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JEFFERSON COUNTY, GEORGIA JEFFERSON COUNTY COMMISSIONERS 217 East Broad Street, P. O. Box 658, Louisville, GA 30434 478‐625‐3332—Telephone 478‐625‐4007—Fax Application: Occupational Tax Certificate (F/K/A Business License) {For clarification, in the context of this application, the term Occupational Tax Certificate and Business License shall have the same meaning.} { } New license { } Renewal Year: Section A: Business Name: Business Description: [You are required to list in detail all services and product types rendered.] Business Location (Check One) { } Commercial/Business Lot { } In/At Home { } Mobile /Door‐To‐Door Street Address: Mailing Address: [If Different from “Street Address” above. If same, indicate “same”] Telephone Number: GA Sales Tax Number (For Retail Sales Only): Federal Identification Number or Social Security Number: Section B—1: Applicant is: (Check One) [ } Owner [ } Manager [ ] Employee [ ] Applicant’s Name: (First) (Middle Initial) (Last) Applicant’s (Home) Address: Applicant’s (Home) Telephone Number: Section B—2 {If same as “Applicant” information above – indicate “same as above.”} Business Owner’s Name: Owner’s (Home) Address: Owner’s (Telephone) Number: Business Manager’s Name: Section C: Do you have more than one office or business location in Jefferson County: { } Yes { } No Have business licenses been issued for any of those locations? { } Yes { } No ---PAGE BREAK--- Section D: Required Confirmations OFFICE USE ONLY If any of the following are checked, you must first have those departments approval prior to issuance of a business license. { } Planning/Zoning Dept. approved?: Signature: Larry Morgan { } Code Enforcement approved? Yes____ Signature: Jimmy Kitchens { } Alcohol License Compliance approved? Yes____ Signature: Bonnie Wells { } Jefferson County Health Dept approved? Yes___ Signature: Michael Standiford { } Yes___ Signature: { } Professional State Certification { } Mobile: { } Bond { } Liability Insurance (Insurance Company Section E: OCCUPATION TAX (BUSINESS LICENSE) Occupation Tax Schedule: Number Of Employees: Up To 5 6‐10 11‐20 21‐30 31‐40 41‐50 More than 50 $400 The number of employees includes full‐time and full‐time equivalent working for the business. The fractional working ties of part‐time employees are combined and rounded to provide a more accurate estimate of full‐ time equivalent employees. The owner and other family members working for the business, whether, paid or not, shall be included in this count. Carnivals $300/WEEK Pawnbrokers $150 Massage Parlors $1,000 Auto and racing $500 Fortune Tellers $1,000 Adult Book Store $1,000 Peddlers $50.00/DAY or $500 WEEK I hereby warrant that I fully understand the information requested and/or stated above, and that the information submitted herein is true and factual to the best of my knowledge. I further understand that giving false information on this application, to the Jefferson County Board of Commissioners, County Administrator or his designee, shall constitute grounds for revocation of my business license. Official Use (Do Not Write Below This Line) Occupational Tax Fee: Based On: { } Employees { } Flat Fee { } Mobile Bus. { } Mailed { } Hand Delivered { } W/Pick Up Other: