Beer Permit Application

I hereby make application for a permit to sell, store, manufacture, or distribute beer or other beverages authorized to be sold, stored, manufactured or distributed under the provision of Tennessee Code Annotated (TCA) 57-5-101 ET SEQ. and base my application upon the answers to the following questions.

This is an application for:*

Full Name of Applicant:*

Applicant's Email:*

example@example.com

Applicant's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant's Drivers License Number:*

Applicant's Drivers License Issuing State:*

Photo of Applicant's Drivers License:*

Applicant's Social Security #:*

Applicant's Date of Birth:*

Date

Applicant's Cell Phone #:*

Applicant's Home (Alt) Phone #:*

Previous Addresses within the last ten years:

This is an application for:*

Name of Business:*

Address of Business:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the Applicant also the Property Owner?*

YesNo

Name of Property Owner (if different than applicant):

Address of Property Owner (if different than applicant):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Copy of the Lease or Renters Agreement:

List all persons firms corporations jointstock companies syndicates or associations having at least a 5 ownership interest in the business attach an additional sheet if necessary

Is the Applicant also the Business Manager?*

YesNo

Name of Manager (if different than applicant):

Address of Manager (if different then applicant):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Manager's Drivers License:

Manager's Drivers License State:

Photo of Managers's Drivers License:

Manager's Social Security #:

Manager's Date of Birth:

Date

Manager's Cell Phone #:

Manager's Home (Alt) Phone #:

Will the permit be used to operate two or more restaurants or other businesses under the same permit as permitted by TCA 57-5-103(a)(4) within the same building?*

YesNo

If yes, specify number:

List the names of the restaurants or other businesses and describe their location:

Has any person having at least a 5% ownership interest, any of the managers listed or any other employee of the business been convicted of any violation of the beer or alcoholic beverage laws or any crime (other than minor traffic violations) within the last ten years?*

YesNo

If yes, give particulars of each charge, court and date convicted:

Has this owner or the owners of the organization ever had a beer permit revoked, suspended, or denied in the State of Tennessee?*

YesNo

If yes, specify where when and why:

Give the name relationship to applicant if applicable and address of the former beer permittee at this location:*

What is the name and address of the church or other place of worship nearest to your business location:*

Worship Distance:

What is the name and address of the school nearest to your business location?*

School Distance:

What is the name and address of the owner of the nearest residential dwelling to your business location?*

Residential Distance:

I am knowledgeable of the laws prohibiting the sale of beer to minors. I am aware that if these laws are violated my permit will be revoked and I could face criminal prosecution. I understand that my permit shall be revoked if my business location causes traffic congestion or interferes with schools, churches or other places of public gathering or otherwise interferes with public health, safety and morals.

NOTE: A non-refundable $250.00 fee must accompany this application. If this application is approved, you are required to provide documentation of sales tax registration to the city within ten days of approval. A privilege tax of $100.00 is imposed on the business of selling, distributing, storing, or manufacturing beer in this state effective January 1, 1994, and each successive January 1. Any holder of a beer permit issued after January 1 shall pay a pro rata portion of this annual tax when the permit is issued.

Any applicant making false statement in this application shall forfeit his/her permit and shall not be eligible to receive any permit for a period of ten years.

Excerpt from Tennessee State Annotated 57-5-606

Qualifications for responsible vendor status:

“(A) Require each and every clerk to successfully complete a responsible vendor training program within sixty-one (61) days of commencing employment, whether the employment is for the first time, after rehiring, or for a different responsible vendor. Responsible vendors shall, prior to employing a clerk, verify with the commission that the clerk is eligible for certification;(B) Each clerk shall successfully complete the responsible vendor training program and after doing so, receive a certificate of completion from the program trainer in a format that is in accordance with rules promulgated by the commission. The training program shall be a minimum of one (1) hour of instruction. A clerk shall not be authorized to sell beer for off-premise consumption, unless the clerk has successfully completed the responsible vendor training program and has received a certificate of completion or is within sixty-one (61) days of the date of hire. The original certificate of completion shall be maintained by the responsible vendor employing the clerk. The responsible vendor shall provide the commission with the names and other identifying information as required by the commission, of certified clerks within twenty-one (21) days of the date of training; and (C) Each clerk shall be issued a name badge by the responsible vendor employer. The name badge must have the clerk’s first name clearly visible. Clerks shall wear this name badge at all times during which they are on duty;”

The below signature confirms I read and understand my obligations to be considered a responsible vendor.

Signature of ApplicantOwner or authorized corporate officer*

Date*

Date

BEER PERMIT APPLICATION