGE BREAK--- Form # 3 Revised 1-1-12 Page 2 of 4 PREMISE AND STRUCTURE FORM 5. DOES THE BUILDING IN WHICH THE BUSINESS IS TO BE LOCATED CONTAIN SUFFICIENT LIGHTING SO THAT THE BUILDING ITSELF AND THE PREMISES ON ALL SIDES OF THE BUILDING ARE READILY VISIBLE AT ALL TIMES FROM THE FRONT OF THE STREET ON WHICH THE BUILDING IS LOCATED AS TO REVEAL ALL OF THE OUTSIDE PREMISES OF SUCH BUILDING? IS THE BUILDING SO ILLUMINATED SO THAT ALL HALLWAYS, PASSAGE WAYS, AND OPEN AREAS MAY BE CLEARLY SEEN BY THE CUSTOMER THEREIN? IF THE ANSWER IS NO TO EITHER OR BOTH OR ABOVE, PLEASE EXPLAIN PROPOSED METHODS TO RECTIFY THE INSUFFICIENT LIGHTING. 6. FOR CONSUMPTION ON PREMISES AND RETAIL PACKAGE APPLICATIONS: (Answer "N/A" for items that are not applicable to your business) NUMBER OF SQUARE FEET OF TOTAL FLOOR AREA: NUMBER OF SQUARE FEET DEVOTED TO DINING AREA: SEATING CAPACITY EXCLUDING BAR AREA: DO YOU HAVE A FULL SERVICE KITCHEN? DOES THE FULL SERVICE KITCHEN CONTAIN A THREE COMPARTMENT SINK? IS THE STOVE AND/OR GRILL PERMANENTLY INSTALLED AND APPROVED BY THE HEALTH AND FIRE DEPARTMENTS? IF THE ANSWER TO ANY OF THE IMMEDIATE FOREGOING IS NO, PLEASE EXPLAIN: HOURS PREPARED MEALS OR FOODS ARE SERVED: HOURS THAT ALCOHOLIC BEVERAGES ARE SERVED or SOLD: HOURS OF OPERATION: MAXIMUM NUMBER OF EMPLOYEES ON HIGHEST SHIFT: NUMBER OF PARKING SPACES: NUMBER OF PARKING SPACES DEVOTED TO HANDICAPPED PERSONS: PACKAGE LIQUOR STORES: DO YOU COMPLY WITH ORDINANCE ARTICLE 5 SECTION 503 - POSTING OF LICENSE NUMBER? Every licensee shall have posted on the front of the licensed premises the name of the licensee together with the following inscription, "County Retail Package Sales of Distilled Spirits License No. " DO YOU COMPLY WITH ORDINANCE ARTICLE 5 SECTION 505 A) - TYPES OF OUTLETS WHERE PACKAGE SALES ARE PERMITTED? Outlets that are devoted exclusively to the retail sale of distilled spirits, malt beverages and/or wine by the package with ingress and egress provided directly to and only to the exterior of the building and not to any other enclosed part of the building or adjoining building. ---PAGE BREAK--- Form # 3 Revised 1-1-12 Page 3 of 4 PREMISE AND STRUCTURE 7. FOR HOTEL/MOTEL ONLY: NUMBER OF ROOMS AVAILABLE FOR HIRE TO GENERAL PUBLIC: NUMBER OF SQUARE FEET OF FLOOR SPACE DEVOTED TO RESTAURANT: NUMBER OF SQUARE FEET OF FLOOR SPACE DEVOTED TO DINING AREA: SEATING CAPACITY EXCLUDING BAR AREA: EXPLAIN IF MORE THAN ONE DINING AREA: DO YOU HAVE A FULL SERVICE KITCHEN? DOES THE FULL SERVICE KITCHEN CONTAIN A THREE COMPARTMENT SINK? IS THE STOVE AND/OR GRILL PERMANENTLY INSTALLED AND APPROVED BY THE HEALTH AND FIRE DEPARTMENTS? IF THE ANSWER TO ANY OF THE IMMEDIATE FOREGOING IS NO, PLEASE EXPLAIN: HOURS PREPARED MEALS OR FOODS ARE SERVED: HOURS THAT ALCOHOLIC BEVERAGES ARE SERVED: MAXIMUM NUMBER OF EMPLOYEES ON THE HIGHEST SHIFT DEVOTED TO THE OPERATION OTHER THAN THE RESTAURANT: MAXIMUM NUMBER OF EMPLOYEES ON HIGHEST SHIFT DEVOTED TO THE RESTAURANT OPERATION: NUMBER OF PARKING SPACES: NUMBER OF PARKING SPACES DEVOTED TO HANDICAPPED PERSONS: FOR ALL APPLICATIONS: 8. ATTACH A CERTIFIED SCALE DRAWING OF THE PROPOSED PREMISES BY A REGISTERED LAND SURVEYOR OR PROFESSIONAL ENGINEER, SHOWING THE DISTANCE REQUIREMENT FROM CHURCH, SCHOOL, DAYCARE FACILITY, OR ALCOHOL TREATMENT CENTER. (See Survey Form # 3-A) 9. ATTACH APPLICANT'S CERTIFICATION THAT THE LOCATION COMPLIES WITH THE DISTANCE REQUIREMENT FROM CHURCH, SCHOOL, DAYCARE FACILITY OR ALCOHOL TREATMENT CENTER. (See Survey Form 3-A) 10. ATTACH EVIDENCE OF OWNERSHIP (DEED, LEASE, SALES AGREEMENT, LETTER OF INTENT). ---PAGE BREAK--- Form # 3 Revised 1-1-12 Page 4 of 4 PREMISE AND STRUCTURE FORM 11. IF THE APPLICANT IS A FRANCHISE, ATTACH A COPY OF THE FRANCHISE AGREEMENT OR CONTRACT. 12. IF THE APPLICANT IS AN EATING ESTABLISHMENT, ATTACH A COPY OF THE MENU(S). 13. IF THE BUILDING IS COMPLETE, ATTACH COPIES OF DETAILED SITE PLANS OF SAID BUILDING INCLUDING OUTSIDE PREMISES AND FLOOR PLAN. IF THE BUILDING IS PROPOSED, ATTACH COPIES OF PROPOSED SITE PLAN AND SPECIFICATIONS AND BUILDING PERMIT OF THE PROPOSED BUILDING. NOTE: Before signing this statement, check all answers and explanations to see that you have answered all questions fully and correctly. This statement is to be executed under oath and subject to the penalties of false swearing, and it includes all attached sheets submitted herewith STATE OF GEORGIA, DAWSON COUNTY I, , DO SOLEMNLY SWEAR, SUBJECT TO THE PENALTIES OF FALSE SWEARING, THAT THE STATEMENTS AND ANSWERS MADE BY ME AS THE APPLICANT IN THE FOREGOING PREMISE AND STRUCTURE STATEMENT ARE TRUE AND CORRECT. APPLICANT'S SIGNATURE I HEREBY CERTIFY THAT SIGNED HIS/HER NAME TO THE FOREGOING APPLICATION STATING TO ME THAT HE/SHE KNEW AND UNDERSTOOD ALL STATEMENTS AND ANSWERS MADE THEREIN, AND, UNDER OATH ACTUALLY ADMINISTERED BY ME, HAS SWORN THAT SAID STATEMENTS AND ANSWERS ARE TRUE AND CORRECT. THIS, THE DAY OF , 20 . NOTARY PUBLIC