Bartow County Occupational License

Transcription

1 Occupational License (Completed by office) Data entered by: Occupational Tax License NON-RESIDENTIAL APPLICATION FOR AN OCCUPATIONAL TAX LICENSE This application must be submitted to the occupational tax office. The application must be filled out completely to obtain an occupational license. Payment must be filed with the application to obtain a license. This application will not be processed if it is not accompanied by the appropriate tax or fee. You will not be billed. Please print with ink or type. If you have any questions, please contact our office at or Federal Tax ID # State Tax ID # NAICS business is: ( ) New ( ) Renewal ( ) Corporation ( ) Sole Proprietor ( ) Partnership ( ) Ownership Change/ ownership changed ( ) I am filing an address/name change for Business # Owner Name Partner Name DOB DOB Phone # Secondary Phone # Owner s full Address Name of Business Bus. Phone # Business Street Address Mailing Address Address If you are required to be licensed by the State of Georgia, a copy of your state license must be presented at the completion of this application. Full Description of Business Is the proposed business a pawnshop, secondhand dealer or precious metals dealer? Yes ; No If yes, additional permits must be obtained from the Sheriff s Office for the owner and all employees Business Began in Bartow County # of Employees E-Verify SAVE (if applicable) Person completing application If you have a Home Office, please indicate the individual responsible for the Occupational tax Name Title Phone Address Have you the applicant, or anyone having any ownership of this business ever violated, been arrested, or convicted of any Federal or State Law, or any ordinance or resolution regulating any business? If yes, please list all dates and locations of the offenses and disposition of charges I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT FALSIFICATION OF ANY PART OF THIS APPLICATION COULD CAUSE DENIAL OR REVOCATION OF THE LICENSE. I ALSO CERTIFY THIS BUSINESS IS NOT A SEXUALLY-ORIENTED BUSINESS AS THAT TERM IS DEFINED IN THE BARTOW COUNTY ADULT ENTERTAINMENT ORDINANCE. I UNDERSTAND THAT AN OCCUPATIONAL TAX CERTIFICATE DOES NOT EXCUSE COMPLIANCE WITH ANY OTHER APPLICABLE COUNTY ORDINANCE, DOES NOT VEST RIGHTS TO THE OPERATION OF A BUSINESS, AND MAY BE REVOKED UNDER THE TERMS OF THE BARTOW COUNTY OCCUPATIONAL TAX ORDINANCE, OR FOR VIOLATIONS OF OTHER COUNTY ORDINANCES OR APPLICABLE LAWS, OR IF THE BUSINESS IS PROHIBITED UNDER OTHER APPLICABLE ORDINANCES OR LAWS. Signature of Applicant ( ) Owner ( )Manager ( )Other Title

2 Occupational License Business Name Owner Name NON-RESIDENTIAL BUSINESSES Tax Parcel ID (You may obtain your Tax Parcel # by visiting or the Tax Assessors Office) The following departments should be contacted for approval when applicable. TAX COMMISSIONER W Cherokee Ave, Suite 217A BUILDING INSPECTIONS (Request the inspections 1 day in advance.) 135 W Cherokee Ave, Suite 124 ZONING W Cherokee Ave, Suite 124 Property Zoned ENGINEERING W Cherokee Ave, Suite 124 FIRE MARSHALL (An Inspection fee will be required before the inspection can be done. Please contact Bartow County Building Inspections to determine the fee, To schedule the appointment, please contact the fire marshal at ) 5435 Hwy 20 SHERIFF S DEPARTMENT (Required for pawn shops, second hand dealers and precious metals dealers) 104 Zena Drive BARTOW COUNTY HEALTH DEPT (Only required for food services/restaurants/etc) 100 Zena Drive I will comply with all restrictions as outlined in the above applicable ordinances. Please see appropriate office to obtain a copy of such ordinances. Applicant Signature Occupational tax certificates are issued pursuant to the Bartow County Occupation Tax Ordinance, as amended, and under the authority of Chapter 13 of Title 48 of the Code of Georgia. An occupational tax certificate is not certification that a business is lawful under other applicable County ordinances, and issuance of an occupational tax certificate shall not vest the holder with any rights or waive any duties of the County to enforce applicable laws and ordinances. Furthermore, an occupational tax certificate shall not authorize violation of recorded covenants or deed restrictions.

3 Government Systematic Alien Verification for Entitlement Affidavit O.C.G.A (e)(2) Form A: All License Holders By executing this affidavit under oath, as an applicant for a(n) occupational tax certificate, as referenced in O.C.G.A , from Bartow County Government, the undersigned applicant verifies one of the following with respect to my application for a public benefit: 1) I am a United States citizen. 2) I am a legal permanent resident of the United States. 3) 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 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 verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A (e)(1), with this affidavit. The secure and verifiable document provided with this affidavit can best be classified as:. 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 , and face criminal penalties as allowed by such criminal statute. Executed on,, 201, in (city), (state). Signature Company Name Subscribed and sworn before me on SSeal l this day of, 20 My Commission Expires

4 Government Private Employer Affidavit of Compliance with the Federal Work Authorization Program Pursuant to O.C.G.A (d) Form B: Less than 10 employees By executing this affidavit, the undersigned private employer verifies that it is exempt from compliance with O.C.G.A , stating affirmatively that the individual, firm, or corporation employs 10 or fewer employees and 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 deadlines established in O.C.G.A I hereby declare this statement to be true and correct under penalty of perjury. Executed on,, 201, in (city), (state). Printed Name of Exempt Private Employer Signature of Authorized Officer or Agent Printed Name and Title of Person Executing Affidavit Subscribed and sworn before me on SSeeaal ll this day of, 20 My Commission Expires

5 Government Private Employer Affidavit of Compliance with the Federal Work Authorization Program Pursuant to O.C.G.A (d) Form C: More than 10 employees By executing this affidavit, the undersigned private employer verifies its compliance with O.C.G.A , stating affirmatively that the individual, firm or corporation named herein employs more than 10 employees and has registered with and utilizes the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A Furthermore, the undersigned private employer hereby attests that its federal work authorization user identification number and date of authorization are as follows: Federal Work Authorization User Identification Number of Authorization Name of Private Employer/Company I hereby declare this statement to be true and correct under penalty of perjury. Executed on,, 201, in (city), (state). Signature of Authorized Officer or Agent Printed Name and Title of Person Executing Affidavit Subscribed and sworn before SSeeaal ll me this day of, 20 My Commission Expires