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HomeMy WebLinkAboutOriginal_Renewal_Liquor_License_Application_PacketRenewal Alcohol Beverage License Checklist for Applicant  Original Alcohol Beverage Application (AB-200). License period is from July 1 to June 30 each year.  Alcohol Beverage Individual Questionnaire (AB-100) is required for each individual, partners in a partnership or officers in a corporation or limited liability company.  Alcohol Beverage Appointment of Agent (AB-101) Corporations and limited liability companies must appoint an agent. The agent will be named on the license and must be given full authority and control over the licensed premises and over all commercial activities on the premises relating to alcohol beverages. Agent must have resided in Wisconsin a minimum of 90 days continuously prior to date of application. o Copy of Agent’s WI Driver’s License/Identification o Agent must provide proof of completion of “Responsible Beverage Server (training) Course” or proof of an Operator’s License from a Wisconsin municipality within the past 2 years.  Completion of Oshkosh Police Department Investigation Form The following forms are situation specific:  Cigarette, Tobacco, and Electronic Vape Application (if applicable, will need: CTV- 100, CTV-101, and CTV-102)  Application for Mechanical Device License (if applicable) After Filing Your Application, Applicant is responsible to:  Confirm real estate taxes, special assessments/charges, water utility and any other outstanding invoices for the establishment are paid in full  It is your responsibility to have licensed Operators on your premises at all times. Please see the Clerk’s Office to obtain Bar Operator Applications Some forms are available on the Wisconsin Department of Revenue’s website. https://www.revenue.wi.gov/Pages/Form/alcohol-Home.aspx Alcohol Beverage License Application AB-200 (N. 03-24)Wisconsin Department of Revenue Form AB-200 License(s) Requested: (up to two boxes may be checked) Class “A” Beer . . . . . . . . . . $ “Class A” Liquor . . . . . . . . . $ “Class A” Liquor (cider only) $ “Class C” Liquor (wine only) $ Class “B” Beer . . . . . . . . $ “Class B” Liquor . . . . . . . $ Reserve “Class B” Liquor $ - 1 - Part B: Questions 1. Has the business (sole proprietorship, partnership, limited liability company, or corporation) been convicted of violating federal or state laws or local ordinances? Exclude traffic offenses unless related to alcohol beverages.Yes No If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Penalty Imposed Law/Ordinance Violated Penalty Imposed Was sentence completed?. . . . . Yes No Was sentence completed?. . . . . Yes No Trial Date Trial Date Location Location Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) 2. Business Trade Name or DBA 3. FEIN 7. Date of Organization6. State of Organization 4. Wisconsin Seller’s Permit Number 11. State 9. Premises Address 19.Premises Description - Describe the building or buildings where alcohol beverages are produced, sold, stored, or consumed, and related records are kept. Describe all rooms within the building, including living quarters. Authorized alcohol beverage activities and storage of records may occur only on the premises described in this application. Attach a map or diagram and additional sheets if necessary. 5. Entity Type (check one) Sole Proprietor Partnership Limited Liability Company Corporation Nonprofit Organization 8. Wisconsin DFI Registration Number 10. City 13. County 12. Zip Code 15. Aldermanic District14. Governing Municipality: 16. Premises Phone 17. Premises Email City Town Village of: 21. City 22. State 23. Zip Code 20.Mailing Address (if different from premises address) Municipality License Period For Municipal Use Only Fees License Fees $ Publication Fee $ Background Check Fee $ Total Fees $ 18. Website - 2 -AB-200 (N. 03-24) 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol . . Yes No beverages. If yes, describe the nature and status of pending charges using the space below. Attach additional sheets as needed. 3. Is the applicant business or any of its officers, directors, members, agent, employees, owners, or other related individuals or entities a restricted investor with any interest in an alcohol beverage producer or distributor? . . Yes No If yes, provide the name of the restricted investor and describe the nature of the interest. 4a. Name of Business Entity 4b. Business Entity FEIN 4. Is the applicant business owned by another business entity?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, provide the name(s) and FEIN(s) of the business entity owners below. Attach additional sheets as needed. 5. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 6. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine?. . . . . . Yes No 7. Does the applicant business owe past due municipal property taxes, assessments, or other fees? . . . . . . . . . . . Yes No Part C: Individual Information List the name, title, and phone number for each person or entity holding the following positions in the applicant business or businesses listed in Part B, Question 4: sole proprietor, all officers, directors, and agent of a corporation or nonprofit organization, all partners of a partnership, and all members, managers, and agent of a limited liability company. Attach additional sheets if necessary. Include Form AB-100 for each person listed below. Corporations and LLCs must appoint an agent by including Form AB-101. Last Name PhoneFirst Name Title Part D: Attestation READ CAREFULLY BEFORE SIGNING: Under penalty of law, I have answered each of the above questions completely and truthfully. I agree that I am acting solely on behalf of the applicant business and not on behalf of any other individual or entity seeking the license. Further, I agree that the rights and responsibilities conferred by the license(s), if granted, will not be assigned to another individual or entity. I agree to operate this business according to the law, including but not limited to, purchasing alcohol beverages from state authorized wholesalers. I understand that lack of access to any portion of a licensed premises during inspection will be deemed a refusal to allow inspection. Such refusal is a misdemeanor and grounds for revocation of this license. I understand that any license issued contrary to Wis. Stat. Chapter 125 shall be void under penalty of state law. I further understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who know- ingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. One of the following must sign and attest to this application: • sole proprietor • one general partner of a partnership • one corporate officer • one member of an LLC Signature Date Title Email Phone Last Name First Name M.I. Part E: For Clerk Use Only Date Application Was Filed With Clerk Date Provisional License Issued (if applicable)Signature of Clerk/Deputy Clerk License Number Date License Granted Date License Issued Who needs an alcohol beverage