Renewal Alcohol Beverage License Application {AT-115}

RENEWAL ALCOHOL BEVERAGE LICENSE APPLICATION Submit to municipal clerk. Read instructions on reverse side. For the license period beginning: (MM DD YYYY) Applicant's WI Seller's Permit No.: FEIN Number: ending: (MM DD YYYY) LICENSE REQUESTED TYPE FEE TO THE GOVERNING BODY of the: Town of Village of City of } (if required by ordinance) County of CHECK ONE Aldermanic Dist. No. Individual Partnership Limited Liability Company Corporation/Nonprofit Organization Complete A or B. All must complete C. A. Individual or Partnership: Full Name(s) (Last, First and Middle Name) Home Address 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 Post Office & Zip Code B. Full Name of Corporation/Nonprofit Organization/Limited Liability Company Address of Corporation/Limited Liability Company (if different from licensed premises) All Officer(s) Director(s) and Agent of Corporation and Members/Managers and Agent of Limited Liability Company: Title Name (Inc. Middle Name) Home Address President/Member Vice President/Member Secretary/Member Treasurer/Member Agent Directors/Managers Business Phone Number Post Office & Zip Code Post Office & Zip Code C. 1. Trade Name 2. Address of Premises 3. Does the applicant understand that they must purchase alcohol beverages only from Wisconsin wholesalers, breweries and brewpubs? Yes 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.) 5. Legal description (omit if street address is given above): 6. a. Since filing of the last application, has the named licensee, any member of a partnership licensee, or any member, officer, director, manager or agent for either a limited liability company licensee, corporation licensee, or nonprofit organization licensee been convicted of any offenses (excluding traffic offenses 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 reverse side b. Are charges for any offenses presently pending (excluding traffic offenses not related to alcohol) against the named licensee or any other persons affiliated with this license? If yes, explain fully on reverse side . . . . . . . . . . . . . . . . . . . . . . . . 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. 8. Was the profit 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. 9. Does the applicant understand they must hold a Wisconsin Seller's Permit? [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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Is the applicant indebted to any wholesaler beyond 15 days for beer or 30 days for liquor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes Yes Yes Yes Yes Yes Yes No No No 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. (Individual applicants and each member of a partnership applicant must sign; corporate officer(s), members/managers of Limited Liability Companies must sign.) 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 Date received and filed with municipal clerk License number issued AT-115 (R. 7-15) American LegalNet, Inc. www.FormsWorkFlow.com Date reported to council/board Date license issued Date license granted Signature of Clerk / Deputy Clerk Wisconsin Department of Revenue INSTRUCTIONS FOR RENEWAL ALCOHOL BEVERAGE LICENSE APPLICATION (AT-115) 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 corporation/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. Each 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: The Officer(s) must sign application. Be sure to answer Question 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 complete Forms AT-104 (Schedule for Appointment of Agent) AND AT-103 (Auxiliary Questionnaire) in addition to this (AT-115) form. LIMITED LIABILITY COMPANY: Members/managers must sign application. Follow procedure under Corporations for any change of members or agent. NOTE: Application must be signed where indicated on all copies in the presence of a notary public. Use ink or typewriter when filling in applications. Be sure to answer all questions fully and accurately. Any lack of