Common Council — Agenda packet

Page 1 of 1 City of Black River Falls COMMON COUNCIL – AGENDA Tuesday – June 2, 2026 – 6:00 PM City Hall – 101 S. Second Street, Black River Falls, WI Join Zoom Meeting: https://us02web.zoom.us/j/86241711746?pwd=3j1mdQUH6aHx285zbIkyh27Na3byaM.1 Or Dial: 1-312-626-6799 Meeting ID: 862 4171 1746 Password: cityhall 1. Call to Order 2. Roll Call 3. Pledge of Allegiance 4. Reading of the Minutes of the May 20, 2026 Special Common Council Meeting – Action 5. Citizens in Attendance 6. Committee Reports: a. Utility Commission May 18, 2026 b. Board of Review May 28, 2026 7. Applications for Renewal of Class A, B and C Beer, Wine, Liquor and Wholesale Retailer Licenses (2026-2027) – Action 8. Application for a Temporary Alcohol Beverage License from Black River Youth Hockey for the 2026 Gun Banquet June 27th at 388 Melrose Street (Milt Lunda Memorial Arena) – Action 9. Application for a Temporary Alcohol Beverage License from the Rotary Club of Black River Falls for Festival in the Park July 11th at 1400 Tyler Street – Action 10. License for Real Property for military to conduct field exercises and training – Action 11. Meetings: Committee of the Whole Wednesday, June 17, 2026 6:00 PM 12. Adjourn Posted: May 29, 2026 The Common Council met in special session at City Hall in the City of Black River Falls on May 20, 2026 at 6:00 P.M. Alderpersons Gearing-Lancaster, Ammann and Peloquin were present. Alderpersons M. Rave, Busse, and Wussow attended remotely via Zoom meetings. Alderpersons E. Rave and Dougherty were excused. Mayor J. Eddy presided. It was moved by Alderperson Gearing-Lancaster seconded by Alderperson Peloquin to dispense with the reading of the minutes of the May 5, 2026 Common Council meeting and approve as presented. Motion carried. CITIZENS IN ATTENDANCE There was one citizen in attendance for an agenda item. COMMITTEE REPORTS It was moved by Alderperson M. Rave, seconded by Alderperson Ammann to approve the minutes of the May 13, 2026 Plan Commission meeting. Motion carried. The Department Head monthly reports were reviewed. Department heads present were Mark Nordahl, Darryl Nelson, Jarod Mayer, Travis Brown, and Brad Chown. Cara Hart was excused. 1. The Street Superintendent reported street work on North 8th Street is going well. 2. The City Administrator advised a television has been installed in the lobby to display advertising material for community events, and the programming will be managed by the Chamber of Commerce. He also advised the updated City website has launched and it looks good. 3. The Parks & Recreation Director advised the water supply line for the tube slide at the Hoffman Aquatic Center has a major leak. Neuman Pools has been called to inspect and potentially repair. This will not affect the pool opening, but the slide will not be in service until repaired. It was moved by Alderperson Ammann, seconded by Alderperson Peloquin to approve Ordinance 904 — an ordinance repealing and recreating Section 5.10(2) of the Code of Ordinances regarding fire inspections. Motion carried. CITY OF BLACK RIVER FALLS ORDINANCE NO. 904 AN ORDINANCE REPEALING AND RECREATING SECTION 5.10(2) OF THE CODE OF ORDINANCES FOR THE CITY OF BLACK RIVER FALLS, JACKSON COUNTY, WISCONSIN REGARDING FIRE INSPECTIONS The Common Council of the City of Black River Falls, Jackson County, Wisconsin, do ordain as follows: SECTION 1. Section 5.10(2) shall be created to read as follows: (2) INSPECTION DUTIES. The Fire Inspectors shall inspect all public buildings and places of employment, as defined in §101.01, Ws. Stats. 101.14 and SPS 314.01(13), within the City and participating towns for the purpose of noting and causing to be corrected any conditions liable to cause fires. Pursuant to SPS 314.01 (13) (7), the chief of the fire department is authorized to reduce the frequency of fire inspections required under SPS 314.01(13) to at least once per calendar year, provided the interval between those inspections does not exceed fifteen (15) months. The Chief of the Fire Department may require or conduct more frequent inspections than required under this subsection. Repairs or alterations necessary to remove the hazardous condition shall be made within a reasonable time at the expense of the owner. The Inspector shall also investigate the storage and handling of explosives and flammable liquids It was moved by Alderperson M. Rave, seconded by Alderperson Gearing-Lancaster to approve the Certified Survey Map submitted by Ethan Remus on behalf of April Riley for property located at 1114 Pierce Street. Motion carried. It was moved by Alderperson Busse, seconded by Alderperson Wussow to approve the Certified Survey Map submitted by Badger-Land Survey, LLC on behalf of PO Properties for property located at 1005 and 1007 Spruce Street. Motion carried. Page 1 of 2 It was moved by Alderperson Wussow, seconded by Alderperson Ammann to approve the vouchers for April 2026 Check #76871 - #76989 totaling $323,898.41. Motion carried. It was moved by Alderperson Gearing-Lancaster, seconded by Alderperson Busse to approve the City Treasurer's Report for April 2026. Motion carried. It was moved by Alderperson Ammann, seconded by Alderperson Peloquin to approve the Revenue & Expense Report for April 2026. Motion carried. It was moved by Alderperson Peloquin, seconded by Alderperson Gearing-Lancaster to adjourn. Motion carried at 6:24pm. A. Brad Chown City Administrator Page 2 of 2 BLACK RIVER FALLS UTILITY COMMISSION MEETING MINUTES May 18, 2026 Utility Commission President John Lund called a meeting of the Black River Falls Municipal Utility Commission to order on May 18, 2026 at 3:30 p.m. in the Utility Conference Room at 349 South McKinley Street. Commissioners in attendance were Jeff Amo, Jay Eddy, and Don Mathews. Commissioner Justin Dougherty was excused. Also present were General Manager Casey Engebretson and Garrett Aleckson (Banner Journal). A motion was made by Commissioner Amo and seconded by Commissioner Eddy to approve the minutes from the April 27th, 2026 regular meeting. Aye: Lund, Amo, Eddy, and Mathews Motion carried. The Commission reviewed the March vouchers. A motion was made by Commissioner Eddy and seconded by Commissioner Mathews to approve the accounts payable vouchers; CK #43722 -43801 and EP #101014 - 101022 — Totaling $957,040.97. Aye: Lund, Amo, Eddy, and Mathews Motion Carried. The Commission reviewed the April 2026 arrears. Casey Engebretson discussed a memo provided to the Commission which contained the engineer's answers to questions posed at the April meeting. Casey stated the last comprehensive water system study was completed in 2014. Subsequent to the 2014 study, a number of changes have occurred, including but not limited to, a new 10th St. tower, small diameter water main replacements, and usage patterns. All of these factors affect water system characteristics. Casey recommended requesting a quote to conduct a new comprehensive system study to allow the Commission to make more informed decisions using up-to-date information, for future system improvements. After a short discussion, the Commission asked Casey to obtain a quote from SEH for a new system study. Casey Engebretson informed the Commission that the weirs in the digestor at the WWTP are showing significant deterioration and will need to be replaced. Casey has asked WWTP staff to procure quotes for this work. Casey Engebretson informed the Commission that EPS was onsite to perform the Plant No. 2 regulator rehabilitation. Casey also stated that the new bucket truck was delivered and the line crew is finishing up transferring tools and equipment from the old truck to the new truck. Casey is obtaining more information from a second option for selling the old bucket truck. Casey Engebretson presented a Simplified Water Rate Case (SRC) application to the Commission. Casey explained the process and confirmed that BRFMU met the criteria to qualify for the SRC. Casey reiterated the fact that the Water Department has been operating at nearly a break-even point for quite some time. Initial plans were to apply for a comprehensive conventional rate increase in conjunction with a large well project. With the substandard well pumping result forcing the Utility to look at other options, Casey felt that applying for a SRC is needed to bridge the gap until a decision is made for a future large project. Casey stated that the SRC will result in a 3.0% increase, resulting in an approximate $1.50 increase per month for a residential customer. The notice would be published on June 3, 2026, with the new rates effective on August 1, 2026. BRFMU IS AN EQUAL OPPORTUNITY PROVIDER A motion was made by Commissioner Amo and seconded by Commissioner Eddy to authorize Casey Engebretson to file a SRC application with the Public Service Commission. Aye: Lund, Amo, Eddy, and Mathews Motion Carried. Casey Engebretson informed the Commission that the company teasing the property adjacent to the Lincoln substation has requested the lease be renewed. The original lease is set to expire in 2033. Casey provided information from the City Attorney to the Commission and a short discussion ensued. The Commission felt there was still ample time remaining on the existing lease and the decision to renew should be made closer to the expiration of the original lease. No action was taken. Casey Engebretson stated that WPPI Energy will be starting the process of asking members to extend the all- requirements power supply contracts later this summer. A typical extension process involves the Commission approving a resolution/recommendation to the City Council to extend the contract, with final approval by the City Council. Casey will provide more information as it becomes available. Casey Engebretson reminded the Commission that the Customer Appreciation Luncheon will be held on Wednesday June 10th from 11 a.m. —1 p.m at the Utility Operations Center at 349 S. McKinley St. Next Meeting: June 29, 2026 @ 3:30 p.m. A motion was made by Commissioner Eddy and seconded by Commissioner Mathews to adjourn the meeting at 4:14 p.m. Aye: Lund, Amo, Eddy, and Mathews Motion Carried. Casey Engebretson, General Manager comm.mtg.minutes.5.18.2026 BRFMU IS AN EQUAL OPPORTUNITY PROVIDER The Board of Review met at City Hall in the City of Black River Falls, WI on May 28, 2026 at 10:00 A.M. Board members present were Mayor Jay Eddy, Alderperson Mike Rave, and City Administrator A. Brad Chown. 