license? Any individual or entity that wants to sell alcohol beverages to consumers or allow consumption in a public place must get a retail alcohol beverage license. Who issues alcohol beverage licenses? Cities, villages, and towns issue alcohol beverage licenses after the governing body (city council, town or village board) grants the license. Specific Instructions License Period: • Annual licenses expire June 30 each year, except licenses issued by the City of Milwaukee. Annual licenses issued by the City of Milwaukee also may be issued at any time throughout the year, but are valid for one year from the date of issuance. License Requested and License Fees: • Select the alcohol beverage license(s) you would like to apply for. • Generally, you may apply for no more than two licenses for the same premises. Further, some license combinations are not acceptable, (e.g., “Class A” and a Class “B”). • For descriptions of each of the alcohol beverage licenses and their authorizations, see Publication 302, Information for Wisconsin Alcohol Beverage and Tobacco Retailers, and Fact Sheet 3101, Licenses for Retail Sale of Alcohol Beverages. • License costs are determined by the municipality within a range set by state law. Ask your clerk how much the license, background check, and publishing fees in that municipality cost. • License fees for licenses issued for less than one year must be prorated according to the number of months or fraction of months remaining in the licensing period. Part A: Premises/Business Information • Box 1: Enter the legal business name or individual name if a sole proprietor. • Box 2: Enter the trade name or “doing business as” name, if different than the name in box 1. • Box 4: Seller ’s permits begin with the digits “456.” For questions about obtaining a seller’s permit, see Seller’s Permit Common Questions. • Box 5: Check one entity type to indicate how the business is legally organized. • Box 6-7: Provide the state and date of organization of the legal entity. • Box 8: Provide the Wisconsin Department of Financial Institutions Registration number. This number is assigned to the entity when it is registered with DFI. It can be located using the Department of Financial Institution’s Corporate Records Search. • Boxes 9-19: All requests for “premises” information are requests for the physical location within the municipality and contact information to reach the business during open hours. • Box 19: Describe the premises in detail. Include outdoor spaces if your municipality allows it. Some municipalities have specific requirements for outdoor spaces as a part of the licensed premises. Call your municipal clerk to learn more. Attach a floor plan if possible. Example: The premises is located at 1234 Main St., Realtown, WI 12345 and includes only the first-floor bar room, dining room, kitchen, north storage room, and south office of the 5,000 square foot building. • Box 20-23 Provide the mailing address for the business, if different from the address in boxes 9-12. Part B: Questions • Questions 1 and 2: Disclose any civil or criminal violations of law and pending charges in any jurisdiction (federal, state, or local ordinance). Include detailed descriptions of any violations of law involving alcohol beverages. Attach additional sheets as necessary. Form AB-200 Instructions Alcohol Beverage License Application Form AB-200 Instructions Wisconsin Department of Revenue- 1 - • Question 3: Wisconsin law generally prohibits alcohol beverage industry members from having an interest in another tier. The law provides some exceptions, with limitations, for restricted investors. If the applicant business, or any of its officers, directors, members, agent, employees, owners, or other related individuals has an interest in an alcohol beverage producer or distributor, list the restricted investors and describe the nature of their interest. A restricted investor with an allowable interest in another tier must complete AB-104, Restricted Investor Affidavit. Attach additional sheets as necessary. • Question 4: If the applicant is owned by another business entity, provide the legal entity name(s) and FEIN(s) of all upstream entity ownership. Attach an organizational chart if possible. Include all persons involved in upstream entity ownership in the table in Part C and submit Form AB-100 for each of those persons with this application. • Question 5: Wisconsin law requires all sole proprietors, partners, and agents of corporations and LLCs to successfully complete a Wisconsin approved responsible beverage server (RBS) training course within the past two years unless one of the following applies. Submit the associated document with this application. ◦ The applicant is renewing a license, or ◦ Within the past two years: a. The applicant held a manager’s or operator’s (bartender) license. b. The applicant held or was the agent of a corporation or LLC that held any municipally issued alcohol beverage license in Wisconsin. Note: To learn about your responsibility to complete the responsible beverage server requirement, please review Publication 302, Information for Wisconsin Alcohol Beverage and Tobacco Retailers. • Question 6: A licensee may only buy liquor or beer for cash or on credit terms for a period not to exceed 15 days for beer and 30 days for liquor. A person may not be issued a license if they are indebted to a wholesaler in excess of these limits. • Question 7: Renewal of licenses may be denied pursuant to a local ordinance if the licensee owes past due municipal taxes, assessments, or other fees. Part C: Individual Information • Provide basic information for all persons involved in the retail alcohol beverage business who are owners, officers, directors, managers, members, or the agent. Include ownership information as identified in Part B, Question 4. Example: Titles could include Agent, President, Treasurer, Director, Chief Financial Officer, Member, Partner, etc. • Sole-proprietors, partners in a partnership, and the agent of an LLC or corporation must reside in Wisconsin continuously for 90 days prior to application. • Include an Alcohol Beverage Individual Questionnaire (Form AB-100) for each person listed in this section with the submission of this application. Part D: Attestation • Read the attestation carefully, then sign and date. Part E: For Clerk Use Only • “Date license granted” means the date the municipal governing body approves the license to be issued. • “Date license issued” means the date the municipal clerk issues the license certificate document. Completion and Submission of AB-200 • Submit the completed application to the clerk of the municipality in which you are applying for a license. • License applications must be filed with the municipal clerk at least 15 days before they can be approved by the governing body, except licenses issued by municipalities within Milwaukee County. Governing bodies of municipalities within Milwaukee County establish their own period that