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BOARD OF COMMISSIONERS LIBERTY COUNTY 100 Main Street, Suite 1320 HINESVILLE, GEORGIA 31313 (912) 876-2164 / FAX (912) 369-0204 www.libertycountyga.com DONALD LOVETTE CHAIRMAN MARION STEVENS, SR. DISTRICT 1 JUSTIN FRAISER DISTRICT 2 CONNIE THRIFT DISTRICT 3 PAT BOWEN DISTRICT 4 GARY GILLIARD DISTRICT 5 EDDIE J. WALDEN DISTRICT 6 JOSEPH W. BROWN COUNTY ADMINISTRATOR APPLICATION FOR ALCOHOL BEVERAGE LICENSE YEAR COUNTY LICENSE NO.: INSTRUCTIONS: This personal statement must be executed, under oath, by every person having ownership or profit sharing interest in, managing, or employed by, any place of business applying for a license from the State Revenue Commissioner to sell or deal in alcoholic beverages or liquors. Each question must be fully answered. If the space provided is not sufficient, answer the question on a separate sheet and indicate in the space provided that such separate sheet is attached. When returning this application to the Liberty County Building and Licensing Department please attach a money order, cashiers check, or cash for the cost of the alcohol license and application fee. If you have any questions about this application please feel free to call us at [PHONE REDACTED]. 1. Full name of applicant: Social Security No.: Home Phone Work Phone # 2. Trade name & address of business of which this personal statement is a part: 3. Position of applicant in dealer's business: 4. Do you have financial interest in any bar, lounge, tavern, restaurant, or other place of business where alcoholic beverages are sold and consumed on the business premises? If so, give details. 5. Do you have any financial interest, or are you employed in any wholesale or retail alcoholic beverages business other that the business submitting license application of which this personal statement is part? If so, give names and locations, and amount of interest in each. ---PAGE BREAK--- How Much? Where? In what County? How many years? Race Sex Certification No.: 9. Business Address: Color of Eyes 6. Do you presently have or had in the past, any financial or ownership interest and/ or presently employeed, or in the past, been employed, in any business engaged in distilling, bottling, rectifying, or selling (wholesale or retail) alcoholic beverages in this State or outside this State which has not otherwise been disclosed in this statement? If so, explain: 7. Other names used by applicant: Maiden name, names by former marriages, former name changed legally or otherwise: Aliases, nicknames, etc. Specify which, and show dates used: 8. Home Address: 10. Place of birth: Date of birth: Date, Place, & Court: U.S. Citizen: Naturalized: By birth: Petition No.: Derived Parents Certification No.(s): Alien Registration No.: Native Country: Date and Port of Entry: 11. How many consecutive years and months have you been a legal resident of Georgia and Liberty County? Years? Months? 12. Single Married Widowed Divorced Separated 13. If married, divorced or widowed, complete the below requested information on spouse. Full Name of Spouse: Social Security Number: Wife Maiden Name: Place of Birth: Date of Birth: Place of Marriage: Date of Marriage: Name of Spouse Employer: Employer's Address: 14. 15. Are you a registered voter in the State of Georgia? 16. For the last calendar year, did you file and pay any county property tax? 17. Have you ever had any financial interest in a alcoholic beverages business which was denied a liquor license? If so, give full details: ---PAGE BREAK--- 18. Has any alcoholic beverages business in which you hold, or have held, any financial interest, or are employed, or have been employed, ever been cited for any violation of the rules and regulation of the State Revenue Commissioner relation to sale and distribution of alcoholic beverages? If so, give full details: 19. Do any of the following presently have, or had in the past, any license or financial or ownership interest whatsoever in any business dealing in alcoholic beverages: spouse, paernts, step-parents, parents-in-law, brothers, sisters, step-brothers, step-sisters, brother-in-law, sister-in-law, children, step-children, and children-in-law? If so, give full details: 20. Have you during the past ten years bought and/ or sold any local or state alcoholic beverage license in this State or outside this State? If so, give details (date, license persons and considerations involved). 21. If during the past ten years you have bought, sold, or exchanged any real estate, automobiles or securities with any other person engaged in the alcohol beverages business, or with any regulatory official, give full details (date, property, persons, and considerations involved). 22. Have you ever visited or resided in any foreign country except while in the Armed Forces of the United States? If so, give details. 23. Have you ever been denied a bond by a commercial surety company: If so, give details. 24. List any close relatives (including in-laws) now residing outside the United States, except those actively serving in the Armed Forces of this Country. (Give name, relationship, age, place of residence, citizenship). 