1. Administrator Chown called the Board of Review to order at 10:00 AM. 2. Administrator Chown verified a recording device was present and recording. 3. Administrator Chown confirmed the May 28, 2026 Board of Review meeting notice was posted April 16, 2026 and published in the Banner Journal on April 29, 2025. 4. Mayor Eddy nominated himself for Chairperson of the Board of Review. There were no other nominations. 5. It was moved by Alderperson M. Rave, seconded by Administrator Chown to close the nominations and cast a unanimous ballot for Mayor Eddy for Chairperson of the Board of Review. Motion carried. 6. Alderperson M. Rave nominated Brad Chown for Vice-Chairperson of the Board of Review. There were no other nominations. 7. It was moved by Alderperson M. Rave, seconded by Mayor Eddy to close the nominations and cast a unanimous ballot for Brad Chown for Vice-Chairperson of the Board of Review. Motion carried. 8. The Board verified that Administrator Chown attended Board of Review Training on May 11, 2026. 9. Administrator Chown verified City of BRF Ordinance 717 — an ordinance relating to the confidentiality of information about income and expenses requested by the Assessor in property assessment matters in the City. 10. Administrator Chown verified City of BRF Resolution 2023-04 — a resolution establishing Board of Review policy and procedure for sworn telephone or sworn written testimony requests. 11. Administrator Chown verified City of BRF Resolution 2023-05 — a resolution establishing Board of Review policy and procedure for waiver of Board of Review hearing requests. 12. Administrator Chown confirmed receipt of the assessment roll from the Assessor. 13. Attorney Bill Wentzel was in attendance representing Wal-Mart Real Estate Trust for the Request for Waiver of Board of Review Hearing from Wal-Mart Real Estate Business Trust for parcel 206-2210.0000. Administrator Chown confirmed timely receipt of the Objection to Real Property Assessment brought by Wal-Mart Real Estate Trust for Parcel 206-2210.0000 for property located at 611 East State Hwy 54 that is assessed at $13,139,300 and a stated opinion of value of $6,910,000 and the Request for Waiver of Board of Review. 14. It was moved by Administrator Chown, seconded by Alderperson M. Rave to grant the Request for a Waiver of a Board of Review Hearing from Wal-Mart Real Estate Business Trust for Parcel 206-2210.0000 located at 611 State Highway 54 to allow them to take the matter directly to circuit court. Motion carried. 15. The Board reviewed the assessment roll and performed their statutory duties. 16. The assessor confirmed there were no Open Book changes to include in the assessment roll. 17. The Board found no need to schedule additional Board of Review dates. 18. It was moved by Administrator Chown, seconded by Alderperson M. Rave to adjourn the Board of Review. Motion carried at 12:01 PM. A. Brad Chown City Administrator Page 1 of 1 STATE QUOTA 12.02(9)(e ) 12.02(9)(a) 12.02(9)(b) 12.02(9)(c ) 12.02(9)(d) C Wine B Liquor B Beer A Liquor A Beer Cider Wholesale Winery 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 9 12 7 8 0 0 0 13 9 14 13 13 8 N/A N/A 9 0 2 6 5 8 N/A N/A **Docside, LLC On Premise Wine Class B Liquor = On Premise Liquor Off Premise Liquor Class B Beer = On Premise Beer Off Premise Beer ** One (1) of the (9) total authorized Class B Liquors is a "Reserve Class B Liquor License" - minimum $10k initial fee (non-refundable) specifically for the Old Pines Property due to annexation. (for state quota compliance) Statutory Quota on "Class B" Liquor Licenses Only - §125.51(4) - All other quotas are controlled locally via ordinance/code R:/clerkdocuments/Liq-Cig Licenses/Liquor Licenses Issued-Available 2026-2027 PJ's Bar (Carpi's Temp, LLC) Kwik Trip, Inc. Hwy 54 E #648 Kwik Trip, Inc. Hwy A #240 Hansen's IGA Adelaid's Delicatessen (Mans Ruin, LLC) Dollar General Store #10118 Corner Store It Is, LLC Pizza Hut Pilot Travel Center, LLC (Flying J) Mr. Pita Miles-Hagen American Legion Post #200 Docside, LLC Rozario's Pizza & Pasta, LLC Viva Cinco De Mayo Stag & Lion Pub, LLC Class A Beer = Revolution Coffee, LLC Skyline Golf Course (BRF Recreation Association) 2026-2027 BEER, LIQUOR, CIDER, WINE, WHOLESALE LICENSE LIST Quota Established by BRF Code Section: Business Name License Type Class A Liquor = Little Vinny's (Mans Ruin, LLC) Falls Florist Leroy's Grill Smoker's Corner Harry Black River Falls Class C Wine = Available ** Total Authorized Total Issued Wal-Mart Save Form AB -200 Alcohol Beverage License Application For Municipal Use Only Municipality Cit of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) ❑ Initial (New) El Renewal License(s) Requested: El Class "A" Beer E "Class A" Liquor ❑ "Class A" Liquor (cider E "Class C" Liquor (wine (up to two boxes may be checked) "B" Beer $ LOV Fees License Fee(s) ___ Regular "Class B" Liquor $38 43 LDRegular Background Check Fee $ only) $ iii Reserve "Class B" Liquor $ Publication Fee only) $ E Above -Quota "Class B" Total Fees (.1) Liquor Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) ,P1,, Li 2. Business Trade Name or DBA 4 ...414,"oes' 1)&be ,c 7 s6e-it/ 3. FEIN "5- .3?0' 7329 4. Wisconsin Seller's Permit Number <-75-6 -- Mao 5, 1P-27c/I —O -2- 5. Entity Type (check one) El Sole Proprietor 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? ❑ Yes I2rNo If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. 7. State of Organization b// 8. Date of Organization /J • oz. • 2.O -2—c, 9. Wisconsin DFI Registration Number X1//26 - 90 10. Premises Address 4A( Zt0i .iti 11. City 19/.9 .!/e ,eq- 12. State / 13. Zip Code s-V6/5' 14. County e:YY1 15. Governing Municipality: 2 City • Town 111 Village of: _ ems_ 16. Aldermanic District 17. Premises Phone 7/5 - - C9-7o. e22 , 49 18. Premises Email Aq40ies . ,.O,1-1.Oz) • eery 19. Website 4d0i ,er6i.ej; , 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking t e box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. ❑ Partnership Limited Liability Company ❑ Corporation ❑ Nonprofit Organization 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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. If yes, list the details of violation below. Attach additional sheets if necessary. El Yes Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes E No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? Ei Yes ❑ No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes beverages. If yes, describe the nature and status of pending charges using the space below. Attach additional sheets as needed. No 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 wholesaler? . . ❑ Yes No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion J2i, Yes No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes IY? No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes No No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. XI have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. yI have provided an accurate Form AB-100 for each person listed in Form AB-200AA. X (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. .;4 I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Namk ii First Na e M.I. Title iCrAt}tie-,e— Email t(Wie,C,e,// 4(0 ,,O, 12/ 4t, . - 6-0 -7 1A Phone 3,05-, q--y -1_, 37...-2,, Signature _,.....----- - Date Part E: For Date Application Was Filed With Clerk 7 License Number Date License Granted Date License Issued Signal of Clerk/Deputy rk ,),S1 .1 ill , • Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - Form AB -200 Alcohol Beverage License Application For Municipal Use Only Municipality City of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) ❑ Initial (New) v Renewal License(s) Requested: (up to two boxes may ❑ Class "A" Beer $ be V checked) Class "B" Beer $ Fees License Fee(s) $ ❑ "Class A" Liquor $ V Regular "Class B" Liquor $ Background Check Fee $ ❑ "Class A" Liquor (cider only) $ ❑ Reserve "Class B" Liquor $ Publication Fee $ ❑ "Class C" Liquor (wine only) $ ❑ Above -Quota "Class B" Total Fees $ Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Miles Hagen American Legion Post 200 2. Business Trade Name or DBA American Legion Post 200 3. FEIN 39-1307215 4. Wisconsin Seller's Permit Number 456-0000432165-02 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership ❑ Limited Liability Company ❑ Corporation r Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form • Yes ❑ No AB-100. 7. State of Organization WI 8. Date of Organization 9. Wisconsin DFI Registration Number 6M05121 10. Premises Address 421 State Hwy 54 West 11. City Blk Rvr Falls 12. State WI 13. Zip Code 54615 14. County Jackson El 15. Governing Municipality: of: Blk Rvr Falls MI City • Town . Village 16. Aldermanic District 17. Premises Phone 715-284-9552 18. Premises Email 19. Website 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. ❑ Bar, kitchen, hall his & her bathrooms 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 rvi No If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are chargeS beverages. If yes, describe for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes the nature and status of pending charges using the space below. Attach additional sheets as needed. ,,/ No 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 wholesaler? . . ❑ Yes If yes, provide the name of the restricted investor and describe the nature of the interest. i ! I v No 4. Have the partners, this license 5. Is the applidant 6. Does the applicant agent, or sole proprietor satisfied the responsible beverage server training requirement for period? Submit proof of completion ❑ Yes business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes business owe past due municipal property taxes, assessments, or other fees? ❑ Yes ❑ v v No No No Part C: Individual Information Check instructions v v be r each bOx fort I have accurately and any buSiness I have provided (For corporations, appoint an agent I understand applying forian I to attest that you have provided the appropriate supplementary information to complete your application. See the Part C of this application, beginning on page 2, to complete this section. listed and provided contact and personal information for all required persons involved in the applicant business identified in Part A, Question 6 using Form AB-200AA. an accurate Form AB-100 for each person listed in Form AB-200AA. limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to on behalf of my business. that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am alcohol beverage license. Part D: AtteStation One of the followI ing must sign and attest to this application: • sole proprietor • one general partner of a partnership • one corporate officer • one member 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name Voge First Name Frank M.I. Title Manager Email • cV0C1C 6 °O rh a I I •C °1'" Phone 920-960-1519 Signature ' 0 Date i 2- (I Z Ce Part E: For Clerk Use Only Date pplication Was Filed With Clerk / 47, ....2O.14, L. ense Number //' Date License Granted Date License Issued ,e o kiDeputy Cle Ati 1/4.....___ Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - Form AB -200 Alcohol Beverage License Application For Municipal Use Only MunicipalityCity of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) ❑ Initial (New) El Renewal License(s) Requested: (up to two boxes may be checked) ❑ Class "A" Beer $ L'vrClass "B" Beer $ Itjai ) Fees License Fee(s) $ tito to ❑ "Class A" Liquor $ ["Regular "Class B" Liquor ($.3/1\ to Background Check Fee $ ❑ "Class A" Liquor (cider only) $ ❑ Reserve "Class B" Liquor $ Publication Fee $ 16.4' I ❑ "Class C" Liquor (wine only) $ ❑ Above -Quota "Class B" Total Fees $ —1-1 0. CilLiquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if si?le proprietorship) GQ,C)6 i22),uc c,--- F-Ci )15 JQ-, c', Aci,,;(--)(.1,--1,,,-,-, v-,, IA( 2. Business,Trade Name or DBA . I jly -1 ).-,,,y__ 6-1,.:',.c (1.1.15\.- ) 3. FEIN C -11 - 6 W-1 Lo 4. Wisconsin Seller's Permit Number LiS&Zit3 5. Entity Type (check one) 0 Sole Proprietor ❑ Partnership alLimited Liability Company ❑ Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form li Yes ❑ No AB-100. 7. State pf Organization 8. Date of Organization 9. Wissonsin DFI Registration Number 10. Premises Address ) 2 ,i() 1 1 1-k. .--Sk-ee. \--11. City . V''') 12) (:' - I l 12. State 13. Zip Code f- ._ ..-- -1--/(:, 15 14. County -,--- i , t.,-C"L‘K i-') 15. Governing Municipality: City ❑ Town ❑ Village of: 13 ictiji-, f,; ,t,' e c• 1-z,„ i I5 16. Aldermanic District 17. Premises Phone 7i'd -- 25 -4 - 2.6:13 18. Premises Email 1-.5 ,. -4 Ie. it='1 PiCtr'10.5e,r4:7'‘ky 19. Website 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking th following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 VC If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed'? Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed'? ❑ Yes No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol Yes Er -Rlo 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 wholesaler? . . ❑ Yes aglo If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for „...-- this license period? Submit proof of completion sEtli,,E. if-i4r - N'Yes No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes r2""qo 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. 'lave accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200M. have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (r; corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name A VC * ‘ \ First Name -------'- V e .( M.I. N I? ) Title (.1' i --.)-eV11,LCCii,k i lk......, 10,,1,4-e, i'---- Email ✓ Phone L-70\ 4‘-h;i ilitakete. 6-:-;- Ay.111-W10).-.C4341ir;` 'ik'L -) i•:/) --- Z-:6/6r-Ift'i( 7 Signature ----- ,-- ...___ _—„,____.---, Date -Y '7 •\ -) 9 - ) - ./ )Part E: For Clerk Use Only Date 14--i-i- Application Was Filed With Clerk 71.1) License Number Date License Granted Date License Issued Signat al Cler Deput Clerk ilL-D Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - For Municipal Use Only Form AB-200 Aicohoi Beverage License iication Application Type (check one Municipality Cit of Black River Falls License Period 07/01/2026 - 06/30/2027 ❑ Initial (New) Renewal License(s) Requested: (up to two boxes may be checked) Fees El Class "A" Beer ❑ "Class A" Liquor 111 "Class A" Liquor (cider only) $ Class "B" Beer $ License Fee(s) 1,Xf Regular " lass B" Liquor oo.`1 Background Check Fee Dir ResePae`-±4 ,-1-Liefuer $160°) Publication Fee CI "Class C" Liquor (wine only) $ El Above-Quota "Class B" Liquor Total Fees IC Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Ca. 1" 's 2. Business Trade Name or DBA 3. FEIN c1 q 3(c3 4. Wisconsin Seller's Permit Number 5. Entity Type (check one) O Sole Proprietor 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? ❑ Yes X No If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. El Partnership cg, Limited Liability Company ❑ Corporation O Nonprofit Organization 7. State of OrganizatiWon 10. Premises Address S+ 11. City • k: 1/4,r( k 14. County jo t ( . 14._...cCrl 17. Premises Phone 8. Date of Organization 9. Wisconsin DFI Registration Number C ivy3 b(t) - L7b tla3 12. State W 15. Governing Municipality: ICity O Town ❑ Village of: 51 iej?),iy rS 18. Premises Email )1, 13. Zip Code 971615-16. Aldermanic District 19. Website 20. Premises Description c‘.-1 initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. ab.) Loiltyt: p c)--e-i ,k_ki 21. Mailing Address (if different from premises address) rvigi 22. City. Vktv (—c Part B: Questions 23. State 24. Zip Code 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. If yes, list the details of violation below. Attach additional sheets if necessary. Yes jg_ No Law/Ordinance Violated Location Penalty Imposed Law/Ordinance Violated Trial Date Was sentence completed? Yes I I No Location Penalty Imposed Trial Date Was sentence completed? LJ Yes LJ No AB-200 (R. 2-26) Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ beverages. Yes No k 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 wholesaler? . . ❑ Yes No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion tX1 Yes ❑ No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes U No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes [ No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. LYE have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name First Name -- M.I. Title , C) vt-er Email ,„. +A sun , d it& e 6-21)c ppic(AL) (AA Phone 1/6' 4) 6,- Li 6S-5-. / / 3 Signature Date S --- (— a () Part E: For Clerk Use Only Date Application Was Filed With Clerk 1 - License Number Date License Granted Date License Issued . ,-. Si to Clerk/De utk iiiYe_..) Date Provisional License Issued (if applicable) gna of erk 7151— rt., pr AB-200 (R. 2-26) - 2 - Form A B -200 Alcohol Beverage License Application For Municipal Use Only Municipality City of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) ❑ Initial (New) ,/ Renewal License(s) Requested: (up to two boxes may be checked) U Class "A" Beer $ itell 15 ❑ Class "B" Beer $ Fees License Fee(s) $ bt y3 . Lt. G "Class A" Liquor $ ff tlal i)_ Regular "Class B" Liquor $ Background Check Fee $ 0 A" Li u (cider only) $ 1OO. ❑ Reserve "Class B" Liquor $ Publication Fee $ M."' r ❑ "Class C" Liquor (wine only) $ ❑ Above -Quota "Class B" Total Fees $ [Cla wLiquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) COillec --)-- -(c_ I-4 - -. .s LL C 2. Business Trade Name or DBA 3. FEIN g 'i 3 (-1') Clq-Vo 4. Wisconsin Seller's Permit Number LIS Co /03 01 3 7 "./..cl-7 co-( 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership 3 Limited Liability Company ❑ Corporation Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? ❑ Yes If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. M No 7. State of Organization • (A) \ 8. Date of Organization .14,6.1 I, 102 ) 9. Wisconsin DFI Registration Number C 1/ 5 y 5 10. Premises Address CtZ) Ma(ii" 54- 11. City g act( Q‘\44, c-c, It, 12. State lA) I 13. Zip Code S ti (0 J-1 14. County Sa.C-K5 s•vi 15. Governing Municipality: B-4-City ❑ Town ❑ Village of: 610.CK Riv,e_i F-,... A i 16. Aldermanic District us arc) 2.- 17. Premises Phone '1(5 - '2.4 ‘-/ - 0 iirCi 18. Premiset Email ivie ciy a _. e_cqie"- e ,..i ..t," • c-,,„...- 19. Website ...- 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. 21. Mailing Address (if different from premises address) „-- 22. City ...V 23. State 24. Zip Code 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. .1 Yes No If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Location --- Trial Date Penalty Imposed — ,..... Was sentence completed? Yes No Law/Ordinance Violated _.,...- --- -location Trial Date Penalty Imposed Was sentence completed? Yes E No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol H 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 wholesaler? . . Yes A" No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion Yes ri No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ] Yes Fil No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? Yes ,,( No Part C: Individual Information Check instructions 21 / IM M each box to attest that you have provided the appropriate supplementary information to complete your application. See the for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name ,6 a e First Name Me) ; Ss-A- M.I. -C Title eirCS i cAtiCr Email Old ;SS-4 _ea 51-O yc-Loo ,c,),— Phone -Ifs- zq q-6 -7 I- signature Date i— 19 -l- G Part E: For Clerk Use Only Date Application Was Filed With Clerk License Number Date License Granted Date License Issued Signa of Clerk/Deputy 1 L --Wt 1_ itivi_ clerls ) Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - Form AB -200 Alcohol Beverage License Application ForhAunicipalUseOnly Municipality City of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) • Initial (New) ES Renewal License(s) Requested: (up to two boxes may be checked) ❑ Class "A" Beer $ Pr /Class "B" Beer $ / ,) 1.1 Fees License Fee(s) $ ❑ "Class A" Liquor $ El i Regular "Class B" Liquor $ 300 Background Check Fee $ • "Class A" Liquor (cider only) $ • Reserve "Class B" Liquor $ Publication Fee $ 1 0 , CO • "Class C" Liquor (wine only) $ • Above -Quota "Class B" Total Fees $ Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) The_ireK KU," (VI (\ ser-2. Business Trade Name or DBA ocs'i de_ U-C_. 3. FEIN L k — LAO \-2:1 10 4. Wisconsin Seller's Permit Number LI sb - 10.- 2 2- 1 L463 /. - 02 5. Entity Type (check one) • Sole Proprietor • Partnership gLimited Liability Company . Corporation • Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? MI Yes II No If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. 7. State of Organization 1 8. Date of Organization 9. Wiwinsin DEI Registration Number 0 0 L A 8 Z .-2 10. Premisps Address 1\1 tO 600 'R i V GC V 1 e4,3 1.f.‘ 11. City -15W,IL R; \tor Fad IS 12. State WI 13. Zip Code S t-iL , IS 14. County JarA.Sc)(\ 15. Governing Municipality: 'City 17 Town • Village of: aCka— %VeAe . 1.