APPLICATION FOR RETAIL BEER AND LIGHT WINE PERMIT
City of Fayetteville, 113 West Mountain, Fayetteville, AR 72701
Regulated by Title XI, Chapter 111 of the City of Fayetteville Code of Ordinances
Type of Permit: ___ On Premises Consumption ___ Off Premises Consumption
Please print or type the following:
Business Applicant
Name:
(Must be person listed on State Permit)
Address:
City, State, Zip:
Phone:
Mailing Address:
Date of Birth:
*ALL INFORMATION MUST BE FILLED OUT
Driver’s License #:
BEFORE APPLICATION WILL BE PROCESSED.
Permit fee for new applicant with no sales history $ 40.00
Sales Information: (Include gross sales of beer and light wine):
1. Gross sales of beer and light wine, year ended 12/31/20 $
2. Less than 12 months of sales: number of months , divide
gross sales by number of months and multiply by 12. $
Permit fee calculation (please enclose check payable to City of Fayetteville):
3. Deduct: $1,000.00 from line 1 or 2 whichever applies
4. Multiply: Line 3 times .005
5. Add: Base fee for up to & including $1,000.00 in gross sales 15.00
Total Amount Due (Add lines 4 & 5) $
OVERPAYMENTS OF $5.00 OR LESS WILL NOT BE REFUNDED
I do hereby swear and affirm that the location of the business for which this permit is sought is not within 200 yards of any church or school
building, if said business is a retail establishment for the sale of alcoholic beverages for consumption off the premises; or is not within 300 feet
of any church or school building for any other business for which a City of Fayetteville alcoholic beverage permit is required.
Affidavit – The below signed applicant, being 21 years of age or older, after first being duly sworn, states that all above information is true and
accurate to the best of his or her knowledge and belief.
Applicant’s signature
(Must be person listed on State Permit)
Subscribed and sworn before me this day of , 20
Notary Public
(Seal)
My commission expires
A COPY OF YOUR CURRENT STATE PERMIT MUST ACCOMPANY THIS APPLICATION
