ORIGINAL ALCOHOL BEVERAGE RETAIL LICENSE APPLICATION Submit to municipal clerk. For the license period beginning ending TO THE GOVERNING BODY of the: County of Town of Village of City of 20 20 ; LICENSE REQUESTED } Aldermanic Dist. No. Applicant’s Wisconsin Seller’s Permit Number: Federal Employer Identification Number (FEIN): (if required by ordinance) 1. The named INDIVIDUAL PARTNERSHIP LIMITED LIABILITY COMPANY CORPORATION/NONPROFIT ORGANIZATION hereby makes application for the alcohol beverage license(s) checked above. TYPE FEE Class A beer Class B beer Class C wine Class A liquor Class B liquor Reserve Class B liquor   Publication fee $ $ $ $ $ $ $ TOTAL FEE $ 2. Name (individual/partners give last name, first, middle; corporations/limited liability companies give registered name): An “Auxiliary Questionnaire,” Form AT-103, must be completed and attached to this application by each individual applicant, by each member of a partnership, and by each officer, director and agent of a corporation or nonprofit organization, and by each member/manager and agent of a limited liability company. List the name, title, and place of residence of each person. Title Name Home Address Post Office & Zip Code President/Member Vice President/Member Secretary/Member Treasurer/Member Agent Directors/Managers 3. Trade Name Business Phone Number 4. Address of Premises Post Office & Zip Code 5. Is individual, partners or agent of corporation/limited liability company subject to completion of the responsible beverage server training course for this license period?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 6. Is the applicant an employe or agent of, or acting on behalf of anyone except the named applicant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 7. Does any other alcohol beverage retail licensee or wholesale permittee have any interest in or control of this business?. . . . . . . . . . . . . . . . . Yes No 8. (a) Corporate/limited liability company applicants only: Insert state and date of registration. (b) Is applicant corporation/limited liability company a subsidiary of any other corporation or limited liability company?. . . . . . . . . . . . . . . . . . Yes No (c) Does the corporation, or any officer, director, stockholder or agent or limited liability company, or any member/manager or agent hold any interest in any other alcohol beverage license or permit in Wisconsin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No (NOTE: All applicants explain fully on reverse side of this form every YES answer in sections 5, 6, 7 and 8 above.) 9. 10. 11. 12. 13. 14. Premises description: Describe building or buildings where alcohol beverages are to be sold and stored. The applicant must include all rooms including living quarters, if used, for the sales, service, and/or storage of alcohol beverages and records. (Alcohol beverages may be sold and stored only on the premises described.) Legal description (omit if street address is given above): (a) Was this premises licensed for the sale of liquor or beer during the past license year?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes (b) If yes, under what name was license issued? Does the applicant understand they must file a Special Occupational Tax return (TTB form 5630.5) before beginning business? [phone 1-800-937-8864]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Does the applicant understand a Wisconsin Seller’s Permit must be applied for and issued in the same name as that shown in Section 2, above? [phone (608) 266-2776] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Is the applicant indebted to any wholesaler beyond 15 days for beer or 30 days for liquor?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No No No No READ CAREFULLY BEFORE SIGNING: Under penalty provided by law, the applicant states that each of the above questions has been truthfully answered to the best of the knowledge of the signers. Signers agree to operate this business according to law and that the rights and responsibilities conferred by the license(s), if granted, will not be assigned to another. (Individual applicants and each member of a partnership applicant must sign; corporate officer(s), members/managers of Limited Liability Companies must sign.) Any lack of access to any portion of a licensed premises during inspection will be deemed a refusal to permit inspection. Such refusal is a misdemeanor and grounds for revocation of this license. SUBSCRIBED AND SWORN TO BEFORE ME this day of , 20 (Officer of Corporation/Member/Manager of Limited Liability Company/Partner/Individual) (Clerk/Notary Public) (Officer of Corporation/Member/Manager of Limited Liability Company/Partner) My commission expires (Additional Partner(s)/Member/Manager of Limited Liability Company if Any) TO BE COMPLETED BY CLERK Date received and filed with municipal clerk Date license granted AT-106 (R. 8-11) Date reported to council/board Date provisional license issued Date license issued Signature of Clerk / Deputy Clerk License number issued Wisconsin Department of Revenue American LegalNet, Inc. www.FormsWorkFlow.com