•-lk% 16. Aldermanic District 17. Premises Phone — I IS — 6-10-gool.-3 18. Premises Email hr c docsIcle__:=ar g9rrciA I . 19. Website i NI A 20. Premises Description CONN Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the fast issued license certificate and the premises description remains the same.g 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 Z. No If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No ta_onn to 1_,C% Wiee.eincin flaarvarimerst elf On•rchnii. 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes jg 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 wholesaler? ❑ Yes X No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion. . . .0(,..) r'rC % /Yes ❑ No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. ❑ I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. • I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. • (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. • I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Na , . (.1..ANGli t INS -Cr - First Name .b-efeAL_ M.I. R Title O k-)0c \ -ex - Email brfacesi el e-AY1 e e_._ ma I • ccrY. Phone —1 Is-E016.--(10 Signatur 0 _etalV "...... :::=%' Da e Y ---i:9 - i s — d"-, r Part E: For Clerk Use Only Date Ap lication Was Filed With Clerk _p 61, ."-,/ 2L/ 2.02(r License Number , / / Date License Granted Date License Issued Signet tid tier epu -Clerk :\ .,-' Date Provisional License Issued (if applicable) Aci_nrin ID 6/3 )/27 BLACK RIVER FALLS CITY(TAX-WI) .:: 101 SOUTH 2ND STREET, 0 '' -• (10118 ./ BLACK RIVER FALLS, WI 54615 For Municipal Use Only Form Alcohol Beverage License 1,'"''n'c'P3 ..'' BLACK RIVER FALLS AB-200 Application ILiconse Period 1 - • 1 . - Application Type (check one) O Initial (New) Eb Renewal License(s) Requested: (up to two boxes may be checked) Zr +Ageluctlangefee: io LI Class "A" Beer S • Class "B" Beer S License Fee(s) S .. , 500' , 511 'Class A' Liquor . . . . . . S O Regular 'Class B" Liquor S Background Check Fee S 40 O -Class A" Liquor (cider only) S D Reserve -Class B' Liquor S D "Class C' a "Class Publication Fee $ 10 Liquor (wine only) S Above -Quota B" Liquor $ Total Fees S 560 Part A: Premises/Business Information 1. Legal Business Name ((individual name if sole proprietorship) Dolgencorp, LLC Vendor #240303./ 2 Business Trade Name or DBA Droller General Store a 10118 Invoice #202710118BLBWCI . 3. FEIN 4. Wisconsin Seller's Permit Number Batch #33664 $510.( 6 1 -095. 7)764 456-0000208845-05 5. Entity Type (check one) El Sole Propnctor ri Partnership El Limited Liability Company ll Corporation ■ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling If yes, the members. managers. officers and directors members other LLCs or corporations'? of those business entities must be listed in Part C and provide a Form Ill Yes No AB-100. 7. State of Organization KY 8. Date of Organization 10/09/2003 9. Wisconsin DFI Registration Number D043567 10. Premises Address 205 E MAIN ST +1. City BLACK RIVER .12. State '1fti I 13, Zip Code 54615-1459 14. County 15. Governing Munici ality, ilrCitv ri Town Village 16. Aldermanic District JACKSON of: BLACK RIVER FALLS 17. Premises Phone (615) 855-4000 18, PtrgagerS na lvinelicense@dollargene ran corn 19. Website www.dolargeneral.com 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the lam iA_ciiivii license certificate and the premises description remains the same, n Separate check(s) Please return to Abby Batey Vendor #240303 Vendor #240303 #202710118BWB( Invoice #202710118BWNEWS49 Invoice $4( 21. Mailing Address (if different from premises address) Batch #33664 $10.00 Attn: Tax Licensing, 100 Mission Ridge Batch #33664 22. City Goodlettsville 23. State TN 24. Zip Code 37072 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. If yes. list the details of violation below. Attach additional sheets if necessary. a Yes El No Law'Ordinance Violated Location Trial Date Penalty Imposed Was sentence cornweteco r - Yes No LawOrcinance Violated Location I Trial Date Penalty Imposed Was sentence completed" 7 Yes No TY45 C50 .00 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ....1" Yes 1,7 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 wholesaler? If yes, provide the name of the restricted investor and describe the nature of the interest L I Yes F No ' 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion 0. Yes D No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquorP.vinel ❑ Yes ,E No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? El Yes E No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. Z• I have accurately listed and provided contact and personal information for all required persons involved in the aoplicary business and any business identified in Part A, Question 6 using Form AB-200M. Frj I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. C1 (For corporations. limited liability companies. and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. Kej 1 understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where lam applying for art alcohol beverage license. Part D: Attestation 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 READ CAREFULLY BEFORE SIGNING: Under penalty of law. I have answered each of the above questions completely and truthfully. I agree that t 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 tnat the rights and responsibilities conferred by the liccnse(s), if granted. will rot be assigned to another individual or ent,ty. I agree to operate tnis business according to the law. ,ncluclmg but not limited to, purcnasing alcohol beverages from state at.thonted wholesalers. I understand that lack of access to any portion of a licensed vernises dJring 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 slate law'. I further understand that I may be prosecuted for submitting false slatemeits and affidavits in connection with this application, and tnat any person who '<nowingly provides materially false information on this application may be required to forfeit rot more than 51.000 if convicted. Last Name visiting First Name 1 Zachary kit.', J Title 'Email M,C. :,..tanage:r.. tax-beerandwineficensegdolIargeneral. corn Phone 1 f 6 1 5 ) 6 5 5 - ,; 0 0 0 Signature -- ,--- . , „„ - ,---- . S-,-.',-' ' ___.. Date 0 3/0 2 / 2 6 Part E: For Clerk Use Ontif .---- Date Aophodtion Was Filed With Clerk Lcerse ',Limber Date License Granted Date License Issued Siena r:.• of Glee , puts Clerk ; Date Provisional License Issued (it apincable) 1-.... -2- Form AB-200 Alcohol Beverage License Application 0,-, "--\.. ... , 113 For Municipal Use Only Municipality City of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) • Initial (New) ig Renewal License(s) Requested: (up to two boxes may be checked) • Class "A" Beer $ • Class "B" Beer $ Fees License Fee(s) $ 1861°• "Class A" Liquor $ • Regular "Class B" Liquor $ Background Check Fee $ • "Class A" Liquor (cider only) $ • Reserve "Class B" Liquor $ Publication Fee $ lath 4"Class C" Liquor (wine only) $ 166, 4) ❑ Above-Quota "Class B" Total Fees $ I IC. % Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Falls Florist & Greenhouse, LLC 2. Business Trade Name or DBA Falls Florist 3. FEIN 83-2860462 4. Wisconsin Seller's Permit Number 456-1030305072-02 5. Entity Type (check one) ❑ Sole Proprietor . Partnership ,,/ Limited Liability Company ❑ Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? II Yes NI No If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. 7. State of Organization WI 8. Date of Organization 02/01/2019 9, Wisconsin DFI Registration Number F060342 10. Premises Address 704 Main Street ii. City Black River Falls 12. State WI 13. Zip Code 54615 14. County Jackson 15. Governing Municipality: NI City . Town • Village of: Black River Falls 16. Aldermanic District 2 17. Premises Phone (715) 284-2821 18. Premises Email fallsflorist@outlook.com 19. Website www.fallsflorist.com a 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 If yes, list the details of violation below. Attach additional sheets if necessary. i No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes beverages. If yes, describe the nature and status of pending charges using the space below. Attach additional sheets as needed. / No 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 wholesaler? . . ❑ Yes If yes, provide the name of the restricted investor and describe the nature of the interest. I No 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion ❑ Yes 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes i V i No No No Part C: Individual Information Check instructions I5I i NI ig each box to attest that you have provided the appropriate supplementary information to complete your application. See the for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name Rave First Name Dana M.I. M Title Owner Email fallsflorist@outlook.com Phone (715) 284-2821 ‘Sijiataile /t- -14 Date 05/01/26 Part E: For Clerk Use Only Date Application Was Filed With 5'+' ID Clerk License Number Date License Granted Date License Issued Signatur Clerk/De Cle Vitt A < a k aide Date Provisional License Issued (if applicable) AB-200 (R 2-26) - 2 - For Municipal Use Only Form Alcohol Beverage License Municipality City of Black River Falls AB -200 Application License Period July 1, 2026 - June 30, 2027 Application Type (check one) ❑ Initial (New) i Renewal License(s) Requested: (up to two boxes may be checked) Fees i Class "A" Beer $ ItY3 ❑ Class "B" Beer $ License Fee(s) $ [D86. 45 I "Class A" Liquor $ qat i) ❑ Regular "Class B" Liquor $ `.° ❑ Background Check Fee $ "Clakft_iquor-(cider only) $ ICO Reserve "Class B" Liquor $ ❑ "Class ❑ "Class Publication Fee $ 10 .4) C" Liquor (wine only) $ Above-Quota B" Liquor $ Total Fees $Lotn.'D Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) HANSEN'S IGA INC 2. Business Trade Name or DBA HANSEN'S IGA INC 3. FEIN 3 9 -1098106 4. Wisconsin Seller's Permit 456-0000340870-03 Number 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership ❑ Limited Liability Company ,/ Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form MI Yes AB-100. 0 No 7. State of Organization WI 8. Date of Organization 9. Wisconsin DFI Registration Number 1H06831 10. Premises Address 449 County Rd A 11. City Black River Falls 12. State WI 13. Zip Code 54615 14. County Jackson 15. Governing Municipality: of: Black River Falls „/ City ❑ Town ❑ Village 16. Aldermanic District 17. Premises Phone (715) 284-4308 18. Premises Email hansbrf@hansensiga.com 19. Website 20. Premises Description Initial (New Applicants Only): Describe the building or buildings records are kept. Describe all rooms within the building, including living occur only on the premises described in this application. Attach a map Renewal Applicants Only: I am renewing a license and by checking license certificate and the premises description remains the same. Entire store where i alcohol beverages are produced, sold, stored, or consumed, and quarters. Authorized alcohol beverage activities and storage of records or diagram and additional sheets if necessary. the box following this statement, I affirm that I have reviewed the last related issued may 21. Mailing Address (if different from premises address) PO Box 160 22. City Bangor 23. State WI 24. Zip Code 54614 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 If yes, list the details of violation below. Attach additional sheets if necessary. I No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed' ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed' ❑ Yes ❑ No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes beverages. If yes, describe the nature and status of pending charges using the space below. Attach additional sheets as needed. i No 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 wholesaler? . . ❑ Yes If yes, provide the name of the restricted investor and describe the nature of the interest. i No 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? / ❑ ❑ Yes Yes Yes ❑ / / No No No Part C: Individual Information Check instructions i I I I each box to attest that you have provided the appropriate supplementary information to complete your application. See the for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name Hansen First Name Nicholas M.I. L Title Owner/Vice President Email nlhansen@hansensiga.com Phone (608) 790-4610 Signature -/t elet4 L iiMAY -1, Date 05/05/26 Part E: For Clerk Use Only Date Application Was Filed With Clerk LS - - AD License Number Date License Granted Date License Issued Sign e of CV)pputIClerk 11 LL) li. nvi ) Date Provisional License Issued (if applicable) AB-200 (R 2-26) - 2 - Form AB-200 Alcohol Beverage License Application For Municipal Use Only Municipality Cit of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) LI Initial (New) Z Renewal License(s) Requested: Ig Class "A" Beer tg "Class A" Liqyor "Class A" (up to two boxes may be checked) $ IOC 4° ❑ Class "B" Beer Fees License Fee(s) _LAA $ El Regular "Class B" Liquor Background Check Fee $ idiar $ "at) I- ILj Reserve "Class B" Liquor Publication Fee $ El "Class C" Liquor (wine only) $ El Above -Quota "Class B" Total Fees Liquor Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) a Jr ' 121L )._ 2. Business Trade Name or DBA 3. FEIN -3c1 - 1409 5. Entity Type (check one) ❑ Sole Proprietor 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? ❑ Yes El No If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. 4. Wisconsin Seller's Permit Number LIS6, - 10-3,?' 1 5 -310 q O Partnership 2Limited Liability Company ❑ Corporation O Nonprofit Organization 7. State of Organization 8. Date of Organization 9. Wisconsin DFI Registration Number 10. Premises Address 11. City 12. State vy 13. ZIE) Code 5 6 15 14. County S ON) 15. Governing Municipality: u City El Town 0 Village of: ► • !c _t.) 121 ; - 16. Aldermanic District 17. Premises Phone 18. Premises Email 19. Website Grp — I 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking th box following this statement, I affirm that I have reviewed the last issued 9 license certificate and the premises description remains the same. - 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 o If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? E Yes VNo Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed'? ❑ Yes ErNo AB-200 (R. 2-26) Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes -..1\lo 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 wholesaler? ❑ Yes No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion Yes E1/4\To 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes g' /I\lo 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes 1 14 .0 Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. ❑ I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. ❑ I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. ❑ (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. ❑ I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name , 5 j. iva)--1 First Name -RA A I-- (\-) D GR M.I. Title 0 VI.---' Email Sirlah P 2 OA iq CI S(d ) q) )0661 -(0' 4 Phone C I 1 j 9- %i 1 SA 1 Signature -- ilah-WirCie 5 )-61,- Date O 5 -' 0 H •- a0 9,.•6 Part E: For Clerk Use Only Date Application Was Filed With Clerk I 5 - - AB jl License Number Date License Granted Date License Issued Signat ' of Clerk/Deputy lerk Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - *-rodurci-f. L.41.)--ERmc Form AB -200 Alcohol Beverage License Application For Municipal Use Only Municipality Black River Falls City of License Period 7/1/2026 to 6/30/2027 Application Type (check one) ❑ Initial (New) Renewal License(s) Requested: (up to two boxes may be checked) 0 Class "A" Beer $ I 0 O ❑ Class "B" Beer $ Fees License Fee(s) $ 5-66- a "Class A" Liquor $ LW — ❑ Regular "Class B" Liquor $ Background Check Fee $ , ❑"Class A" Liquor (cider only) $ ❑ Reserve "Class B" Liquor $ Publication Fee $ )0 — ❑ "Class C" Liquor (wine only) $ ❑ Above -Quota "Class B" Total Fees $ 570 — Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Kwik Trip, Inc. 2. Business Trade Name or DBA Kwik Trip 240 3. FEIN 39-1036365 4. Wisconsin Seller's Permit Number 456-0000287614-03 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership ❑ Limited Liability Company • Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB . Yes ❑ No -100. -N/A- 7. State of Organization WI 8. Date of Organization 10/07/1964 9. Wisconsin DFI Registration Number 1K04801 10. Premises Address 15 County Hwy A 11. City Black River Falls 12. State WI 13. Zip Code 54615 14. County Jackson 15. Governing Municipality: City ❑ Town ❑ Village of: Black River Falls City o 16. Aldermanic District 17. Premises Phone 715-284-245 18. Premises Email LicensingDept@kwiktrip.com 19. Website www.KwikTrip.com 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checkin the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. IMI One story frame construction with storage in walk-in cooler, on sales floor and behind sales counter. 21. Mailing Address (if different from premises address) Kwik Trip - Legal Dept., P.O. Box 2107 22. City La Crosse 23. State Wi 24. Zip Code 54602-2107 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 **Please see enclosed listing of retail store violations** Location Trial Date Penalty Imposed Was sentence completed? Yes No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? Yes No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 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 wholesaler? . . 7 Yes No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion Yes H No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine9 Yes No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? Yes No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 READ CAREFULLY BEFORE SIGNING: Under penalty of law, I have answered each of the above questions completely and truthfully. I agree tha 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 tc any portion of a licensed premises during inspection will be deemed a refusal to allow inspection. Such refusal is a misdemeanor and grounds fo 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 furthe understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person whc knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name Zietlow First Name Scott M.I. P Title CEO & President Email LicensingDept@kwiktrip corn Phone (608) 791-7385 (608) 793-4741 Signature .5 4,0# P 7 -(2 "/C Date 02 / 27 / 2026 Part E: For Clerk Use Only Date Application Was Filed With Clerk 14 -- License Number Date License Granted Date License Issued Signat of CIneputy lerIit ) I - Date Provisional License Issued (if applicable) AB-200 (R 2-26) - 2 - Form AB-200 Alcohol Beverage License Application For Municipal Use Only Municipality Black River Falls City of License Period 7/1/2026 to 6/30/2027 Application Type (check one) ❑ Initial (New) • Renewal License(s) Requested: (up to two boxes may be $ )60— ❑ checked) Class "B" Beer Regular "Class B" Reserve "Class B" Above -Quota "Class Liquor $ Fees A Class "A" Beer License Fee(s) $ 5 - 06 — $ L/0O—❑ Liquor $ til "Class A" Liquor Background Check Fee $ — ❑"Class A" Liquor (cider ❑"Class C" Liquor (wine only) $ ❑ Liquor $ Publication Fee $ lc) — only) $ ❑ B" $ Total Fees $ 576 - Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Kwik Trip, Inc. 2. Business Trade Name or DBA Kwik Trip 648 3. FEIN 39-1036365 4. Wisconsin Seller's Permit Number 456-0000287614-03 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership ❑ Limited Liability Company Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form . Yes ❑ No AB-100. -N/A-7. State of Organization WI 8. Date of Organization 10/07/1964 9. Wisconsin DFI Registration Number 1K04801 10. Premises Address 751 State Highway 54 11. City Black River Falls 12. State W 13. Zip Code 54615 14. County Jackson 15. Governing Municipality: City ❑ Town ❑ Village of: Black River Falls City of 16. Aldermanic District 17. Premises Phone 715-284-9247 18. Premises Email Licensing Dept@kwiktrip.com 19. Website www.KwikTrip.com 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checkinalhe box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. ll One-story frame construction with storage in lockable walk-in cooler, on sales floor and behind sales counter. 