HomeMy WebLinkAboutLiquor_License_PacketPage 1 of 1
ALCOHOL BEVERAGE LICENSE APPLICATION GUIDELINES
This policy explains the City’s expectations and requirements for all new alcohol beverage license
applicants which are in addition to the requirements detailed in Wis. Stats. Ch. 125, City of Oshkosh
Ordinances, and the required forms from the Wisconsin Department of Revenue. This policy reflects the
values of the City and promote public safety, responsible service, and quality of life by setting clear and
consistent local standards for premises readiness, operations, and community development.
This policy applies to all new applicants for an alcohol beverage license within the City of Oshkosh,
including but not limited to:
• Class “A”, “Class A”, or Class “A”/ “Class A” (off-premises consumption)
• Class “B” or Class “B”/ “Class B” (on-premises consumption)
• “Class C” (on-premises consumption)
New Applicants must complete and provide the following:
• Payment of Alcohol Beverage License Application Fees including publication fee
• Original Alcohol Beverage License Application (AB-200)
• Alcohol Beverage Individual Questionnaire (AB-100) – this form needs to be completed by each
individual, partners in a partnership, or officers in a corporation or limited liability company
• Alcohol Beverage Appointment of Agent (AB-101) – Agent must have resided in Wisconsin a
minimum of 90 days continuously prior to date of application
o Copy of Agent’s Wisconsin Driver’s License/Identification
o Proof of Agent’s Completion of “Responsible Beverage Server Course” or proof of an
Operator’s License from a Wisconsin municipality within the past two (2) years
• Oshkosh Police Department Investigation Form
• Oshkosh Supplemental Application/Economic Impact Questionnaire
• Copy of current Wisconsin Seller’s Permit Certificate
• Proof of ownership or permission to operate on the premises (exp. Lease, Deed, Land Contract,
Purchase Agreement, etc.)
• Relinquishment/Surrender of Liquor License (only applicable if another entity currently holds the
liquor license)
All forms and payment must be received and on file with the City Clerk for a minimum of fifteen (15) days
prior to Council action to allow for publication, inspections, background checks, and processing.
Following completion of the above forms, new applicants must:
• Contact the Winnebago County Health Department (920-232-3000) for license information and
inspection
• Contact the Oshkosh Fire Department (920-236-5242) for inspection of premises
• Confirm all real estate taxes, special assessments/charges, water utility, and any other
outstanding invoices for the establishment are paid in full
• Confirm a licensed Operator will be on premises at all times of service. Contact Clerk’s Office to
obtain Bar Operator Licenses.
New Alcohol Beverage License Checklist for Applicant
Original Alcohol Beverage Application (AB-200). License period is from July 1 to June 30
each year. To be considered at next Common Council meeting, Application must be on file in
the Clerk’s Office 15 days prior to the meeting.
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
Copy of WI Seller’s Permit Certificate
Proof of ownership or permission to operate on the premises (exp. Lease/Deed/Land
Contract/Purchase Agreement)
The following forms are situation specific:
Relinquishment/Surrender of Liquor License (if another entity currently holds the
liquor license)
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:
Contact the Winnebago County Health Department (920-232-3000) for license information
and inspection, if your establishment will be offering ANY food sales.
Contact the Oshkosh Fire Department (920-236-5242) for an inspection of the premises.
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
Completion of Oshkosh Supplemental Application/Economic Impact Questionnaire
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
Note: All information contained in this supplemental application is subject to approval by the City of Oshkosh Common Council.
Deviating from the approved plan of operation will subject licensee to suspension and/or non -renewal of alcohol beverage license.
Contact the City Clerk’s Office for information on how to request changes to an approved license.
NEW ALCOHOL BEVERAGE SUPPLEMENTAL APPLICATION
City of Oshkosh Clerk’s Office
215 Church Avenue, Office 108, Oshkosh, WI 54903
(920) 236-5011 e-mail: city_clerk@oshkoshwi.gov www.oshkoshwi.gov
Legal Name of Owner/Entity:
Business Name:
Premise Address & Tax Parcel Number:
Contact Person:
Contact Person Phone & Email:
Proximity of Premises to Church, School, Daycare Center or Hospital
Is the premises location within 300 feet of any church, school, daycare center, or hospital?
Business Information
Provide a detailed description of the type of business you plan on operating:
Type of Business on Premises: (please check all that apply)
□ Bar/Tavern □ Restaurant □ Brewery/Brewpub □ Hotel □ Nightclub
□ Music Venue □ Theatre □ Bowling Alley □ Entertainment Center
□ Arcade □ Private Club □ Other, please describe: _________________________________
What are the anticipated typical days/hours of business operation:
How many jobs are anticipated to be created/retained: Full-Time _______________ Part-Time _________________
What percentage of revenue is expected to be generated from the alcohol beverage license applied for as compared
to other sources of revenue (food, other):
Square Footage of establishment: _____________ Maximum Occupancy: _____________________
Business Compliance
Does the premises meet a statutory exception (Wis. Stat. 125.32(3m)) allowing for the presence of underage persons
upon the premises? No Yes If yes, describe:
Is there adequate separation of facilities and a plan to address/prevent underage persons from entering the premises
and consuming alcohol beverages?
Describe security of access to alcohol beverages:
Describe plan to adequately address any neighborhood issues (parking, noise, litter, etc.):
Any other information you’d like to share with City Council regarding your business:
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.
City of Oshkosh
LICENSE SURRENDER
TO:
Diane Bartlett, City Clerk
P.O. Box 1130
215 Church Avenue
Oshkosh, WI 54901-1130
I, , am the current license holder.
(Name of current license holder, if an individual)
Or
I, am the registered agent/president/member/partner and authorized to act for the
current license holder:
(Name Of Current License Holder, If an Entity)
for premises locate at: of Oshkosh, Wisconsin.
(Address Of Licensed Premises)
As the licensee or authorized agent/officer/member of the licensee I am surrendering the following license(s)
(check all that apply):
_____"Class B" Liquor
_____Class "B" Beer (Fermented Malt Beverage)
_____"Class A" Liquor
_____Class "A" Beer (Fermented Malt Beverage)
_____"Class C" Wine
To The City of Oshkosh. The surrender is conditioned upon, and licensee requests that the license be granted
to:
(Name Of New Applicant)
to whom the licensee has sold/transferred the business/premises, and who intends to apply for and maintain a
license for use at the business premises. Should the council not approve the new applicant for a license as
requested this request for license Surrender shall be null and void.
I understand that upon granting of a license to new applicants the current license will be officially surrendered
as provided Heron and will be canceled and a license granted to the new applicant for the premises listed
above.
Dated this day of 2023
Signature