applications must be filed with the municipal clerk. • In addition to Form AB-200, include: ◦ Form AB-100, Alcohol Beverage Individual Questionnaire, for all individiuals listed in part C ◦ Form AB-101 Alcohol Beverage Appointment of Agent, for corporation, nonprofit organizations, and LLC applicants ◦ License and publication fees as required by your municipality - 2 -Form AB-200 Instructions - 3 - ◦ Responsible beverage server training course completion certificate or other acceptable replacement document described in Part B, Question 5 ◦ Proof the applicant holds a seller’s permit, such as a copy of the seller’s permit document Note: See Publication 206, Sales Tax Exemptions for Nonprofit Organizations, for information on when a nonprofit organization may be exempt from holding a seller’s permit. ◦ All other information and documents required by your municipality NOTE: You are required by federal law to register as an Alcohol Dealer with the federal Alcohol and Tobacco Tax and Trade Bureau (TTB) before beginning business. Use Form TTB F 5630.5d, Alcohol Dealer Registration, and return the form to the address listed on the instructions. Open Records This application is an open record under Wisconsin law (sec. 19.35, Wis. Stats.) and may be provided to the public. If this license is issued by your municipality, your municipality must report the license to the Wisconsin Department of Revenue. The department publishes a list of alcohol beverage licensees reported by municipalities. The department will not disclose personal information such as residential addresses, home phone numbers, social security numbers, age, birth date, and place of birth of individuals, including partners, officers, directors, members, managers, and agents of corporations or LLCs. Assistance This form is designed by the Department of Revenue for use by municipal governments. If you require assistance with this form, consider reaching out to your municipal clerk for assistance with the following: • Submission of this application and associated forms • Availability and cost of certain licenses If you have questions about alcohol beverage laws and regulations, you may contact the Department of Revenue using the contact information below. Website: DOR Alcohol Beverage (wi.gov) Write: DORAlcohol@wisconsin.gov Call: (608) 264-4573 Resources Provided by the Department of Revenue License frequently asked questions Publication 302 Information for Wisconsin Alcohol Beverage and Tobacco Retailers Publication 309 Retail Alcohol Beverage Licensing Guide for Municipalities Fact Sheet 3101 Licenses for Retail Sale of Alcohol Beverages Fact Sheet 3103 Licensed or Permitted Premises Description Fact Sheet 3116 Reserve “Class B” Liquor Licenses Fact Sheet 3118 “Class B” Liquor License Quotas Form AB-200 Instructions Alcohol Beverage Individual Questionnaire Form AB-100 All individuals involved in the alcohol beverage business must complete this form, including: • sole proprietor • all officers, directors, and agent of a corporation or nonprofit organization • all partners of a partnership • members and agent of a limited liability company Your alcohol beverage application or renewal is not complete until all required Individual Questionnaires are submitted. Date AB-100 (N. 03-24)Wisconsin Department of Revenue- 1 - Part B: Individual Information 1. Last Name 4. Relationship to Business (Title) 7. Home Address 5. Email 6. Phone 8. City 12. Drivers License/State ID Number 9. State 10. Zip Code 11. Date of Birth 13. Drivers License/State ID State of Issuance 2. First Name 3. M.I. Part A: Business Information 1. Legal Business Name (individual name if sole proprietor) 2. Business Trade Name or DBA 3. Entity Type (check one) Sole Proprietor Partnership Limited Liability Company Corporation Nonprofit Organization Continued → Part C: Address History Previous Address 1 Previous Address 2 Previous Address 3 Years Months 2. List in chronological order all of your addresses within the last 5 years. Attach additional sheets if necessary. 3. List all states and counties you have lived in as an adult. Attach additional sheets if necessary. State County State County State County State County State County State County State County State County City State Zip Code City State Zip Code City State Zip Code Previous Address 4 City State Zip Code Previous Address 5 City State Zip Code 1. Do you currently reside in Wisconsin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes to 1 above, how long have you continuously lived in Wisconsin prior to the date of application? . . . . - 2 -AB-100 (N. 03-24) Part E: Attestation READ CAREFULLY BEFORE SIGNING: Under penalty of law, I have answered each of the above questions completely and truthfully. I certify that I am not prohibited from participating in this business due to any involvement in another tier of the alcohol beverage industry as a restricted investor. I understand that any license issued contrary to Wis. Stat. Chapter 125 shall be void under penalty of state law. I further understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Signature Date Part D: Criminal History Law/Ordinance Violated 1. Have you ever been convicted of any offenses (excluding traffic offenses unless related to alcohol beverages) for violation of any federal, Wisconsin, or another state’s laws or of any county or municipal ordinances? . . . . . . Yes No If yes to question 1, please list details of each conviction below. Attach additional sheets as needed. Penalty Imposed Conviction Date 2. Are charges for any offenses currently pending against you (excluding traffic offenses unless related to alcohol beverages) for violation of any federal, Wisconsin, or another state’s laws or any county or municipal ordinances?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes to question 2, describe nature and status of pending charges using the space below. Attach additional sheets as needed. Was sentence completed?. . . . . Yes No Location Law/Ordinance Violated Conviction Date Penalty Imposed Was sentence completed?. . . . . Yes No Location Law/Ordinance Violated Conviction Date Penalty Imposed Was sentence completed?. . . . . Yes No Location Who must complete Form AB-100? All persons involved in the applicant business who are sole proprietors, partners of a partnership, officers, directors, members, managers, or agents must complete and submit Form AB-100. These persons are identified in Form AB-101, Alcohol Beverage Appointment of Agent, Form AB-200, Alcohol Beverage License Application, or an alcohol beverage permit application. Where do I submit Form AB-100? If applying for a retail alcohol beverage license, submit this form with Form AB-200, Alcohol Beverage License Application to the clerk of the municipality in which the applicant business is located. If applying for an alcohol beverage permit, submit this form as required by the permit application to the Division of Alcohol Beverages. To update the agent for an alcohol beverage license or