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Form #2 Revised 7.08.24 1 I Page Dawson County Alcohol Licensing 25 Justice Way, Suite 2223 I [PHONE REDACTED] Application for Alcoholic Beverage License This application must be signed by the applicant and notarized. Every question must be fully answered with the answer typewritten or printed. If the space provided is not sufficient, answer on a separate sheet and indicate in the space provided that a separate sheet is attached. When completed, the application must be dated, signed, and verified under oath by the applicant and submitted to Planning and Development, together with the license fee(s) and the administrative/investigative fee (separate checks). All fees are payable to Dawson County in certified funds (bank check, certified check, or money order). The applicant must be not less than 21 years of age. NOTICE: Any and all false information provided to the Alcohol Licensing Office verbally or written will subject the person that provides this false information to prosecution to the full extent of the law and will subject the application to denial or revocation. ***KEEP A COPY OF ALL FORMS SUBMITTED*** FOR OFFICIAL USE ONLY: Name of Business: Date Received: License Fee Enclosed: $ Approved: Denied: State License Number: Local License Number: Administrative/ Investigative Fee Enclosed: Fee Enclosed: 1. Type of License: (check one): New Amendment (transfer) 2. Administrative and Investigative Fee $300.00 (Consumption on Premises) Administrative and Investigative Fee $300.00 (Retail Package) Administrative and Investigative Fee $300.00 (Transfer of License) Note: Administrative/Investigative fees may be higher depending on the number of persons for which we conduct a federal and state background check ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 2 I Page Advertising Fee: $50.00 (Distilled Spirits) (Consumption on Premises & Retail Package) 3. Type of Business: Eating Establishment Super Market Convenience Store Hotel/Motel Private Club Other Please explain: Will live entertainment be offered? If yes, explain: 4. Type of License and Fees: (Check all that apply) **Payment by certified funds only. If license is issued after July 1st, fees are one half. a) Retail Package: (Total: Beer – Wine – Distilled Spirits = $5,800) (Total: Beer – Wine = $1,500) Beer $1,000 Wine $1,000 Distilled Spirits $4,500 Grocery & Convenience Stores: Attach copy of Department of Agriculture food establishment license. b) Retail Consumption on Premises: (Total: Beer – Wine – Distilled Spirits = $4,800) (Total: Beer – Wine = $1,500) Distilled Spirits $3,300 Additional Fixed Bars # $500.00 (each bar) Beer $1,000 Movable Bars # $200.00 (each bar) Wine $1,000 Wine, Farm Winery, Tasting Room $500 Brewpub $300 Alcohol Beverage Catering $300 c) Hotel In-Room Service: (Must obtain a Retail Consumption on Premise license before Hotel In-Room Service license is issued.) Beer & Wine $100 ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 3 I Page 5. Business: a) Business Name: b) Location: Street Number Street Name City State Zip Code Phone Number c) Mailing Address: Street Number Street Name City State Zip Code Phone Number 6. Owner: a) Full Name: Social Security Number b) Corporation or LLC Name (if applicable) c) Location: Street Number Street Name City State Zip Code Phone Number d) Mailing Address: Street Number Street Name City State Zip Code Phone Number 7. Name of Licensee: e) Full Name: Social Security Number f) Location: Street Number Street Name City State Zip Code Phone Number ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 4 I Page g) Mailing Address: Street Number Street Name City State Zip Code Phone Number 8. Registered Agent: (Applicant may name a Registered Agent – attach Registered Agent Consent Form # 3-A.) a) Full Name: Social Security Number b) Address: Street Number Street Name City State Zip Code Phone Number 9. Type of Ownership: Sole Proprietorship Legally Registered Partnership Private Held Corporation Public Held Corporation Public Held Corporation Subject to S. E. C. Regulations Limited Liability Company Other; explain: 10. For Partnership Only: a) Date the Partnership was formed: b) Attach Partnership Agreement c) List Partners: (Attach separate sheet if necessary) Name & Resident Address Social Security Number G- General L- Limited S- Silent Investment Participation $ Interest % ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 5 I Page 11. For Corporation of LLC Only: (Attach Articles & Certificate of Incorporation/ Organization) a) Date of Incorporation/ Organization: b) Place of Incorporation/ Organization: c) State Parent Corporation, if applicable: d) Number of Shares of Capital Stock, if applicable: e) Number of Shares of Outstanding Stock, if applicable: f) For Corporations of LLC’s, list officers, directors, members, and/or principal shareholders with 20% or more of the stock: Name Social Security Number Position Interest % g) Is the corporation owned by a parent corporation or held by a holding company? If yes, explain: 12. For Private Clubs Only: a) Date of organization under the laws of the State of Georgia: b) State the total number of regular dues paying members: c) Is any member, officer, agent, or employee compensated directly or indirectly from the profits of the sale of distilled spirits beyond a fixed salary