Fillable Original Alcohol Beverage Retail License Application (City of Port Washington)

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Original Alcohol Beverage Retail License Application (City of Port Washington)

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1. The named Individual Partnership Limited Liability Company
Corporation/NonprotOrganization
herebymakesapplicationforthealcoholbeveragelicense(s)checkedabove.
2. Name(individual/partnersgivelastname,rst,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 ofcer, director and agent of a corporation or nonprot 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 (Last, First, M.I.) Home Address Post Ofce & 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Ofce&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ofcer,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. 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,consumption,and/orstorageofalcoholbeveragesandrecords.(Alcoholbeverages
maybesoldandstoredonlyonthepremisesdescribed.)
10. Legaldescription(omitifstreetaddressisgivenabove):
11. (a) Wasthispremiseslicensedforthesaleofliquororbeerduringthepastlicenseyear? ...................................... Yes No
(b) Ifyes,underwhatnamewaslicenseissued?
12. DoestheapplicantunderstandtheymustregisterasaRetailBeverageAlcoholDealerwiththefederalgovernment,Alcoholand
TobaccoTaxandTradeBureau(TTB)byling(TTBform5630.5d)beforebeginningbusiness?[phone1-877-882-3277] .............. Yes No
13. DoestheapplicantunderstandtheymustholdaWisconsinSeller’sPermit?
[phone(608)266-2776] .......................................................................................... Yes No
14. DoestheapplicantunderstandthattheymustpurchasealcoholbeveragesonlyfromWisconsinwholesalers,breweriesandbrewpubs? .. Yes No
Original Alcohol Beverage Retail License Application
Submit to municipal clerk.
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signer.Anypersonwhoknowinglyprovidesmateriallyfalseinformationonthisapplicationmayberequiredtoforfeitnotmorethan$1,000.Signeragrees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,oronememberof
apartnershipapplicantmustsign;onecorporateofcer,onemember/manager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.
For the license period beginning 20 ;
ending 20
Town of
TO THE GOVERNING BODY of the:
Village of
City of
County of Aldermanic Dist. No.
(if required by ordinance)
}
(Officer of Corporation / Member / Manager of Limited Liability Company / Partner / Individual)
Wisconsin Department of RevenueAT-106 (R. 7-18)
TO BE COMPLETED BY CLERK
Applicant’s WI Seller’s Permit No.:
FEIN Number:
LICENSE REQUESTED
FEE
Class A beer $
TOTAL FEE $
TYPE
Class B beer $
Class C wine $
Class A liquor $
Class A liquor (cider only) $
Class B liquor $
Reserve Class B liquor $
Class B (wine only) winery $
Publication fee $
N/A
Date received and led with municipal clerk
Date license granted
Date reported to council / board Date provisional license issued
Date license issued License number issued
Signature of Clerk / Deputy Clerk
FYI - click mouse in 'For the license period beginning' field to begin and tab
throughout. Use mouse to check appropriate boxes, spacebar or enter.
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PORT WASHINGTON
OZAUKEE
n/a
100
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Original Alcohol Beverage Retail License Application (City of Port Washington)

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Completed 20 August 2020

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