permit, submit this form with Form AB-101, Alcohol Beverage Appointment of Agent to the issuer of the authorization. Specific Instructions Date • Date the form in the top right corner. Part A: Business Information • Box 1: Enter the legal business name. If sole proprietor, enter the individual’s first and last name. • Box 2: Enter the business trade name or “doing business as” name, if different than the name in box 1. • Box 3: Check one entity type to indicate how the business is legally organized. Note: This business information must match the information on any license application (Form AB-200) or existing license certificate. Part B: Individual Information • Provide all requested personal information. • Box 4: Enter your title or describe your relationship to the business. Examples: President, Treasurer, Director, Chief Financial Officer, Member, Partner, Agent, etc. Part C: Address History • Question 2: List in chronological order all residential addresses within the last five years starting with your most recent address. Part D: Criminal History • Question 1: Disclose any civil or criminal violations of law in any jurisdiction (federal, state, or local ordinance), and include detailed descriptions of any violations of law involving alcohol beverages (OWI, disorderly conduct, etc.). • Question 2: Disclose any pending charges against you in any jurisdiction and include detailed descriptions of any charges involving alcohol beverages. Note: Subject to the Wisconsin Fair Employment Law (Ch. 111, Wis. Stats.), persons with convictions or pending charges may, if those offenses are sufficiently relevant, be prohibited from holding alcohol beverage license and permits under sec. 125.04(5)(a)(1) Wis. Stats. See the Department of Revenue’s Permit Predetermination Common Questions for offenses that may prevent someone from holding a license. Part E: Attestation • Read the attestation carefully, then sign and date. Form AB-100 Instructions Alcohol Beverage Individual Questionnaire Form AB-100 Instructions Wisconsin Department of Revenue- 1 - Assistance This form is designed by the Department of Revenue for use by municipal governments. Reach out to your municipal clerk for assistance with the following: • Submission of the retail license application and supplemental forms • Availability and cost of certain licenses. If you have questions about alcohol beverage laws and regulations, you may contact the Department of Revenue using the contact information below. Website: DOR Alcohol Beverage (wi.gov) Write: DORAlcohol@wisconsin.gov Call: (608) 264-4573 Resources Provided by the Department of Revenue License frequently asked questions Publication 302 Information for Wisconsin Alcohol Beverage and Tobacco Retailers Publication 309 Retail Alcohol Beverage Licensing Guide for Municipalities Fact Sheet 3101 Licenses for Retail Sale of Alcohol Beverages Fact Sheet 3103 Licensed or Permitted Premises Description Fact Sheet 3116 Reserve “Class B” Liquor Licenses Fact Sheet 3118 “Class B” Liquor License Quotas - 2 -Form AB-100 Instructions Alcohol Beverage Appointment of Agent Form AB-101 Date Part A: Business Information 1. Legal Business Name (individual name if sole proprietor) 3. Entity Type (check one) 2. Business Trade Name or DBA 6. Describe the reason for appointing a successor agent, if successor is checked above. 4. Alcohol Beverage Business Authorization (check one)5. If successor agent, provide State Permit or Municipal Retail License Number Municipal Retail License State Permit Limited Liability Company Corporation Nonprofit Organization AB-101 (N. 03-24)Wisconsin Department of Revenue- 1 - Continued → Agent Type (check one) Original (no fee)Successor ($10 fee for municipal licensees only) Part C: Agent Questions 1. Have you satisfied the responsible beverage server training requirement? . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Submit proof of completion. 2. Have you completed Form AB-100, Alcohol Beverage Individual Questionnaire?. . . . . . . . . . . . . . . . . . . . . . . . Yes No Submit a completed Form AB-100 with this form. 3. Have you been a Wisconsin resident for at least 90 continuous days?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No See instructions for exceptions. Part B: Agent Information 4. Email 6. Home Address 5. Phone 7. City 11. Drivers License/State ID Number 12. Drivers License/State ID State of Issuance 8. State 10. Age9. Zip Code 1. Last Name 2. First Name 3. M.I. Part D: Business Attestation READ CAREFULLY BEFORE SIGNING: I, the Undersigned, authorize the above-named individual to act for the above-named corporation, nonprofit organization, or limited liability company with full authority and control of the premises and of all alcohol beverage activities on such premises. I certify that I am authorized by the above-named entity to authorize this individual to act on behalf of the entity. If I am appointing a successor agent, I rescind all previous agent appointments for this premises. Further, I understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. AB-101 (N. 03-24)- 2 - Signature Date Last Name First Name M.I. Title Email Phone READ CAREFULLY BEFORE SIGNING: I, the Agent, hereby accept this appointment as agent for the above-named corporation, nonprofit organization, or limited liability company and assume full responsibility for the conduct of all alcohol beverage activities on the premises for the above-named business. I further understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Part E: Agent Attestation Signature Date Last Name First Name M.I. Who must complete Form AB-101? State law requires corporations and limited liability companies (LLCs) to appoint an agent that takes responsibility for the licensed or permitted premises. Use this form to appoint an agent for a new premises or to appoint a successor agent when there is a change before the license or permit is up for renewal. Where do I submit Form AB-101? Submit Form AB-101 to the appropriate issuing authority, either the clerk of the municipality in which the business or organization is located, or the Division of Alcohol Beverages. Form AB-101 may be submitted with a license or permit application or at any time to indicate there is a change in agent prior to the license or permit renewal period. Specific Instructions Date: • Date the form in the top right corner. Agent Type: • Select original appointment if you are applying for your license or permit for the first time or are renewing a license or permit. • Select successor agent if you are reporting a change of agent during the licensing or permitting period. Part A: Business Information • Box 1: Enter the legal business name. If a sole-proprietorship, enter the individual’s first and last name. • Box 2: Enter the trade name or “doing business as”, if different than the name in box 1. • Box 3: Check one entity type to indicate how the business is legally organized. Note: This business information must match the information on the license or permit application. • Box 4: Select which alcohol beverage authorization you hold or are applying for. • Box 5: For appointment of a successor agent, enter your state permit number (15-digit Wisconsin Tax ID number) or municipal retail license number (if applicable) for which you are appointing a successor agent. If you do not have a municipal retail license number, provide any applicable identifier (e.g., store number or location). • Box 6: For appointment of a successor agent, describe the reason for the change in agent. Part B: Agent Information • Provide all requested personal information. Part C: Agent Questions • Question 1: Wisconsin law requires all agents of corporations and LLCs to successfully complete a Wisconsin approved responsible beverage server (RBS) training course within the past two years unless: ◦The applicant is renewing a municipal alcohol beverage retail license, or ◦Within the past two years: a. The applicant held a manager’s or operator’s (bartender) license. b. The applicant held or was the agent of a corporation or LLC that held any municipally issued retail alcohol beverage license in Wisconsin. Form AB-101 Instructions Alcohol Beverage Appointment of Agent Form AB-101 Instructions - 1 -Wisconsin Department of Revenue • Some agents for state permittees are exempt from responsible beverage server course requirements. The following permittees are exempt from RBS course requirements: Alcohol Beverage Warehouse, Industrial Fermented Malt Beverages, Wholesalers, Manufacturers, Rectifiers, Direct Wine Shippers, Wholesale Alcohol, Medicinal Alcohol, Industrial Alcohol, and Industrial Wine. ◦If you are applying to be the agent of one of these exempt permittees, answer “yes” to Question 1. • To learn about your responsibility to complete the responsible beverage server requirement, review Publication 302, Information for Wisconsin Alcohol Beverage and Tobacco Retailers. • Question 2: Appointed agents must submit Form AB-100, Alcohol Beverage Individual Questionnaire, in addition to this form. • Question 3: Appointed agents must be Wisconsin residents for at least 90 continuous days prior to the date of application, except for direct wine shipper permittees. Part D: Business Attestation • An authorized representative should sign, date, and provide requested personal information on behalf of the business. Part E: Agent Attestation • The agent being appointed should read the attestation carefully, then sign and date. Assistance If you have questions about alcohol beverage laws and regulations, you may contact the Department of Revenue using the contact information below. Website: DOR Alcohol Beverage (wi.gov) Write: DORAlcohol@wisconsin.gov Call: (608) 264-4573 - 2 -Form AB-101 Instructions Oshkosh Police Department Investigation for City Liquor License APPLICANT INFORMATION Last Name First M.I. Date Street Address Apartment/Unit # City State ZIP Phone E-mail Place of Birth Date of Birth Previous Name Previous Address (up to the last 5 years) BUSINESS WHERE LIQUOR LICENSE WILL BE HELD Name Phone Address License Type What type of establishment do you intend to operate? ____Retail ____Restaurant ____Tavern / Bar ____Nightclub Do you understand the State Statues & City Ordinances concerning the laws & regulations in the operation of this establishment? YES NO Do you understand there must be a licensed bartender or yourself on duty at all times. YES NO Will you have any type of entertainment? If so, what type? YES NO Will your music be kept at a level acceptable to the neighborhood? YES NO Do you understand that the license you are applying for will expire June 30th of each year and that checks will be made by the Police Department, that records will be kept of complaints and these records may have a bearing on the Common Council renewing any future licenses? YES NO What experience do you have in the operation of this type of establishment? How will you prevent underage drinking on premises? Have you ever been convicted of violating any federal, state, local laws or ordinances related to alcohol beverages - If yes, please explain: YES NO Signature of Applicant Date Applicant Approved YES NO Signature of Investigating Officer Date Council Date Cigarette, Tobacco, and Electronic Vaping Device Retail License Application CTV-100 (N. 2-24)Wisconsin Department of Revenue Form CTV-100 Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietor) 2. Business Trade Name or DBA 3. FEIN 4. Wisconsin Seller’s Permit Number 6. State of Organization 7. Date of Organization 8. Wisconsin DFI Registration Number 9. Premises Address (do not use PO Box) 11. State 14. Governing Municipality: of: 12. Zip Code 15. Aldermanic District 10. City 18. State 19. Zip Code17. City 21. Premises Email 22. Website20. Premises Phone 13. County 16. Mailing Address (if different from premises address) 5. Entity Type (check one) 1. What products will be sold at this business location? (check all that apply) 3. Is the applicant business owned by another business entity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, provide the name and FEIN of the parent company below, identify parent company members in Part C, and attach Form CTV-101 for all of the parent company’s members, partners, or officers. 3a. Name of Parent Company: 3b. FEIN of Parent Company: 2. How will cigarettes, tobacco, and/or electronic vaping devices be sold? (check all that apply) 23.Premises Description - Describe the building or buildings where cigarettes, tobacco products, and electronic vaping devices are to be sold and stored. Describe all rooms including living quarters, if used, for the sales and/or storage of cigarettes, tobacco products, and electronic vaping devices and records. Cigarettes, tobacco products, and electronic vaping devices may be sold and stored ONLY on the premises described in this application. Attach a floor plan if possible. Sole Proprietor Cigarettes Over the counter Partnership City Town Village Tobacco Products Vending machine Limited Liability Company Electronic Vaping Devices Corporation Part B: Questions Municipality License Period FOR CLERKS ONLY - 1 - - 2 - Part C: Individual Information An Individual Questionnaire, Form CTV-101, must be completed and attached to this application for each person involved in the applicant business and any parent company indicated in Part B. Such persons include: sole proprietor, all officers and agents of a corporation, all partners of a partnership, and all members and agents of a limited liability company. List the full name, title, and phone number for each person below. Attach additional sheets if necessary. Last Name PhoneFirst Name Title Part D: Attestation READ CAREFULLY BEFORE SIGNING: I understand and agree to the following: • I will only purchase cigarettes, tobacco, and vapor products from distributors, jobbers, or subjobbers permitted by the Wisconsin Department of Revenue, unless I also hold the proper distributor’s permit and pay all applicable excise taxes. • I will not purchase or exchange products from another retailer, including transferring existing stock to a new owner. • I will provide tobacco sales training that has been approved by the Wisconsin Department of Health Services to my employees. (https://witobaccocheck.org). • I will not sell single cigarettes. • I will not sell, give, or otherwise provide cigarettes, tobacco, or any nicotine products to minors. • I will keep product invoices on the licensed premises for two years and ensure the records are available for inspection by law enforcement. Failure to comply with this will result in criminal penalties, including loss of inventory. • I will not sell cigarettes or roll-your-own (RYO) tobacco products unless listed on the Wisconsin Department of Justice’s directory of certified tobacco manufacturers and brands. Further, under penalty provided by law, I state that this application has been truthfully answered to the best of my knowledge. I agree to operate this business according to law and that the rights and responsibilities conferred by the license(s), if granted, cannot be assigned to another. 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. Any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000. One of the following must sign and attest to this application: • sole proprietor • one general partner of a partnership • one corporate officer • one managing member of an LLC Signature Date Name (Last, First, M.I.) Title Email Phone Part E: For Clerk Use Only Date application was filed with clerk License numberDate license expiresDate license issued Signature of Clerk/Deputy ClerkLicense fees CTV-100 (N. 2-24) Who needs a cigarette, tobacco, and electronic vaping device retail license? Any individual or entity that wants to sell cigarettes, tobacco products, or electronic vaping devices to consumers over the counter or through a vending machine must obtain a retail cigarette, tobacco, and electronic vaping device license. Who issues cigarette, tobacco, and electronic vaping device retail licenses? Municipal clerks of cities, villages, and towns issue cigarette, tobacco, and electronic vaping device retail licenses. Specific Instructions Part A: Business Information • Box 1: Enter the legal business name. • Box 2: Enter the business trade name or “doing business as” name, if different than the name in box 1. • Box 4: For questions about obtaining a seller’s permit, see Seller’s Permit Common Questions. • Box 5: Check one entity type to indicate how the business is legally organized. • Box 14: Check a municipality type and write the name of the governing municipality where the business is located. This may be different from the city listed in the premises address. • Box 20 – 23: All requests for “premises” information are requests for the physical location within the municipality and contact information to reach the business during open hours. • Box 23: Describe the premises in detail. Attach a floor plan if possible. ◦ Example: The premises is located at 1234 Main St., Realtown, WI 12345 and includes only the first-floor sales floor, humidor, north storage room, and south office of the 5,000 square foot building. Part B: Questions 1. Check the box(es) corresponding to each type of product you intend to sell. You may check multiple boxes. 2. Check the box(es) corresponding to the type of retail sale intended. This license does not authorize any online sales. Cigarette vending machine retailers must also obtain a Cigarette Vending Machine Operator by completing Form CT- 129. 3. If you answer yes to this question, provide the Legal Business Name and FEIN of the parent company in boxes 3a and 3b. Part C: Individual Information • Provide basic information for all persons involved in the cigarette, tobacco product, or electronic vaping device business who are sole-proprietors, partners, officers, members, or agents. • Example titles: President, Treasurer, Chief Financial Officer, Member, Partner, etc. • Include an Individual Questionnaire (Form CTV-101) for each person listed in this section with the submission of this application. • If the applicant is owned by another corporation or LLC as indicated in Part B, Question 3, include information about the parent company’s members or officers in the table, including the completion of Form CTV-101. Part D: Attestations • Read the attestation carefully, then sign and date. Part E: For Clerks Use Only • “Date license issued” means the date the municipal clerk issued the license certificate document. Form CTV-100 Instructions Cigarette, Tobacco, and Electronic Vaping Device Retail License Application CTV-100-INST (N. 2-24) Form CTV-100 Instructions - 1 -Wisconsin Department of Revenue Completion and Submission of Form CTV-100 • Submit the completed application to the clerk of the municipality in which you are applying for a license. • In addition to Form CTV-100, include: ◦ Form CTV-101 for the sole-proprietor; all officers, directors, and agent of a corporation; all partners of a partnership; all managing members and agent of a limited liability company ◦ Form CTV-102 if the applicant is an LLC or corporation ◦ Proof the applicant holds a seller’s permit, such as a copy of the seller ’s permit document. Search for active sales tax accounts at revenue.wi.gov under My Tax Account, click on “Search Account Number” under the Businesses section. If you have questions about whether a person holds a seller’s permit, contact the Department of Revenue at 608-266-2776 ◦ All other information and documents required by your municipality Open Records This application is an open record under state law (sec. 19.35, Wis. Stats.) and may be provided to the public. If this license is issued by your municipality, your municipality must report the license to the Wisconsin Department of Revenue. The department may publish a list of cigarette, tobacco product, and electronic vaping device licensees reported by municipalities. The department will not disclose personal information such as residential addresses, home phone numbers, social security numbers, age, birth date, and place of birth of individuals, including partners, officers, directors, members, managers, and agents of corporations or LLCs. Assistance This form is designed by the Department of Revenue for use by municipal governments. Reach out to your municipal clerk for assistance with the following: • Submission of the retail license application and supplemental forms • Availability of certain licenses If you have questions about cigarette, tobacco product, and electronic vaping device laws and regulations, you may contact the Department of Revenue using the contact information below. Website: www.revenue.wi.gov Write: DORAlcoholTobaccoEnforcement@wisconsin.gov Call: (608) 264-4573 Resources Provided by the Department of Revenue Wisconsin Department of Revenue Cigarette, Tobacco, and Vapor Product Landing Page Permit Predetermination Common Questions Vapor Products Tax Common Questions Fact Sheet 3501 Vapor