25. Education: (all schools avove elementary-give name of school, address, dates attended, and degrees or certificates received.) ---PAGE BREAK--- 26. Employment Record: (Give most recent experience first, if self-employed, give details. From Month/Year To Month/Year Occupation and description of duties performed Salaries Recieved Employers State Reason for Leaving Dates: Street Address: City: State: From To Present 27. List in reverse chronological order all your residents for the past ten years. ---PAGE BREAK--- 28. References: Give three personal references, not relatives, former employers, fellow employees, or school teachers, who are responsible, reputable, adults, business or professional men or women, who have known you well during the past five years. (Name, residence, business address, and number of years known). 29. Military service: (Serial number, branch of service, period of service, type of discharge). 30. Have you ever been arrested, or held by Federal, State, or other law-enforcement authorities, for any violation of any federal law, state law, county, or municipal law, regulation or ordinances? (do not include traffic violations. All other charges must be included even if they were dismissed. Give reason charged or held, date, place where charged and disposition). ---PAGE BREAK--- ALCOHOLIC BEVERAGE CODE OF ORDINANCE CERTIFICATION I, , certify that I have read and understand provisions of Liberty County Code Chapter 4 dealing with Alcoholic Beverages. I certify that I have received a copy of said chapter for display on premises. Signature: Date: ---PAGE BREAK--- 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. VERIFICATION State of Georgia, County I, , do solemnly swear, subject to the penalties of false swearing, that the statement and answers made by me as the applicant in the foregoing personnel statement are true. Applicant's Signature (Full name and in ink) I hereby certify that is personally known to (the above named person ) me, that he/she signed their 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 statement and answers are true. This day of 20 . Notary Public (Affix Seal) ---PAGE BREAK--- BOARD OF COMMISSIONERS LIBERTY COUNTY 100 Main Street, Suite 1320 HINESVILLE, GEORGIA 31313 (912) 876-2164 / FAX (912) 369-0204 www.libertycountyga.com DONALD LOVETTE CHAIRMAN MARION STEVENS, SR. DISTRICT 1 JUSTIN FRAISER DISTRICT 2 CONNIE THRIFT DISTRICT 3 PAT BOWEN DISTRICT 4 GARY GILLIARD DISTRICT 5 EDDIE J. WALDEN DISTRICT 6 JOSEPH W. BROWN COUNTY ADMINISTRATOR TO: Liberty Consolidated Planning Commission FROM: County Adminstrator SUBJECT: Alcohol Beverage License Application 1. Consider the location for which the enclosed license is sought and determine possible traffic congestion; no original license shall be issued hereunder, where the business building in which the license is located is within one hundred and fifty (150) feet of any area zoned residential, or unless the business building of the proposed location is situated more than six hundred (600) feet from any property line of any library, church, shrine, chapel or a mortuary, or other place used exclusively for religious services, and more than six hundred (600) feet from any property line of any school or college campus. The distance set out shall be measured in a straight line and shall be computed from property line of the aforesaid library, church, school, or area zoned residential to the building in which is located the business for which the license is being sought. 2. Following an on-sight inspection of the proposed location, I recommend that this license (circle one). BE ISSUED BE DENIED If you do not reccommend approval, indicate your reasons below: Date Rep. , LCPC ---PAGE BREAK--- ALCOHOL BEVERAGE LICENSE APPLICATION CRIMINAL HISTORY CHECK LIBERTY COUNTY SHERIFF'S DEPARTMENT Clerk of Courts / State and Superior Court Detectives Office / Warrants City Detectives Office District Attorney's Office C.I.D. / Fort Stewart G.C.I.C. - Criminal History & Drivers History Photo of Building: Is it in a Business or Residential area or near a School Zone? Detective: Date: FOR OFFICE USE ONLY ---PAGE BREAK--- CONFIDENTIAL REPORT OF BEVERAGE LICENSE INVESTIGATION Trade Name: Name of Applicant: Address of Business: County: City: Date: Assigned To: Due Date: Agents Signature: Date Investigation Completed: Meets all requirements: Yes: No: FROM: Comments: TO: Sheriff of Liberty County, Georgia I have completed this investigation report and recommend the license applied for be APPROVED DISAPPROVED FOR OFFICE USE ONLY ---PAGE BREAK--- License Fees: Liquor - Consumption on premises Liquor - Consumption off premises (package) Beer - Consumption on premises Beer - Consumption off premises (package) Wine - Consumption on premises Wine - Consumption off premises (package) Total Amount of License or Licenses Approved by Governing Authority Disappoved by Governing Authority Date: New License No.: Further comments concerning application or restrictions applicable to this business: Joseph Brown, County Administrator Liberty County Board of Commissioners FOR OFFICE USE ONLY