Rev. 5/2019 Page 1 of 3
City of Portage Alcohol and Fermented Malt Beverage
Class A Application Supplemental Form
1. Applicant Information:
Applicant Name:
Trade name of business:
Business address:
Business Telephone Number:
Business email:
This application is a:
New application
Renewal application
This application is for a:
Class “A” (fermented malt beverage)
Class A” (intoxicating liquor)
Class A” (cider only)
2. Business Plan
Describe the business; provide copy of business plan (business plan is for office use
only).
Describe your management experience.
Hours of Operation.
Number and type of employees expected to work at establishment.
Anticipated opening date:
(new applicants only)
3. Explain your security plan, including presence and type of security surveillance,
including recording and store of surveillance video.
Rev. 5/2019 Page 2 of 3
4. Do you have a policy to train employees in the sale of alcohol? Yes No
If yes, how often is the policy review by the management and employees?
5. Explain your process for age verification of customers.
6. Who will conduct the actual sale of the alcohol? This is the transaction where the
patron hands the money to the cashier after reviewing the patron’s identification.
The purchase of alcohol is defined when the money is exchanged, not when the
merchandise is scanned at the register.
Only employees over the age of 18
Only a licensed operator on the
premises
Other (please explain)
7. Attach a detailed site plan depicting the licensed premises, parking, garbage
storage area, entrances/exits, liquor storage areas, coolers, external lighting,
signage, etc.
8. Premises Description
Describe area where alcohol beverages are to be stored and indicate on site plan:
Describe area where alcohol records are to be stored and indicate on site plan:
Describe area where alcohol beverages are to be sold and indicate on site plan:
Describe the locations in the store where alcohol will be displayed and the type of
structure that will be used for the display (for example, temporary/permanent shelving,
rolling shelf, pallet, etc.)
9. Is there currently a license at this location (new applicants only)?
Yes No
If yes, what, if any, changes are being proposed?
Rev. 5/2019 Page 3 of 3
10. Is there any other business conducted on the premises? Yes No
If yes, please explain:
11. Describe goods and services to be sold at this location, along with the estimated
% of sales devoted to alcohol, food, other products and services.
Percent gross receipts from intoxicating liquor and/or
fermented malt beverages
Percent gross receipts from other (list below)
12. Who may we contact between 8:00am and 4:30pm regarding this license?
Contact person
Email address
Telephone number
13. The following must be included with the application:
a. New Application
Federal Identification Number
Wisconsin Seller’s Permit or Use Tax Registration Certificate with expiration date
Articles of Incorporation (Corporation/LLC only)
Deed, Lease or Offer to Purchase Agreement
Form for surrender of previous license (if applicable)
Responsible Beverage Service Training Course Certificate
b. Renewal Application-attach or check no changes box
Wisconsin Seller’s Permit or Use Tax Registration Certificate with expiration date
Federal Identification Number no change from last application
Articles of Incorporation (Corporation/LLC only) no change from last application
Deed, Lease or Offer to Purchase Agreement no change from last application
current year tax bill can be submitted in place of a deed
Form for surrender of previous license (if applicable)
Responsible Beverage Service Training Course Certificate
submit only if change of agent
I certify the information provided on this form is true and correct to the best of my
knowledge
Signature
Date
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome