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PICKENS COUNTY PLANNING & DEVELOPMNENT 1266 East Church Street, Suite 136 Jasper, GA 30143 Phone [PHONE REDACTED] Email: [EMAIL REDACTED] Fax [PHONE REDACTED] Revised 01/05/2022 APPLICATION FOR BUSINESS LICENSE All businesses must register with the Tax Assessor’s Office before applying for a business license. If your business has a storefront location, you will need to contact the Fire Marshal at [PHONE REDACTED] prior to your business license being issued. Business Name: Physical Address: Mailing Address: Owner Name: Phone Number: Email: Nature of Business: Federal Tax I.D. Georgia law, O.C.G.A. § 36-60-6 requires employers with 10 or more employee register with E-Verify Number of Everify Number: Is Food Being Prepared for Resale? Yes No If yes, a copy of your food service permit must be attached to the application. Does your line of work require state licensure under Title 43 of the Official Code of Georgia Annotated? Yes No If yes, a copy of your state license must be attached to the application. Are you the property owner of the physical address for the business? Yes No If no, a copy of your lease agreement must be attached to the application. APPLICANT AGREES TO CONFORM WITH ALL LAND USE INTENISTY REGULATIONS. *See Use Chart 6-1-1 in Chapter 67 of Pickens County Code of Ordinances for use and zoning restrictions. I hereby certify the information provided above is true and correct to the best of my knowledge Signed Date: FOR PLANNING & DEVELOPMENT USE ONLY Current Zoning Use: (CIRCLE) AG SA ER RR SR UR SPC SRPC NC HB I Is the zoning appropriate for the business use? Yes No Date Paid: Cash/Check/Card: Receipt#: Approved By: ---PAGE BREAK--- PICKENS COUNTY PLANNING & DEVELOPMNENT 1266 East Church Street, Suite 136 Jasper, GA 30143 Phone [PHONE REDACTED] Email: [EMAIL REDACTED] Fax [PHONE REDACTED] Updated 1/24/2022 Affidavit Verifying Status For a Pickens County Public Benefit Application Please complete, notarize, and return this affidavit with your license application or renewal. By executing this affidavit under oath, as an applicant for a Pickens County, Georgia Business License, Alcohol License, or other public benefit, as referenced in the Georgia Security and Immigration Compliance Act (O.C.G.A. Section 50-36- I am stating the following with respect to my application for a Pickens County Business License. I hereby affirm and swear that: I am a United States citizen or OR 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. Name of Business Date Signature of Applicant: (name of natural person applying on behalf Alien Registration number for non-citizens of individual, business, corporation, partnership, or other private entity) Printed Name SUBSCRIBED AND SWORN BEFORE ME ON THIS THE, DAY OF 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. NON-CITIZENS NEED TO INDICATE THE DOCUMENT BELOW THAT VERIFIES YOUR RESIDENCY STATUS AND ATTACH A COPY OF THE DOCUMENT (Front and back) I-327 (Reentry Permit) Machine Readable Immigrant Visa I-551 (Permanent Resident Card) Temporary I-551 Stamp (on passport or I-94) I-571 (Refugee Travel Document) I-94 (Arrival/Departure Record) I-688 (Temporary Resident Card) Unexpired Foreign Passport I-688A (Employment Authorization Card) I-20 (Certificate of Eligibility for Nonimmigrant I-688B (Employment Authorization Document) (F-1) Student Status) I-766 (Employment Authorization Card) DS2019 (Certificate of Eligibility for Exchange Visitor Certificate of Citizenship (J-1) Status) Naturalization Certificate Other (Use Document Description) ---PAGE BREAK--- PICKENS COUNTY PLANNING & DEVELOPMNENT 1266 East Church Street, Suite 136 Jasper, GA 30143 Phone [PHONE REDACTED] Email: [EMAIL REDACTED] Fax [PHONE REDACTED] Updated 1/24/2022 Private Employer Affidavit Pursuant to O.C.G.A. § 36-60-6(d) By executing this affidavit under oath, the undersigned private employer verifies on of the following with respect to its application for a business license, occupation tax certificate, or other document required to operate a business as references in O.C.G.A. § 36-60-6(d): Section 1. Please check only one: On January 1st of the below-signed year, the individual, firm, or corporation employed more than ten (10) employees 1. If you select Section1 please fill out Section 2 and then execute below. On January 1st of the below-signed year, the individual, firm, or corporation employed ten (10) or fewer employees. Section 2. The employer has registered with and utilizes the federal work authorization program in accordance with the applicable provisions and deadlines established in O.C.G.A. § 36-60-6. The undersigned private employer also attests that its federal work authorization user identification number and date of authorization are as follows: Name of Private Employer Federal Work Authorization User Identification Number Date of Authorization I hereby declare under penalty of perjury that the foregoing is true and correct. Executed on in (city), (state). Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF NOTARY PUBLIC My Commission Expires: 1 To determine the number of employees for purpose of this affidavit, a business must count its total number of employees company- wide, regardless of the city, state, or county in which they are based, working at least 35 hours a week,