21. Mailing Address (if different from premises address) Kwik Trip - Legal Dept., P.O. Box 2107 22. City La Crosse 23. State W 24. Zip Code 54602-2107 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 **Please see enclosed listing of retail store violations** Location Trial Date Penalty Imposed Was sentence completed? E Yes No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? Yes No AB-200 (R. 2-26) -1- Wisconsin Department of Revenue 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 wholesaler? . . Yes No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion Yes No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? n Yes No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? Li Yes No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 READ CAREFULLY BEFORE SIGNING: Under penalty of law, I have answered each of the above questions completely and truthfully. I agree tha 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 tc any portion of a licensed premises during inspection will be deemed a refusal to allow inspection. Such refusal is a misdemeanor and grounds fo 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 furthe, understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person whc knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name Zietlow First Name Scott M.I. P Title CEO & President Email LicensingDept@kwiktrip corn Phone (608) 791-7385 (608) 793-4741 Signature 5„# ? .7-r..e6‘,„ Date 02 / 27 / 2026 Part E: For Clerk Use Only Date Application Was Filed With Clerk License Number Date License Granted Date License Issued Sign e of Gleeputy Clerk L t.t ,,2 Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - For Municipal Use Only Form Alcohol Beverage License Municipality City of Black River Falls AB -200 Application License Period 07/01/2026 - 06/30/2027 Application Type (check one) ❑ Initial (New) 1 Renewal License(s) Requested: (up to two boxes may be checked) Fees Class "A" Beer $ Class "B" Beer $ IDCP' ❑ igf License Fee(s) $ (.) ..tr .) °61") ❑ "Class A" Liquor $ ❑ Regular "Class B" Liquor $ "Class Background Check Fee $ ❑ A" Liquor (cider only) $ ❑ Reserve "Class B" Liquor $ 4"Class C" Liquor (1)0 cl • Above "Class B" Publication Fee $ ID(wine only) $ -Quota Liquor $ Total Fees $ Part A: Premises/Business Information ,,-;21()6c 1. Legal Business Name (individual LOS -C \I S name if sole roprietorship) 2. Business Traele Name or DBA 3. FEIN -3 bq iv L 4. Wisconsin Seller's Permit 45(0 -1(larn -755,53 Number -o.') 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership Limited Liability Company ❑ Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form 0 Yes AB-100. • No 7. State of Organization, 8. Date of 1:4 Organization -0 - 01c 9. Wisconsin 1- C DFI Regis ration tuber & ._-,/_, 10. Pre is iei jress .---. I f < e61 :174-On Pa3 11. City /3 laLk K) V I'Q. r 1- O Hs kA) i 12 State 13. Zip Code '(i+5 14: County , ' ''•—A.VC-k -S e 11 15. Governing Muni ipality City Town )❑ Village of: 131 ac i vp tr k-ctis 16. Aldermanic District 17.Prgoizes Phong., _... ( ..0 0.7- 7 CE) — Premises Ema 18. xt:ys I riWyak-u,cov 19. Website 20. Premises Description Initial (New Applicants Only): Describe the building or buildings where records are kept. Describe all rooms within the building, including living occur only on the premises described in this application. Attach a map Renewal Applicants Only: I am renewing a license and by checking license certificate and the premises description remains the same. 1 DI In 1 ori 6-6-at _ cL, 0 alcohol beverages are produced, sold, quarters. Authorized alcohol beverage or diagram and additional sheets if necessary. the box following this statement, I affirm ❑ stored, or consumed, and related activities and storage of records may that I have reviewed the last issued 21. Mailing Address (if different from premises address) SC-Li /At_ 22. City 23. State 24. Zip Code Part B: Questions 1. Has the business (sole proprietorship, partnership, limited liability company, or corporation) been violating federal or state laws or local ordinances? Exclude traffic offenses unless related to alcohol If yes, list the details of violation below. Attach additional sheets if necessary. convicted of • beverages. ❑ Yes No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? Yes ❑ No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol E 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 wholesaler? If yes, provide the name of the restricted investor and describe the nature of the interest. ll Yes p(No 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? I M Yes No Yes o Yes o Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. 7t , I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. % I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. ' (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Nam•T_, D-V51 AC:I CC First Name Le fey M.I. .A Title MA) NI 1"---R Email 1 efC\IS eA.r:ila yoziLco, COY Phone teLX-7E30.-531/Signature \-1 Dat Part E: For erk Use Only / Date Application Was Filed With Clerk p-f-i/ 4c-/, 020.14a Li nse Number Date License Granted Date License Issued Signature of e eputy CI ( ' 4 .er.- (2.—A.,_.•,_ Date Provisional License Issued (if applicable) N A AB-200 (R. 2-26) - 2 - Save Print Form AB -200 Alcohol Beverage License Application For Municipal Use Only Municipality City of Black River Falls License Period 07/01/2026 — 06/30/2027 Application Type (check one) ❑ Initial (New) ii Renewal License(s) Requested: (up to two boxes may be checked) • Class "A" Beer $ /Class "B" Beer $ ILL.(4 Fees License Fee(s) $l.5t10 (11❑ "Class A" Liquor $ /Regular "Class B" Liquor $.21)ti te' . Background Check Fee $ • "Class A" Liquor $ • Rosoraio "Cloos B" Liquor- $ iwi 3 Publication Fee $ lb.(A (cider only) • "Class C" Liquor (wine only) $ ❑ UsXrdtg-I4Ys6aY Total Fees St510. tLiquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) RA"OMS X t/i 'Ai Z Le 2. Business Trade Name or DBA L. i Afr/e. 1/: ovAdvi ss 3. FEIN 39S 328 752e+ 4. Wisconsin Seller's Permit Number 4/T6- /03o /a92 71/ — 0 7-- 5. Entity Type (check one) ll Sole Proprietor M Partnership ZrLimited Liability Company ❑ Corporation . Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? III Yes WNo If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. 7. State of Organization ci.." J ...S eZTYLEs .1A) 8. Date of Organization a) ' D "2- • 00 Z- 0 9. Wisconsin DFI Registration Number /14/ 12. ST 0 10. Premises Address (13 WA IA/ S r it City ei,,,4 R, 'ven_ IC, //c 12. State w1 13. Zip Code ‘v geois--14. County Jis c....14,CcryN._ 15. Governing Municipality: City iill Town . Village of: 6 beack R, , ,, eel_ .p„,// c. 16. Aldermanic District 17. Premises Phone -7/6"--C.9-70 -01 27 18. Premises Email t ;41 1/e(ti'kuUtit .5A ,? P yAgoo, eAryv 19. Website 20.. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by the ing the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 EiOlo If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed'? . . . ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No AB-200 (R. 2-26) -1- Wisconsin Department of Revenue 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 wholesaler? . . ❑ Yes ,No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion Yes ❑ No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes ,I I/ No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. l have provided an accurate Form AB-100 for each person listed in Form AB-200AA. /(For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name ,'&14--- e44-4 First Na e M.I. Title ,62A.1Ai&g--, Email (i t 44- ,/.414e4). 61Pvt /61/,'Nruic 8 6) Phone 3°5-. 9'') ' 32-2`. Signature Date 47( 2 .9. 2-4' ..„. ..-- ( Part E: For my Date Application Was Filed With Clerk I+. -110 License Number Date License Granted Date License Issued Signa of Clerk/Deputi Clerk D L II I :l ... 1 LeiL Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - For Municipal Use Only Form AB-200 Alcohol Beverage License Application Municipality City of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) ❑ Initial (New) 2 Renewal License(s) Requested: (up to two boxes may be checked) ErClass "A" Beer Class "B" Beer $ 1 An 0 "Class A" Liquor $ 0 Regular "Class B" Liquor $ 0 "Class A" Liquor (cider only) $ 0 Reserve "Class B" Liquor $ '''Class C" Liquor (wine only) $ Ilf.1. 42 El Above -Quota "Class B" Liquor Fees License Fee(s) Background Check Fee 4$ Publication Fee $ kr° Total Fees <0 Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) R.Peta— SA_ - Trt -si c.-12. Business Trade Name or DBA P1R- 3. FEIN 3.7-3911 5335-5. Entity Type (check one) El Sole Proprietor El Partnership 4. Wisconsin Seller's Permit Number 2 97 3 2. -4) Co 2_, [gf Limited Liability Company [1] Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? ❑ Yes No If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. 7. State of Organization tivi s 10. Premises Address .2 V /Vet 1.04teer Sire,zf 11. City BicLA—k R(P -et/. PiSS 14. County ficy5(A/ 17. Premises Phone ' t 5 • Co 76 130,0 8. Date of Organization 0 2 /Zeig 9. Wisconsin DFI Registration Number 12. State 15. Governing Municipality: EK City Ll Town D Village of: 31el-K 18. Premises Email mait 13. Zip Code ,5Y6/ 16. Aldermanic District 19. Website 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. [si 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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. If yes, list the details of violation below. Attach additional sheets if necessary. El Yes [5ii No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? El Yes Ei No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? El Yes El No AB-200 (R 2-26) Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes lia 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 wholesaler? ❑ Yes gi No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ir ❑ ❑ Yes ❑ No Yes JD No Yes D. No Part C: Individual Information Check instructions la ❑ • fill each box to attest that you have provided the appropriate supplementary information to complete your application. See the for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200M. I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name .-7. IRO 3 I LC- - (--) First Name 5/41 41'R ,Cil M.I. &- Title C U-'-3 0 f 1r Email yy\ r_ p% 1r, iii--c--elYYk a; 1 Phone L,68 1-7Ye r —S--926 Signature r ke ,i Date 57// 2._ 62 e_p Part E: For CI -Use Oifty Date Application 6 - 1 - Was Filed With Clerk 6 License Number Date License Granted Date License Issued Signa of Clerk/Dep at taLaU y Clerk thL 1 Date Provisional License Issued (if applicable) AB-200 (R.2-26) - 2 - " Form AB -200 Alcohol Beverage Licenset ir Application — For Municipal Use Only Municipality City of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) ❑ Initial (New) 4 Renewal License(s) 0Class Requested: (up to two boxes may be checked) "A' Beer $ 186 '4 0 Class 'B" Beer $ Fees License Fee(s) SZCL U) g 'CI 18, ° ❑ "Class Background Check Fee $ Liquor $ Regular B' Liquor $ ❑ "Class A" Liquor (cider only) S ❑ Reserve "Class B" Liquor $ Publication Fee S Ib.' ❑ "Class C" Liquor (wine only) S ❑ Above -Quota 'Class B" Total Fees $6(). l0 Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Pilot Travel Centers LLC 2. Business Trade Name or DBA Flying J Travel Center #756 3. FEIN 34-1953155 4. Wisconsin Seller's Permit 456-0000318168-03 Number 5. Entity Type (check one) ❑ Sole Proprietor MI Partnership ,/ Limited Liability Company . Corporation I. Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form In Yes AB-100. 4 No 7. State of Organization DE 8. Date of Organization 04/19/2001 9. Wisconsin DFI Registration Number P038222 10. Premises Address 780 WI -54 11. City Black River Falls 12. State WI 13. Zip Code 54615 14. County Jackson 15. Governing Municipality: of: Black River Igi City Falls U Town ill Village 16. Aldermanic District N/A 17. Premises Phone (865) 588-7488 18. Premises Email licensing@pilottravelcenter 19. Website pilotcompany.com CI 20. Premises Description Initial (New Applicants Only): Describe the building or buildings records are kept. Describe all rooms within the building, including living occur only on the premises described in this application. Attach a map Renewal Applicants Only: I am renewing a license and by checking license certificate and the premises description remains the same. where alcohol beverages are produced, sold, stored, or consumed, and related quarters. Authorized alcohol beverage activities and storage of records or diagram and additional sheets if necessary. the box following this statement, I affirm that I have reviewed the last issued may 21. Mailing Address (if different from premises address) Attn: Licensing Dept. PO Box 10146 22. City Knoxville 23. State TN 24. Zip Code 37939 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 If yes, list the details of violation below. Attach additional sheets if necessary. i No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed" Yes ❑ No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes 71 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 wholesaler? . . Li Yes Ili No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine'? 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? 1 ❑ ❑ Yes Yes Yes ❑ i v/ No No No Part C: Individual Information Check instructions J i Igl Ig each box to attest that you have provided the appropriate supplementary information to complete your application. See the for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. I have provided an accurate Form AB-100 for each person listed in Form AB-200M. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name Rigamonti First Name Eva M.I. V Title EVP, Chief Legal Officer Email licensing@pilottravelcenters.co Phone (865) 588-7488 Signature rit..-A 11 1/ ----A it, 142,-,„ -i-f (Date i j ,.., OF (0 Part E: For Clerk Use ly Dat Application 1.4., Was Filed With Clerk License Number Date License Granted Date License Issued Sign e of Clerk/ eputy NI --1 Clerk 1 Date Provisional License Issued (if applicable) AB-200 (R 2-26) -9- For Municipal Use Only Form AB-200 Alcohol Beverage License Application Application Type (check one) Municipality Cit of Black River Falls License Period 07/01/2026 - 06/30/2027 O Initial (New) Renewal License(s) Requested: (up to two boxes may be checked) O Class "A" Beer Y1 Class "B" Beer E "Class A" Liquor sl(0 O Regular "Class B" Liquor $ O "Class A" Liquor (cider only) $ O Reserve "Class B" Liquor $ 10 "Class C" Liquor (wine only) $ ❑ Above -Quota "Class B" Liquor Fees License Fee(s) Background Check Fee Publication Fee Total Fees $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Northfield Restaurant Corp 2. Business Trade Name or DBA Pizza Hut 3. FEIN 48-0950344 5. Entity Type (check one) ❑ Sole Proprietor 4. Wisconsin Seller's Permit Number 456-0000083212-03 E Partnership E Limited Liability Company El Corporation E Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? E Yes LI No If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. 7. State of Organization WI 10. Premises Address 666 State Highway 54 11. City Black River Falls 14. County Jackson 17. Premises Phone (715) 284-4000 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. E One story free standing bldg with storage 8. Date of Organization 08/04/1983 9. Wisconsin DFI Registration Number N022006 12. State WI 15. Governing Municipality: E City ❑ Town Ill Village of: Black River Falls 18. Premises Email 13. Zip Code 54615-5448 16. Aldermanic District 19. Website www.dalandcorporation.co 21. Mailing Address (if different from premises address) 9313 E 34th St N, Suite 100 (eff 06/01 8200 E Thorn Dr, Suite 150 Wichita KS) 22. City Wichita 23. State KS 24. Zip Code 67226 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. E If yes, list the details of violation below. Attach additional sheets if necessary. Yes k No Law/Ordinance Violated Location Penalty Imposed Law/Ordinance Violated Trial Date Was sentence completed' Yes ❑ No Location Trial Date Penalty Imposed AB-200 (R. 2-26) - 1 - Was sentence completed'? ❑ Yes No WiscmsinDepartmeriloMevenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes xi 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 wholesaler? . . Yes ri No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion xi Yes No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? Yes AT No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes X . No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. X I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. X I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. ir (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. ix I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name Seiwert First Name Alan M.I. E Title Trea urer . Email alanseiwert@dalandcorp.com _} Phone 316.681.1081 Signature , Date r . I , r fP -i 12.b Part E: For Clerk Use Only Date Application Was Filed With Clerk 5- I - 710 License Number Date License Granted Date License Issued Signatu ofCIerk/Deputy W11._ Clerk ) Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - For Municipal Use Only Form Alcohol Beverage License , ,ilunicipality • City :-.-;f Black River Falls AB -200 Application License Period .:!7/01/2026 - 06/3012027 Application Type (check one) Fl Initial (New) lb11 Renewal License(s) Requested: (up to two boxes may be checked) MM ❑ Class "A" Beer $ l'E, Class "B" Beer $ Iti fl ° Fees License Fee(s) $ 2t8 u'O "Class A' Liquor $ ______ O Regular "Class B" Liquor $ _._-.___w_ ❑ "Class A" Liquor (cider only) $ O Reserve "Class B" Liquor $ Background Check Fee $ Publication Fee $ le. tlAA Lo A"Class C" Liquor (wine only) $1LU, O Above-Quota "Class B" Total Fees $ 2 ,10. Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Revolution Coffee LLC 2. Business Trade Name or DBA Revolution Coffee 3. FEIN 81-3926 I 4. Wisconsin Seller's Permit Number I 456-1029280501-02 5. Entity Type (check one) o Sole Proprietor Z Partnership II Limited Liability Company O Corporation O Nonprofit Organization 6. If the applicant business is an LLC, are the controlling If yes, the members, managers, officers and directors members other LLCs or corporations? O Yes O No of those business entities must be listed in Part C and provide a Form AB-100. 7. State of Organization Wi 8. Date of Organization 4/1/2017 9. Wisconsin DFI Registration Number iRitittat -10. Premises Address 38 Main Street 11. City Black River Falls 12. State WI 13. Zip Code 54754 14. County Jackson 115. I Governing Municipality: of: Black River be Falls City ❑ Town O Village 16. Aldermanic District 17. Premises Phone 1 1 8. l ,, 11s -L518-61A1 I r(licildionaf_fuly-f-d-cimai Premises Email i. can 19. Website 20. Premises Description Initial (New Applicants Only): Describe the building records are kept. Describe ail rooms within the building, occur only on the premises described in this application. Renewal Applicants Only: I am renewing a license license certificate and the premises description remains or buildings including living Attach a map and by checking the same. where V ' _..) alcohol beverages are produced, sold, stored, or consumed. and related quarters. Authorized alcohol beverage activities and storage of records may or diagram and additional sheets if necessary. the box following this statement. I affirm that I have reviewed the last issued 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code Part B: Questions 1. Has the business (sole proprietorship, partnership, violating federal or state laws or local ordinances? If yes, list the details of violation below. Attach additional limited liability company, or corporation) been convicted of Exclude traffic offenses unless related to alcohol beverages. D Yes g No sheets if necessary. Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? Li Yes I No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? 71 Yes ' No — AB-200 R. 2-20' ',,lisccnsin Department of ReAwue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol D Yes NoT 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 wholesaler? Yes I No If yes, provide the name of the restricted investor and describe the nature of the interest. _ . 4. Have the partners. agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? 