Operator'S License Application Form - Village Of Withee, Wi printable pdf download

Village of Withee

License Application – Bartender/Operator

P.O. Box A, Withee, WI 54498 Phone: (715)229-4319

(PLEASE PRINT)

Date of Application:

________________________________

Licensing Year: __________________________________

Check the one that applies: New Application:______ Renewal Application: _____

Name of Applicant:

_________________________________________________ Date of Birth: _____________________

(FIRST)

(MIDDLE)

(LAST)

Address:

_________________________________________________ Phone Number: ____________________

City, State & Zip

_________________________________________________

Name of Business

Working At:

_________________________________________________ Telephone #:

____________________

Applicant’s

Drivers License #:

_________________________________________________ DL Issuing State: ___________________

(ATTACH COPY OF LICENSE)

Name & address of physician signing your health certificate filed herewith (if required):__________________________________

_________________________________________________________________________________________________________

Date Rec’d

Answer the Following Questions Completely

Yes

No/NA

. Have you provided the Village Clerk with proof that you attended Responsible Beverage

Servers Class or a copy of a previous operator’s license? (Attach copy of the scheduled class

enrollment, resp. beverage class certificate or copy of previous license to this application)

. Have you been convicted of a felony, misdemeanor or other offense, which substantially

relates to the circumstances of the licensed activity?

(If yes, please explain below)

Enter applicable arrest and conviction information, including dates, here: ________________________________________________________

____________________________________________________________________________________________________________________

I, the undersigned, do hereby respectfully make application to the local governing body of the Village of Withee, County of Clark, State of Wisconsin for a License

to serve Fermented Malt Beverages and Intoxicating Liquors, subject to the limitations imposed by Section 125.32 (2) and 125.68 (2) of the Wisconsin Statutes and

all acts amendatory thereof and supplementary thereto, and hereby agree to comply with all laws, resolutions, ordinances and regulations, Federal, State, or local,

affecting the sale of such beverages and liquors if a license be granted to me.

I certify that I am at least 18 years of age and do not have an arrest or conviction record to SS.111.321, 111.322 and 111.335.

I hereby certify the forgoing answers are true and correct.

_________________________________________________

(Applicant Signature)

For office use only:

Date Received: ________________

Payment Receipt #: ____________________

Approved by Chief of Police On: ____________________________

Approved by the Village Board On: ___________________________

Operator License No. ________________

Date License Issued: _____________________