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1 Thomson-McDuffie County, Georgia MCDUFFIE COUNTY PLANNING COMMISSION 210 RAILROAD STREET, SUITE 1544, THOMSON, GA 30824 [PHONE REDACTED] [EMAIL REDACTED] Occupational Tax Certificate (A/K/A Business License) Application Notes: The term Occupational Tax Certificate and Business License shall have the same meaning. Date: License Number *For Office Use Only. *For Office Use Only: COUNTY: CITY: A COPY OF DRIVER LICENSE FRONT & BACK MUST BE ATTACHED TO APPLICATION. PLEASE PRINT CLEARLY (IF APPLICATION IS NOT LEGIBLE, YOUR PAPERWORK WILL NOT BE PROCESSED.) Section A: Business Information Business Name: DBA Business Email Address: Business Description: *You are required to list in detail all services and product types rendered. Business Location: [ ] Commercial/Business Lot [ ] In/At Home [ ] Mobile/Door-To-Door *Check only one Parcel ID Number: (For Office Use Only) Business Address: Street City Zip Mailing Address: *If different from “Street Address” above. If same, indicate “same”. Business Phone Number: Ga. Sales Tax Number (For Retail Sales Only): Employer Identification Number (EIN): E-Verify Number: Section B-1: ---PAGE BREAK--- 2 Business Owner’s Name: Owner’s (Home) Address: City State Zip Owner’s Mailing Address: City State Zip Owner’s Personal Email Address: Owner’s Phone Number: Business Manager’s Name: Section B-2: Notes: If same as “business owner” information above - indicate “Same As B-1.” Applicant is: [ ] Owner [ ] Manager [ ] Employee [ ] Other: *Check only one. Applicant’s Name: *Only one Name. (First) (Middle Initial) (Last) Applicant’s Home Address: City State Zip Personal Email Address: Applicant’s Home Phone Number: Mobile No. Section B-3: THIS SECTION MUST BE COMPLETED: Property Owner’s Name: ---PAGE BREAK--- 3 Property Owner’s (Home) Address: City State Zip Property Owner’s Mailing Address: City State Zip Property Owner’s Personal Email Address: Property Owner’s Phone Number: Section C: Do you have more than one office or business location in Thomson-McDuffie County? [ ] Yes [ ] No Have business licenses been issued for any of those locations? [ ] Yes [ ] No Section D: Professions Requiring State Certification (OCGA Title 43- - ) Any and all that apply to your profession, or to the type of business being conducted. employees. [OCGA 48-13-10(g)]. If State Certification is required you MUST bring in copy of certificate. [ ]*Accountant 3-6 [ ] Driving Instructor/School 13-6 [ ] Massage Therapist 36-30-6 [ ] 39-6 [ ]*Architect 4-11 [ ] DUI School 13-6 [ ] Motor Vehicle Racetrack 25-2 [ ] Real Estate Appraiser 39A-7 [ ] Athlete Agent 4A-4.1 [ ] Elect, Plumbing, HVAC 14-8 [ ] Nurse 26-7 [ ] Real Estate Broker/Sales 39A-7 [ ] Athletic Trainer 5-7 [ ]*Engineer 15-9 [ ] Nursing Home Administrator 27-6 [ ] Registered Nurses [ ]*Attorney [ ]*Family Therapist 10A-7 [ ] Occupational Therapist 28-8 [ ] Res. and Gen. Contractors [ ] Auctioneer 6-9 [ ] Firearms Dealer 16-2 [ ]*Optometrist/Optician 29-7 [ ] Security Agencies 38 [ ] Audiologist 44-7 [ ] Foresters [ ] Pest Control 45-9 [ ]*Social Worker 10A-7 [ ] Barber 7-11 [ ]*Funeral Dir./Embalming 18-40 [ ] Pharmacy [ ] Speech Pathologist 44-7 [ ] Building Contractor [ ] Geologist 19-10 [ ]*Physical Therapist 33-11 [ ] Used Motor Vehicle/Parts Dealer [ ]*Chiropractor 9-7 [ ] Hearing Aid Dealer 20-7 [ ]*Physicians 34+ [ ]*Veterinarian 50-30 [ ] Cosmetologist 10-8 [ ]*Landscape Architect 23-5 [ ] Podiatrist 35 [ ] Water/Waste Water Treatment 51 [ ] Counselor (Professional) 10A-7 [ ]*Land Surveyor 15-12 [ ] Practical Nurse 26-7 [ ] Scrap Metal Dealers [ ]*Dentist 11-40/Dental Hygienist 11-70 [ ] Librarians 24 [ ] Private Detective 38-6 [ ] Dietician 11A-8 [ ]*Marriage Therapist 10A-7 [ ] Professional Counselor 10A-7 Section E: Occupational Tax (Business License) Fee Notes: Occupational tax fees in McDuffie County are based on the greatest number of full-time and part-time employees that worked for the business the previous calendar year. Part-time employees are converted to equivalent full-time employees by adding the working hours of all part- time employees for the calendar year, then dividing the hours by 2,080 to determine the number of equivalent annual full-time employees. If you are a new business, your fee will be based on an estimate of greatest number of employees during the opening year. Fee Declaration: (Check Only One). Section E-1 ---PAGE BREAK--- 4 Enter below the greatest number of full-time and part-time employees in your business at anytime during the past year, or, if a new business, the highest anticipated number of employees you will have this year. Please include all owner(s) in the full-time employees count. [ ] Owner(s) & Declared Number of Employees: Full –Time Part –Time [ ] Professional flat fee of $275 for each professional at the business. If you one of the professions in Section D which has an asterisk you, as the “professional”, are permitted to choose either of the business license fee schedules: Declared Number of Employees or Professional Flat Fee. Section F: Acknowledgements (Initial Below) I acknowledge that business licenses are business type specific. Example - If a clothing store closes, and reopens as a jewelry store (at the same location), a new business license must be obtained. I acknowledge that business licenses are site/location specific. Example - If the business moves from one location to another, you must obtain a new license. I acknowledge that, to the best of my knowledge, the business complies with all McDuffie County requirements