as established by its members at any annual meeting or by its governing board out of the general revenue of the ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 6 I Page d) Attach minutes of the annual meeting setting salaries. For private club, list officers, directors and/or principal shareholders with 20% or more of the stock. Name Social Security Number Position 13. Financing: a) Bank to be used by business, include branch: b) State total amount of capital that is or will be invested in the business by any party or parties: c) State total amount of funds invested by the Owner: d) State total amount of funds invested by parties other than the Owner: e) If any capital is borrowed, please identify the lender below: Name of Lender Date Amount ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 7 I Page 14. General Information: a) Does Owner and/or individual Partner, Shareholder, Director, Officer or Member have any interest in any manufacturer or wholesaler of alcoholic beverage? b) Has Owner and/or individual Partner, Shareholder, Director, Officer or Member received any financial aid or assistance from any manufacturer or wholesaler of alcoholic beverages? c) If answer is "Yes" to either of immediate foregoing, explain: d) On the following page, show hereunder any and all persons, corporations, partnerships, limited liability companies or associations (other than persons stated herein as Owner(s), Director(s), Officer(s) or Member(s)) who have received or will receive, as a result of your operation under the requested license, any financial gain or payment derived from any interest or income from the operation. Financial gain or payment shall include payment or gain from any interest in the land, fixtures, building, stock, and any other asset of the proposed operation under the license. In the event any Corporation or limited liability company is listed as receiving an interest or income from this operation, show the names of the Officers, Directors or Members of said corporation together with the names of the principal stockholders. e) List all other businesses engaged in the sale of alcohol beverages that you the Owner, or any individual, Partner, Shareholder, Officer, Director or Member has interest in, is employed by or is associated with in any way whatsoever, or has had interest in, has been employed by, or has been associated with in the past. ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 8 I Page 15. List wholesalers from which the business will procure alcohol: a) In accordance with the Georgia state law, Rule 560-2-3-. 08 Retailer Purchase from Licensed Wholesaler, businesses in Georgia must purchase alcoholic beverages from licensed wholesalers. (To ensure compliance, there will be an opportunity each month on the Dawson County Excise Tax Reporting Form, to identify new wholesalers from which the business purchases alcohol.) Wholesaler’s Name Phone Number 16. For Package Liquor Store Applicants: ***State of Georgia Regulations*** a) The State of Georgia will not issue a State Alcohol License to any person who has more than two retail package liquor licenses. See official language below. Do not apply for a Dawson County License if you already have (or have interest in) two package liquor store licenses in the State of Georgia. O.C.G.A. 3-4-21 and Regulation 560-2-2-40. No person shall be issued more than two retail package liquor licenses, nor shall any person be permitted to have a beneficial interest in more than two retail package liquor licenses issued by the Department regardless of the degree of such interest. For the purposes of explanation and applicability of the Code: "Beneficial interest" as used here means: when a person holds the retail package liquor license in his own name, or when he has a legal, equitable or other ownership interest in, or has any legally enforceable interest or financial interest in, or derives any economic benefit from, or has control over a retail package liquor business. The term "person" shall include all members of a retail package liquor dealer licensee's family; and the term "family" shall include any person related to the holder of the license within the first degree of consanguinity and affinity as computed according to the canon law which includes the following: spouse, parents, step-parents, parents-in-law, brothers and sisters, step-brothers and step-sisters, brothers-in-law and sisters-in-law, children, step-children and children-in-law. b) Do you currently hold any package liquor licenses in your own name or have a beneficial interest in any package liquor licenses as described above? No. If yes, attach a separate sheet listing names, addresses, and license numbers. ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 9 I Page 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 APPLICATION ARE TRUE AND CORRECT. APPLICANT’S SIGNATURE I HEREBY CERTIFY SIGNED HIS NAME TO THE FOREGOING APPLICATION STATING TO ME THAT HE 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. DAY NOTARY PUBLIC ---PAGE BREAK--- Application for Alcoholic Beverage License Form #2 Revised 7.08.24 10 I Page FOR OFFICIAL USE ONLY: COMMUNITY DEVELOPMENT DIRECTOR REVIEW: Date: Applicant has obtained all necessary Permits and Licenses. (Building Permit / Business License) Dawson County Alcohol Administrator Dawson County Community Development Director