Products Tax Other Resources Tobacco Sales Training – Wisconsin Department of Health Services Tobacco 21 – Wisconsin Department of Health Services - 2 -CTV-100-INST (N. 2-24) Form CTV-100 Instructions Cigarette, Tobacco, and Electronic Vaping Device License - Individual Questionnaire CTV-101 (R. 4-24)Wisconsin Department of Revenue Form CTV-101 Date Part A: Business Information 1. Legal Business Name (individual name if sole proprietor) 2. Business Trade Name or DBA 3. Entity Type (check one) Sole Proprietor Partnership Limited Liability Company Corporation Part B: Individual Information 1. Name (Last) 4. Relationship to Business (Title) 7. Home Address 5. Email 6. Phone 8. City 12. Drivers License/State ID Number 9. State 10. Zip Code 11. Date of Birth 13. Drivers License/State ID State of Issuance 2. Name (First)3. Name (M.I.) Part C: Individual’s Address History List in chronological order all of your addresses within the last 5 years. Attach additional sheets if necessary. Previous Address 1 City State Zip Code Previous Address 2 City State Zip Code Previous Address 3 City State Zip Code If applicable, list all states and counties you have lived in as an adult. Attach additional sheets if necessary. State County State County State County State County Previous Address 4 City State Zip Code Previous Address 5 City State Zip Code Continued → Previous Address 6 City State Zip Code State County State County State County State County Part D: Individual’s Criminal History Law/Ordinance Violated 1. Have you ever been convicted of any offenses (other than traffic offenses) for violation of any federal, Wisconsin, or another state’s laws, or of any county or municipal ordinances? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes to question 1, please list details of each conviction below: Penalty Imposed Law/Ordinance Violated Penalty Imposed Was sentence completed?. . . . . Yes No Was sentence completed?. . . . . Yes No 2. Are charges for any offenses currently pending against you (other than traffic offenses) for violation of any federal, Wisconsin, or another state’s laws or any county or municipal ordinances? . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes to question 2, describe nature and status of pending charges using the space below. Attach additional sheets as needed. Penalty Imposed Was sentence completed?. . . . . Yes No Law/Ordinance Violated Trial Date Trial Date Trial Date Part E: Attestation by Individual READ CAREFULLY BEFORE SIGNING: I understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on an application for ciga- rette, electronic vaping devices, and tobacco products retail license may be required to forfeit not more than $1,000 if convicted. I declare under penalties of the law that I have examined this information and, to the best of my knowledge, it is true, correct, and complete to the best of my knowledge and belief. Signature Date Part F: Licensing Authority Approval I hereby certify that I have checked municipal and state criminal records. To the best of my knowledge, with the available information, this individual qualifies to serve in the reported role with the above-named business. Name of Local Official DateSignature of Local Official Title - 2 -CTV-101 (R. 4-24) Location Location Location Form CTV-101 Instructions Cigarette, Tobacco, and Electronic Vaping Device License - Individual Questionnaire Who must complete Form CTV-101? This form must be submitted to the municipal clerk along with Form CTV-100. One CTV-101 must be completed by each person involved in the applicant business. Such person include: sole proprietor; all officers, agents of a corporation; all partners of a partnership; and all members and agents of a limited liability company. Note: Your cigarette, tobacco, and electronic vaping device license application (Form CTV-100) is not complete until all required Individual Questionnaires are submitted. Where do I submit Form CTV-101? Submit this form with the license application (Form CTV-100) to the clerk of the municipality in which the applicant business is located. Specific Instructions Date Date you are preparing this form using the format MM/DD/YYYY. Part A: Premises/Business Information • Box 1: Enter the legal business name. If the applicant is a sole proprietor, enter the individual’s first and last name. • Box 2: Enter the trade name or “doing business as” name, if different than the name in box 1. • Box 3: Check one entity type to indicate how the business is legally organized. Note: This business information must match the information on the license application (Form CTV-100). Part B: Individual Information • Provide all requested personal information. • Box 2: Enter your title or describe your relationship to the business. Examples: President, Treasurer, Chief Financial Officer, Member, Partner, Agent, etc. Part C: Address History • List your addresses within the past five years. • List any states and counties you have lived in not already listed in Part C. Part D: Criminal History • Question 1: Disclose any civil or criminal violations of law in any jurisdiction (federal, state, or local ordinance). • Question 2: Disclose any pending charges against you in any jurisdiction. Note: Subject to the Wisconsin Fair Employment Law (Ch. 111, Wis. Stats.), persons with convictions or pending charges may, if the offenses are sufficiently relevant, be prohibited from holding a retail cigarette, tobacco, and electronic vaping device license under sec. 134.65(1m), Wis. Stats. See the Department of Revenue’s Permit Predetermination Common Questions for offenses that may prevent someone from holding a license. Part E: Attestation: • Read the attestation carefully, then sign and date. Part F: Licensing Authority Approval This section is for use by the appropriate municipal official to attest to the qualifications of the individual. Form CTV-101 Instructions Wisconsin Department of Revenue- 1 - Assistance This form is designed by the Department of Revenue for use by municipal governments. Reach out to your municipal clerk for assistance with the following: • Submission of the retail license application and supplemental forms • Cost of certain licenses If you have questions about cigarette, tobacco, and electronic vaping device laws and regulations, you may contact the Department of Revenue using the contact information below. Website: https://www.revenue.wi.gov/Pages/Businesses/Tobacco.aspx Write: DORAlcoholTobaccoEnforcement@wisconsin.gov Call: (608) 264-4573 Resources Provided by the Department of Revenue Wisconsin Department of Revenue Cigarette, Tobacco, and Vapor Product Landing Page Permit Predetermination Common Questions Vapor Products Tax Common Questions Fact Sheet 3501 Vapor Products Tax Other Resources Tobacco Sales Training – Wisconsin Department of Health Services Tobacco 21 – Wisconsin Department of Health Services - 2 -Form CTV-101 Instructions Cigarette, Tobacco, and Electronic Vaping Device Appointment of Agent Form CTV-102 