including, but not limited to, any health permits, bonds, certificates, licensing, zoning approvals, and the like; and that failure to obtain, maintain, and comply with any of the above may result in the revocation of the business license. In order to safeguard property, employees, and the general public, upon prior notice by county or state officials, the structure housing the business may be inspected for compliance with any or all applicable codes and ordinances, and that any violations will be corrected prior to issuance of a business license. I acknowledge that the business will cooperate with McDuffie County in all matters for the purpose of obtaining a business license. As an authorized representative of the business 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 or to any county representative or designee shall constitute grounds for revocation of the business license. Signature: Date: Section G: For Office Use Only: [ ] Planning/Zoning Department: Yes No Signature: Planning & Zoning ---PAGE BREAK--- 5 [ ] Fire Inspection: Yes No Signature: Fire Inspector [ ] McDuffie County Health Department: Yes No Signature: Health Department ([PHONE REDACTED]) [ ] All Property Taxes Paid: Yes No Signature: Tax Commission [ ] Commercial Building Inspection: Yes No Signature: Building Inspector [ ] McDuffie County Sheriff’s Department: Yes No Signature: Sheriff’s Department Signature: [ ] Thomson’s Police Department: Yes Police Department Affidavit Citizenship/Immigration Status [Pursuant to Georgia state law O.C.G.A. § 50-36-1(e)(2)] By executing this affidavit under oath, as an applicant for a business license (a/k/a Occupational Tax Certificate) from McDuffie County, Georgia, the undersigned applicant confirms one of the following with respect to his/her application for a business license: Check only one: As the business owner: I am a United States citizen. I am a legal permanent resident of the United States. I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or ---PAGE BREAK--- 6 other federal immigration agency. My alien number issued by the Department of Homeland Security or other federal immigration agency is: The undersigned applicant also hereby confirms that he or she is 18 years of age or older and has provided with this affidavit a secure and verifiable document as proof of his/her citizenship status, as required by O.C.G.A. § 50-36-1(e)(1). The document provided indicating citizenship status is the following: Check Only One: [ ] Driver’s License [ ] U.S. Passport [ ] Military I.D. [ ] “Green Card” [ ] Other: 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 O.C.G.A. § 16-10-20, and shall be subject to criminal penalties as allowed by such criminal statute. Executed on this the day of in (city), (state). Signature of Applicant Printed Name of Applicant Business Name SUBSCRIBED AND SWORN BEFORE ME, THIS: THE DAY OF NOTARY PUBLIC My Commission Expires: Private Employer Exemption Affidavit Pursuant To O.C.G.A. § 36-60-6(d) By executing this affidavit, the undersigned private employer verifies that it is exempt from compliance with O.C.G.A. . § 36-60-6, stating affirmatively that the individual, firm or corporation employs less than five hundred (500) employees and therefore, is not required to register with and/or utilize the federal work authorization program commonly known as E- Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadline established in O.C.G.A. § 13-1090. Please Check Only One: ---PAGE BREAK--- 7 Section 1. On January 1 of the below-signed year, the individual, firm, or corporation employed more than ten (10) employees. ***If you select Section 1, please fill out Section 2 & 3 and have it notarized. On January 1 of the below-signed year, the individual, firm, or corporation employed ten (10) or fewer employee. ***If you select Section 1, please fill out Section 3 and have it notarized. 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 Section 3. I hereby declare under penalty of perjury that the foregoing is true and correct. Executed on 20 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 OF 20 NOTARY PUBLIC My Commission Expires: ---PAGE BREAK--- 8 FOR OFFICE USE ONLY Name-Based Criminal History Record Information Consent/Inquiry Form I hereby authorize THOMSON POLICE DEPARTMENT to conduct an inquiry for Agency/Company the purpose listed below and receive any Georgia and/or national criminal history record information as authorized by state and federal law. Full Name (print) Address Sex Race Date of Birth Social Security Number This authorization is valid for days from date of signature. I, , give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment. Attorney for Individual (Pur E and U Only) Bar Number Date ---PAGE BREAK--- 9 Date of Inquiry: Time of Inquiry: Operator’s Initials: Purpose Code Used: (check one) NON-CRIMINAL JUSTICE PURPOSES E - Employment M - Working with Mentally Disabled N - Working with Elderly W - Working with Children P - Public Records (no consent required) PERSONAL REQUEST (INDIVIDUAL OR THEIR ATTORNEY) U - Personal Copy CRIMINAL JUSTICE EMPLOYMENT J - Civilian Criminal Justice Employment (State & III Info Received) Z - Sworn Criminal Justice Employment (State & III Info Received) The inquiry resulted in the following: (check all that apply) No Criminal Record Available Criminal Record (Attached/Released) No NCIC/GCIC Warrant Possible NCIC/GCIC Warrant (List Wanting Agency Below) Wanting Agency Name: THOMSON POLICE DEPARTMENT / Wanting Agency Telephone: (706) 595-2166 Agency Designee Signature and Title Date Revised March 2019