Fillable Operators License Application Fillable And Epay (Town of Richfield)

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Operators License Application Fillable And Epay (Town of Richfield)

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  • 18 check-boxes
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VILLAGE OF RICHFIELD
4128 HUBERTUS RD, HUBERTUS, WI 53033
262-628-2260
APPLICATION FOR OPERATOR/BARTENDER LICENSE TO SERVE FERMENTED MALT BEVERAGES
AND INTOXICATING LIQUORS
New License ($50) Renewal License ($25) Provisional License ($10)
(2 Months Only)
-- CONTINUED ON BACK --
License #: ____________
*** A FALSE or INCOMPLETE answer or statement in this application
could result in denial or revocation of the license***
Applicant Information
NAME OF APPLICANT: ____________________________________________________________________________________
LAST FIRST MI
RESIDENCE STREET ADDRESS: ____________________________________________________________________________
CITY: _________________________ STATE: _______ ZIP: ____________ PHONE NO: ____________________________
The following information is required for background check
DL #: ____________________________________________ ISSUING STATE: _____________
Attach a copy
BIRTHDATE: _____/_____/_______ AGE _____ GENDER: M F RACE: _____________
ESTABLISHMENT YOU WILL BE SERVING AT? _______________________________________________________________
HAVE YOU COMPLETED THE RESPONSIBLE BEVERAGE SERVICE COURSE WITHIN THE LAST 2 YEARS? YES NO Attach a copy
----------------- OR -------------------
HELD A VALID OPERATOR LICENSE IN THE STATE OF WISCONSIN WITHIN THE LAST 2 YEARS? YES NO Attach a copy
IF YES, INDICATE MUNICIPALITY: ___________________________________ AND LICENSE NO._____________________
Have you ever been CONVICTED of committing any crimes (felony or misdemeanor - including traffic
crimes, operating while intoxicated, eluding, operating while revoked, etc)? YES NO
Have you ever been CONVICTED of violating ANY State Law, or Local Ordinances that regulate alcoholic
beverages (ie: procure/sell/dispense/give to underage person, licensee furnishing to underage person)? YES NO
If you answered YES to any of the above questions, please complete the information below.
List any and all convictions separately. If additional space is needed, use the back of this form.
Date
Offense
Municipality
Are you currently on probation and/or parole? YES NO
If yes, for what offense? _______________________________________________________________________________________
Are you currently on bond restrictions? YES NO
If yes, in what county? ________________________________________________________________________________________
Do you have any PENDING criminal cases against you for violating ANY State Law or Local Ordinances? YES NO
*PENDING means an offense that you were cited or arrested for, that has not yet been resolved.
OFFENSE: ___________________________________________________________________________________________________
Name of Law Enforcement Agency: ______________________________________________________________________________
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WAIVER AND CONSENT
I hereby certify that the answers on the above application are complete, true and correct to the best of my knowledge and
belief. I am eighteen years of age or older. I agree in the consideration of the granting of this license, for the term
ending JUNE 30, 20___, to comply with the laws of the State of Wisconsin, the Ordinances of Washington County, and
all the provisions of the Municipal Code of Ordinances of the Village of Richfield.
I, by the signing of this application, consent to the full investigation of my background by law enforcement officials and
also consent to the use and disclosure by the Village of Richfield, its elected officials, its employees and its agents of any
and all information obtained in said investigation relative to my fitness to be a licensed operator in the Village of
Richfield.
I hereby waive all rights to privacy or privilege that I may have in the use of the material and information obtained from
said investigation. Further, I do hereby release and hold harmless, and agree to release and hold harmless the Village of
Richfield, its elected officials, its employees and its agents from any and all manner of action or cause of action,
judgments, executions, debts, claims and demands which I may have or my heirs or assigns may have regarding the
investigation of my background and use of said material and information obtained from said investigation.
APPLICANT’S SIGNATURE: ____________________________________________________ DATE: ________________
L:\Licenses & Permits>Applications>Operators License Application Rev 2/5/2019
I hereby apply for a license to serve from the date hereof to June 30, 20___, inclusive (unless sooner revoked), Fermented
Malt Beverages and Intoxicating Liquors subject to the limitations imposed by Sections 125.32(2) and 125.68(2) of the
Wisconsin Statutes and all acts amendatory thereof and supplementary thereto, and hereby agree to comply with all laws,
resolutions, ordinances, and regulations, Federal, State or Local affecting the sale of such beverages and liquors if a
license is granted to me.
APPLICANT’S SIGNATURE: ____________________________________________________ DATE: ________________
Please Note:
FEES ARE NON- REFUNDABLE
Should you withdraw your application or the application be denied by the Village Board.
If paying online, please check this box
To submit payment online, please click here and select "fees".
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Operators License Application Fillable And Epay (Town of Richfield)

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Completed 14 July 2020

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