CTV-102 (R. 4-24)Wisconsin Department of Revenue Date Limited Liability Company Corporation Part A: Agent Information Part C: Business Information 1. Last Name 2. First Name 1. Legal Business Name (individual name if sole proprietor) 6. Home Address 3. Entity Type (check one) 4. Email 2. Business Trade Name or DBA 5. Phone 3. M.I. 7. City 4. Premises Address 11. Drivers License/State ID Number 5. City 8. State 6. State 9. Zip Code 7. Zip Code 10. Date of Birth 12. Drivers License/State ID State of Issuance Part B: Questions 1. Have you completed Form CTV-101, Cigarette, Tobacco, and Electronic Vaping Device License - Individual Questionnaire? Submit a completed Form CTV-101 with this form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 2. If this is a change of agent, please describe the reason for the agent change. Attach additional sheets if necessary. Part D: Attestations READ CAREFULLY BEFORE SIGNING: I, the Licensee, authorize the above-named individual to act for the above-named corporation or limited liability company with full authority and control of the premises and of all business relative to cigarettes, tobacco products, and/or electronic vaping devices conducted therein. I certify that I am authorized by the entity to authorize this individual to act on behalf of the entity. If I am appointing a successor agent, I rescind all previous agent appointments for this premises. Further, I understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Signature of Licensee (officer, member, or authorized signatory) Name of Person Signing for Licensee Date Title Agent Type (check one):Original Change READ CAREFULLY BEFORE SIGNING: I, the Agent, herby accept this appointment as agent for the above-named corporation or limited liability company and assume full responsibility for the conduct of all business relative to sales of cigarettes, tobacco products, and/or electronic vaping devices conducted on the premises for the above-named business. I further understand that I may be prosecuted for submitting false statements and affidavits in connection with this form, and that any person who knowingly provides materially false information on this form may be required to forfeit not more than $1,000 if convicted. Signature of Agent Date Form CTV-102 Instructions Appointment of Agent Who must complete Form CTV-102? Wisconsin law requires corporations and limited liability companies (LLCs) to appoint an agent that takes responsibility for the licensed premises. Submit this form with CTV-100 to appoint an agent while applying for a license, or as a standalone document to report a change in appointed agent. Where do I submit Form CTV-102? Form CTV-102, Appointment of Agent, must be submitted to the clerk of the municipality in which the business or organization is located. Specific Instructions Date: Date you are preparing this form using the format MM/DD/YYYY. Agent Type: Select original appointment if you are appointing an agent with your license application (Form CTV-100). Select change if you are reporting a change of agent mid-licensing period. Part A: Agent Information Provide all requested personal information for the appointed individual. Part B: Agent Questions • These questions should be answered by the appointed individual. • Question 1: Submit a completed Form CTV-101, Individual Questionnaire, with this form. • Question 2: Describe the reason why the business entity must appoint a new agent. ◦ Examples include: the previous agent is no longer an employee of the entity, the previous agent is no longer eligible to be an agent of the premises, the previous agent was not responsive to business needs. Part C: Licensee Information • Box 1: Enter the legal business name. • Box 2: Enter the trade name or “doing business as” name, if different than the name in box 1. • Box 3: Check one entity type in to indicate how the business is legally organized. Note: This business information must match the information on the license application (Form CTV-100) or license certificate if reporting a change of agent during the license period. Part D: Attestations • An authorized representative of the licensee should read the first attestation carefully and sign to acknowledge the appointment of this agent. • If the business in Part C is a corporation, the attestation must be signed by an authorized corporate officer or director. • If the business in Part C is an LLC, the attestation must be signed by an authorized LLC member (i.e., managing member). • The agent should read the second attestation carefully and sign to accept the appointment. • An authorized representative of the licensee may appoint themselves as the agent by signing both attestation sections. CTV-102-INST (R. 4-24) Form CTV-102 Instructions - 1 -Wisconsin Department of Revenue Assistance This form is designed by the Department of Revenue for use by municipal governments. Reach out to your municipal clerk for assistance with the following: • Submission of the retail license application and supplemental forms • Availability of certain licenses If you have questions about cigarette, tobacco product, and electronic vaping device laws and regulations, you may contact the Department of Revenue using the contact information below. Website: www.revenue.wi.gov Write: DORAlcoholTobaccoEnforcement@wisconsin.gov Call: (608) 264-4573 Resources Provided by the Department of Revenue Wisconsin Department of Revenue Cigarette, Tobacco, and Vapor Product Landing Page Permit Predetermination Common Questions Vapor Products Tax Common Questions Fact Sheet 3501 Vapor Products Tax Other Resources Tobacco Sales Training – Wisconsin Department of Health Services Tobacco 21 – Wisconsin Department of Health Services CTV-102-INST (R. 4-24) Form CTV-102 Instructions - 2 - CLERK’S OFFICE USE ONLY LICENSE NUMBER ISSUED: _________ EXPIRATION DATE: 06/30/__________ APPLICATION FOR MECHANICAL DEVICE LICENSE Name of Business ________________________________________________________________ Business Address ________________________________________________________________ Name of Applicant/Agent __________________________________________________________ TYPE OF LICENSE FEE QTY AMOUNT DUE___ Mechanical Devices (Coin Operated) $20/device _____ ___________ Billiard License (Non-Coin Operated) $5/device _____ ___________ Bowling Lanes $10/lane _____ ___________ Mini Golf License $5 N/A ___________ Total ___________ ____________________________________________ ___________ Signature of Applicant/Agent Date Application is hereby made for a license to operate Mechanical Device(s) as provided by the City of Oshkosh Municipal Code Book. SECTION 5-36 LICENSE REQUIRED: No person, firm or corporation shall operate any device, machine or contrivance for entertainment which is operated by placing of a coin in said instrument or in any mechanism connected thereto, or by in any manner paying the owner or operator thereof a fee or charge of any kind, without first obtaining a license as herein provided.