Fillable Renewal Alcohol Beverage License Application (City of Port Washington)

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Renewal Alcohol Beverage License Application (City of Port Washington)

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Renewal Alcohol Beverage License Application
(Submit to municipal clerk.
Read instructions on page 3.
)
Check one: Individual Limited Liability Company
Partnership Corporation/NonprotOrganization
Forthelicenseperiodbeginning:
ending:
}
Town of
TotheGoverningBodyofthe: Villageof
City of
County of
Aldermanic Dist. No
.
(if required by ordinance)
(mm dd yyyy) (mm dd yyyy)
Applicant’s Wisconsin Seller’s Permit Number
FEIN Number
Publication fee $
TYPE OF LICENSE
REQUESTED
FEE
Class A beer $
TOTAL FEE $
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$
N/A
Complete A or B. All must complete C.
A. Individual or Partnership:
Full Name (Last) (First) HomeAddress(Street,CityorPostOce,&ZipCode)
(Middle Name)
Full Name (Last) (First) (Middle Name)
HomeAddress(Street,CityorPostOce,&ZipCode)
Full Name (Last) (First) (Middle Name)
HomeAddress(Street,CityorPostOce,&ZipCode)
C. Business Information
Wisconsin Department of RevenueAT-115 (R. 5-19)
1. TradeName BusinessPhoneNumber
2. AddressofPremises PostOce&ZipCode
3.
Doestheapplicantunders
tandthattheymustpurchasealcoholbeveragesonlyfromWisconsinwholesalers, breweries
and brewpubs? .................................................................. Yes No
4. 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.)
B. LLC or Corporation (and Agent):
FullLegalNameofCorporation/NonprotOrganization/LimitedLiabilityCompany AddressofCorporation/LimitedLiabilityCompany(ifdierentfromlicensedpremises)
All Ocer(s) Director(s) of Corporation and Members / Managers of Limited Liability Company:
VicePresident/MemberLastName
Secretary / Member Last Name
Treasurer / Member Last Name
(First)
(First)
(First)
(First)
(Middle Name)
(Middle Name)
(Middle Name)
(Middle Name)
President / Member Last Name (First) (Middle Name)
HomeAddress(Street,CityorPostOce,&ZipCode)
HomeAddress(Street,CityorPostOce,&ZipCode)
HomeAddress(Street,CityorPostOce,&ZipCode)
HomeAddress(Street,CityorPostOce,&ZipCode)
HomeAddress(Street,CityorPostOce,&ZipCode)
Directors/ManagersLastName
(First) (Middle Name)
HomeAddress(Street,CityorPostOce,&ZipCode)
Directors/ManagersLastName
Allcorporations/organizationsorlimitedliabilitycompaniesapplyingforalicensetosellfermentedmaltbeveragesand/orintoxicating
liquormustappointanagent.
AgentLastName
(First) (Middle Name) HomeAddress(Street,CityorPostOce,&ZipCode)
TAB through to navigate. Use mouse to check
applicable boxes, press spacebar, or press Enter.
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Clear
07 01 2020
06 30 2021
✔
PORT WASHINGTON
OZAUKEE
N/A
Go to Page 2
TO BE COMPLETED BY CLERK
Datereceivedandledwithmunicipalclerk
Date reported to council / board Datelicensegranted
License number issued
Date license issued SignatureofClerk/DeputyClerk
5. Legaldescription(omitifstreetaddressisgivenonpreviouspage):
6. a. Sincelingofthelastapplication,hasthenamedlicensee,anymemberofapartnershiplicensee,orany
member,ocer,director,manageroragentforeitheralimitedliabilitycompanylicensee,ornonprot
organizationlicenseebeenconvicted of any oenses(excludingtracoensesnotrelatedtoalcohol)
for violation of any federal laws, any Wisconsin laws, any laws of other states, or ordinances of any county
or municipality? If yes, complete page 3 . .................................................... Yes No
b. Are charges for any oenses presently pending(excludingtracoensesnotrelatedtoalcohol)against
thenamedlicenseeoranyotherpersonsaliatedwiththislicense?If yes, explain fully on page 3. ..... Yes No
7. Exceptforquestions6aand6b,havetherebeenanychangesintheanswerstothequestionsassubmitted
by you on your last application for this license? If yes, explain ................................... Yes No
8. WastheprotorlossfromthesaleofalcoholbeveragesforthepreviousyearreportedontheWisconsinIncome
orFranchiseTaxreturnofthelicensee?If not, explain ............................................. Yes No
9. Does the applicant understand they must hold a Wisconsin Seller’s Permit? ........................... Yes No
