7325 W Forest Home Ave
Greenfield, WI 53220
For the license period beginning and ending:
License(s) Desired (Up to two)
Entity Type (check one)
Do you want to adjust your premises to include more or less territory?
Has your designated agent changed since your most recent application was submitted?
If yes, submit an approved Responsible Beverage Server course certificate here.
Have any of your partners, members, officers, directors, managers, or agent changed since your most recent application was submitted?
Please list the names, titles and phone numbers of any changed members or agents AND attach FORM AT-103 for all NEW members.
Choose to add or remove this person.
Has the licensee, or any officer, director, stockholder, member, manager, or agent had any changes to their most recently filed Form AT-103 including updated contact information, changes in address, criminal history, interest restrictions, etc? IF YES, AFFECTED MEMBERS SHOULD SUBMIT UPDATED AT-103s
Does the entity or any of its officers, directors, or agents hold any direct or interest in any other alcohol beverage wholesaler or producer (e.g. brewery, brewpub, winery, distillery) in Wisconsin?
Is the person or business identified in the Premises/Business Information, the genuine seller of alcohol beverages and operator of the business (e.g. reporter of profit/loss from the sale of alcohol beverages on their income tax return, holder of the seller's permit for the business location, payer of employees, taxes, utilities, and other expenses for the business, etc)?
Is the business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor?
Are all municipal property taxes, assessments, or other fees incurred by this business reported and paid?
Who must sign this application?
• Sole proprietor • One general partner of a partnership • One corporate officer • One member/manager of an LLC
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 permit 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted.