Original Alcohol Beverage License Application {AT-106}

ORIGINAL ALCOHOL BEVERAGE RETAIL LICENSE APPLICATION Submit to municipal clerk. For the license period beginning ending 20 20 Town of Village of City of ; Applicant's WI Seller's Permit No.: FEIN Number: LICENSE REQUESTED TYPE FEE TO THE GOVERNING BODY of the: County of 1. The named } (if required by ordinance) Aldermanic Dist. No. INDIVIDUAL PARTNERSHIP LIMITED LIABILITY COMPANY CORPORATION/NONPROFIT ORGANIZATION hereby makes application for the alcohol beverage license(s) checked above. Class A beer 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 TOTAL FEE $ $ $ $ $ $ $ $ $ $ N/A 2. Name(individual/partnersgivelastname,first,middle;corporations/limitedliabilitycompaniesgiveregisteredname): 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. President/Member Vice President/Member Secretary/Member Treasurer/Member Agent Directors/Managers Trade Name Business Phone Number AddressofPremises PostOffice&ZipCode Is individual, partners or agent of corporation/limited liability company subject to completion of the responsible beverage server training course for this license period? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Is the applicant an employe or agent of, or acting on behalf of anyone except the named applicant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Does any other alcohol beverage retail licensee or wholesale permittee have any interest in or control of this business?. . . . . . . . . . . . . . . (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? . . . . . . . . . . . . . . . . (c) Doesthecorporation,oranyofficer,director,stockholderoragentorlimitedliabilitycompany,oranymember/manageror agent hold any interest in any other alcohol beverage license or permit in Wisconsin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (NOTE: All applicants explain fully on reverse side of this form every YES answer in sections 5, 6, 7 and 8 above.) Title Name Home Address Post Office & Zip Code 3. 4. 5. 6. 7. 8. Yes Yes Yes Yes Yes No No No No No 9. Premisesdescription:Describebuildingorbuildingswherealcoholbeveragesaretobesoldandstored.Theapplicantmustinclude 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. Legaldescription(omitifstreetaddressisgivenabove): 11. (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? 12. DoestheapplicantunderstandtheymustfileaSpecialOccupationalTaxreturn(TTBform5630.5d) before beginning business? [phone 1-800-937-8864] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes 13. Does the applicant understand they must hold a Wisconsin Seller's Permit? [phone (608) 266-2776] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes 14. Does the applicant understand that they must purchase alcohol beverages only from Wisconsin wholesalers, breweries and brewpubs? . . 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.(Individualapplicantsandeachmemberofapartnershipapplicantmustsign;corporateofficer(s),members/managersofLimitedLiabilityCompaniesmustsign.)Anylackof 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 (Clerk/Notary Public) , 20 (Officer of Corporation/Member/Manager of Limited Liability Company/Partner/Individual) (Officer of Corporation/Member/Manager of Limited Liability Company/Partner) (Additional Partner(s)/Member/Manager of Limited Liability Company if Any) My commission expires TO BE COMPLETED BY CLERK Datereceivedandfiled with municipal clerk Date license granted AT-106 (R. 9-16) American LegalNet, Inc. www.FormsWorkFlow.com Datereportedtocouncil/board Date license issued Dateprovisionallicenseissued License number issued SignatureofClerk/DeputyClerk Wisconsin Department of Revenue