[phone (608) 266-2776]
10.Doestheapplicantunderstandthatalcoholbeverageinvoicesmustbekeptatthelicensedpremisesfor2years
from the date of invoice and made available for inspection by law enforcement? ......................... Yes No
11. Is the applicant indebted to any wholesaler beyond 15 days for beer or 30 days for liquor? . . . . . . . . . . . . . . . . Yes No
12.Doestheapplicantowemunicipalpropertytaxes,assessments,orotherfees? ......................... Yes No
(Note:Renewaloflicensesmaybedeniedpursuanttoalocalordinance,ifthelicenseeowesmunicipaltaxes,
assessments or other fees).
- 2 -
AT-115 (R. 5-19)
READ CAREFULLY BEFORE SIGNING:Underpenaltyprovidedbylaw,theundersignedstatesthateachoftheabovequestionshas
beentruthfullyansweredtothebestoftheknowledgeofthesigner.Thesigneragreesthathe/sheisthepersonnamedintheforegoing
application; that the applicant has read and made a complete answer to each question, and that the answers in each instance are true
andcorrect.TheundersignedfurtherunderstandsthatanylicenseissuedcontrarytoChapter125oftheWisconsinStatutesshallbe
void,andunderpenaltyofstatelaw,theapplicantmaybeprosecutedforsubmittingfalsestatementsandadavitsinconnectionwith
thisapplication.Anypersonwhoknowinglyprovidesmateriallyfalseinformationonthisapplicationmayberequiredtoforfeitnotmore
than $1,000.
Title / Member
Signature
Contact Person’s Name (Last, First, M.I.)
Phone Number Email Address
Date
Return to Page 1
THIS RENEWAL FORM CANNOT BE USED IF:
1. Thereisachangeinbusinessentity(i.e.,individualhas
changedtopartnershiporcorporation/limited liability
company;partnershipchangedtoindividualorcorpo-
ration/limitedliabilitycompany;corporationchangedto
individual, partnership or limited liability company) and
if limited liability company has been dissolved.
2. Partners are added or dropped.
3. Application is made in a different municipality.
PARTNERSHIPS:
Indicatefullnameandhomeaddressofeachpartner.One
partnermustsignapplication.Reminder: If partners have
been added or dropped since your last application, you must
useFormAT-106(OriginalBeverageLicenseApplication).
CORPORATIONS:
Oneofficermustsignapplication.BesuretoanswerQues-
tionNo.7byindicatinganychangeofofficers,directors,
and/orchangesinhomeaddress.Ifthereareanychanges
in officers and/or directors each must complete Form AT-
103(AuxiliaryQuestionnaire).Iftherehasbeenachange
inagentsinceyourlastapprovedagent,he/shemustcom-
pleteFormsAT-104(ScheduleforAppointmentofAgent)
ANDAT-103(Auxiliary Questionnaire)inaddition tothis
(AT-115) form.
Instructions for Renewal Alcohol Beverage License Application
LIMITED LIABILITY COMPANY:
Onemember/managermustsignapplication.Followpro-
cedure under Corporations for any change of members
oragent.
NOTE:Useinkortypewriterwhenfillinginapplications.
Besuretoanswerallquestionsfullyandaccurately.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.
DISCRIMINATION CLAUSE – (City of Milwaukee only)
The applicant shall not willfully refuse to provide those
services offered under this license or refuse to employ or
dischargeanypersonotherwisequalifiedbecauseofrace,
color,creed,sex,nationaloriginorancestry,theapplicant
shall not seek information as a condition of employment,
orpenalizeanyemployeeordiscriminateintheselection
ofpersonnelfortrainingorpromotionsolelyonthebasisof
such information. The applicant also shall not discriminate
againstanymemberofthemilitaryservicedressedinuniform
bywillfullyrefusingservicesofferedunderthislicense.
Complete,signandreturnthisformtotheclerk.
Ifanswerto QuestionsNo.6aand/or6bonpage 2are
“YES,” outline details below:
CONVICTIONS
1. NAME STATUTENO./LOCALORDINANCE
CHARGE WHERECONVICTED
DATE PENALTY MISDEMEANOR FELONY
2. NAME STATUTENO./LOCALORDINANCE
CHARGE WHERECONVICTED
DATE PENALTY MISDEMEANOR FELONY
3. NAME STATUTENO./LOCALORDINANCE
CHARGE WHERECONVICTED
DATE PENALTY MISDEMEANOR FELONY
PENDING CHARGE
1. NAME STATUTENO./LOCALORDINANCE
PENDING CHARGE DATE
AT-115 (R. 5-19)
- 3 -
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Renewal Alcohol Beverage License Application (City of Port Washington)

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Completed 20 August 2020

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