6. Does the applicant business owe past due municipal property taxes, assessments. or other fees? is ❑ E Yes Yes Yes r- X LI No No No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. f•E' I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. E•' I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. rk (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than S1,000 if convicted. Last Name t imp I First Name i I Carrie L 1 M.I. A _ Title Owner .. Email carrietimp@rocketmail.c.om Phone 715-896-4729 Signet Date 4/29/2026 Part E: For Clerk Use Only Date Application Was Filed With Clerk 4- 7-9 - 714) License Number Date License Granted I Date License Issued Signatur Clerk/ pu 111t Cfeit. al Date Provisional License Issued (if applicable) AB-20018.2-25 i - 2 - Form AB -200 Alcohol Beverage License Application municipam City of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) - „ ❑ Initial (New) 6/ Renewal License(s) Requested: (up to two boxes may be checked) ❑ Class "A" Beer $ ;X:r. Class "B" Beer $ A ) D Fees License Fee(s) $ 1100, oa ❑ "Class A" Liquor $ p Regular "Class B" Liquor $ 3C0 Background Check Fee $ ❑ "Class A" Liquor (cider only) $ ❑ Reserve "Class B" Liquor $ Publication Fee $ /0.00 ❑ "Class C" Liquor (wine only) $ ❑ Above -Quota "Class B" Total Fees $ LI /0, CC Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Rozario's LLC 2. Business Trade Name or DBA Rozario's Pizza 3. FEIN 87-2731200 4. Wisconsin Seller's Permit Number 456-1030799584-04 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership v Limited Liability Company ❑ Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form ll Yes AB-100. i,, No 7. State of Organization WI 8. Date of Organization 09/2021 9. Wisconsin DFI Registration Number O eS) 0-7 0 3 7 / 10. Premises Address 42 N 1st ST 11. City Black River Falls 12. State WI 13. Zip Code 54615 14. County Jackson lal 15. Governing Municipality: of: BlackRiverFalls 4., City ❑ Town ❑ Village 16. Aldermanic District 17. Premises Phone 715-284-0006 18. Premises Email nickrespicio@gmail.com 19. Website 20. Premises Description Initial (New Applicants Only): Describe the building or buildings records are kept. Describe all rooms within the building, including living occur only on the premises described in this application. Attach a map Renewal Applicants Only: I am renewing a license and by checking license certificate and the premises description remains the same. where v alcohol beverages are produced, sold, stored, or consumed, and quarters. Authorized alcohol beverage activities and storage of records or diagram and additional sheets if necessary. the box following this statement, I affirm that I have reviewed the last related issued may 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 If yes, list the details of violation below. Attach additional sheets if necessary. V No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed'? ❑ Yes ❑ No 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol ❑ Yes beverages. If yes, describe the nature and status of pending charges using the space below. Attach additional sheets as needed. v No 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 wholesaler? . . ❑ Yes If yes, provide the name of the restricted investor and describe the nature of the interest. v No 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? r ❑ ❑ Yes Yes Yes ❑ v v No No No Part C: Individual Information Check instructions ./ v r IN each box to attest that you have provided the appropriate supplementary information to complete your application. See the for Part C of this application, beginning on page 2, to complete this section. I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than 51,000 if convicted. Last Name Respicio First Name Nicholas M.I. S Title Owner Email nickrespicio@gmail.com Phone 608-386-3383 Signature (-----)..-- . - ..1-• - --7- Date 2--,0 2 C _ ,. , Part E: For Clerk Use Only 2. --- ---- Date Application Was Filed With Clerk Lb ) 0,. /.. --, ij C) 4- 4.) License Number Date License Granted Date License Issued Signaty.'4of_Clery/Deputy Clerk ._., 4 ',..._4" - b --,. ' ( A-,-,,o._.... ---_. Date Provisional License Issued (if applicable) Form AB-200 Alcohol Beverage License Application For Municipal Use Only Municipality City of Black River Falls License Period 07/01/2026 - 06/30/2027 I Application Type (check one) ❑ Initial (New) ,/ Renewal License(s) Requested: (up to two boxes ay be checked) ❑ Class "A" Beer $ P 1X Class "B" Beer $ JAIL Fees License Fee(s) $148Cy ° ❑ al "Class A" Liquor $ I. 1% Regular "Class B" Liquor t ) AO Background Check Fee $ ❑ "Class A" Liquor (cider only) $ ❑ Reserve "Class B" Liquor $ Publication Fee $ I O.❑ "Class C" Liquor (wine only) $ ❑ Above-Quota "Class B" Total Fees $ 41(1 (6Liquor $ Part A: Premises/Business Information vidualimibig sole proprietorship) 1. Lsr. egal Business Name (indiNi v I 4-63 eba 2. Business Trade Name or DB01, . ,.s S7-Xfr6 ? 2112/4 p "Di 3. FEIN F6933q24 11•( 4. Wiscon in Seller's Permit Number V — /030 1 34d -4i -- 6t / 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership Limited Liability Company ❑ Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form II Yes P(No AB-100. 7. State o Organization a)/ 8. Date of Organization L i e-- /5 . '" '210 ?4 .s-/3 -3? -3(- 9. Wisconsin DFI Rggistration umber 10. Premises Address /23 /114/A/S....--" 7 11. c.ity, gaz z etvw‘ru 1Z State a)( 13. Z g p9le ,,..- &of A 14. County <7"ActeSoi 15. Governing Municipality: V iCity 1 Town Village of .34er-o-ieiv&z__- 16. Aldermanic District i 17. Premis Phone ( -Yr ) 18. Premises Email - i 4-1-eft ilirit ch 0 mem i. eask19. Website 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. ❑ 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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. E Yes A No If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? Yes 7 No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? Yes No AB-200 (R. 2-26) -1- Wisconsin Department of Revenue 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 wholesaler? . . Yes No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion A Yes ❑ No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? ❑ Yes ( No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? ❑ Yes PA No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instr ctions for Part C of this application, beginning on page 2, to complete this section. have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. ❑ I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. VrFor corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. el understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name in e 9,a—i Firs ame M.I. I . Title Emai APPI (dtb4 Mail0s4, Phone at z 5.Fi-isl I S Date Part E: For C erk Use Only Date Application Was Filed With Clerk License Number Date License Granted Date License Issued Signatur- Clerk/D puty Clerk Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - Form AB-200 Alcohol Beverage License Application For Municipal Use Only Municipality City of Black River Falls License Period 07/01/2026 - 06/30/2027 Application Type (check one) ❑ Initial (New) v Renewal License(s) Requested: (up to two boxes may ❑ Class "A" Beer $ be Ci checked) Class "B" Beer $ Fees License Fee(s) $ ❑ "Class A" Liquor $ g Regular "Class B" Liquor $ Background Check Fee $ ❑ "Class A" Liquor (cider only) $ ❑ Reserve "Class B" Liquor $ Publication Fee $ ❑ "Class C" Liquor (wine only) $ ❑ Above-Quota "Class B" Total Fees $ Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) \i%V.c c(tco &-e. MA:1/4A° MM. knc-2. Business Trade Name or DBA 3. FEIN Ca q -• 04°16 -121 4. Wisconsin Seller's Permit Number 456- (03 (5 viz cn - 0 ci 5. Entity Type (check one) ❑ Sole Proprietor ❑ Partnership ❑ Limited Liability Company X Corporation ❑ Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form III Yes ❑ No AB-100. 7. State of Organization CV ( 5 CooSi (1 8. Date of Organization 9. Wisconsin DFI Registration Number V 034 Oq 5 10. Premises Address tot main S+ 11. City (MACK Pt1Vcr Pott1S 12. State cukt 13. Zip Code r 4 (0 i 5 14. County tfA.C. -S OA 15. Governing Municipality: ❑ City ❑ Town ❑ Village of: 16. Aldermanic District 17. Premises Phone -- 1 ( 5 28 q SC° If 18. Premises Email i taCk‘ i0 .S\i‘Ac€ smaik• co rn 19. Website 20. Premises Description Initial (New Applicants Only): 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same. N 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 li No If yes, list the details of violation below. Attach additional sheets if necessary. Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? E Yes X No Law/Ordinance Violated .' Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes IV No AB-200 (R. 2-26) - 1 - Wisconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol beverages. If yes, describe the nature and status of pending charges using the space below. Attach additional sheets Yes X No 1 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 wholesaler? . . ❑ Yes IV No If yes, provide the name of the restricted investor and describe the nature of the interest. 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion Yes ❑ No 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine? E Yes K No 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? 1 Yes a No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. X I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. ❑ I have provided an accurate Form AB-100 for each person listed in Form AB-200AA. ❑ (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. ❑ I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name ..-, y o&N,co First Name . may (X M.I. ,...., ..D Title cti.1 ).k 6vie\—k Email . .1 Mari aS \I kincAcOrlait• corn Phone Lit (1 - ii vt- ow7 Signature t_... ...S.4 Date L A leg i 2.02- b Part E: For Clerk Use Only 'i ) Date lication Was Filed With Clerk PAan ti t;1O- 1- LP License Ntimber / Date License Granted Date License Issued Ferri natu -o D,epunle_rk , ._..... 10-A - \-) i , fr 1/4-491, -O-- -' - ---- - Date Provisional License Issued (if applicable) AB-200 (R. 2-26) - 2 - Form AB-200 Alcohol Beverage License Application For Municipal Use Only Municipality City cf. Black River Falls License Period 7/1/26 - /30/27 Application Type (check one) • Initial (New) al Renewal License(s) Requested: (up to two boxes may be checked) al Class "A" Beer S 100 • Class "B" Beer $ Fees License Fee(s) S 500 ES "Class A" Liquor S 400 II Regular "Class B" Liquor $ Background Check Fee S • "Class A" Liquor (cider only) S • Reserve "Class B" Liquor S Publication Fee S 10 O "Class C" Liquor (wine only) S • Above-Quota "Class B" Total Fees $ 510 Liquor $ Part A: Premises/Business Information 1. Legal Business Name (individual name if sole proprietorship) Wal-Mart Stores East, LP 2. Business Trade Name or OBA Walmart #1277 3. FEIN 71-0862119 4. Wisconsin Seller's Permit Number 456-1020028180-05 5. Entity Type (check one) • Sole Proprietor ISI Partnership • Limited Liability Company • Corporation • Nonprofit Organization 6. If the applicant business is an LLC, are the controlling members other LLCs or corporations? • Yes • No If yes, the members, managers, officers and directors of those business entities must be listed in Part C and provide a Form AB-100. 7. State of Organization DE 8. Date of Organization 11/09/2001 9. Wisconsin DFI Registration Number W042856 10. Premises Address 611 State Highway 54 11, City Black River Falls 12. State WI 13. Zip Code 54615 14. County Jackson 15. Governing Municipality: IN City • Town • Village of: Black River Falls 16. Aldermanic District 17. Premises Phone (715) 284-2434 18. Premises Email j0v00s3.s01277.us@wal-mart. www.walmart.com 19. Website 20. Premises Description Initial (New Applicants Only): Describe the bui ding 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. Renewal Applicants Only: I am renewing a license and by checking the box following this statement, I affirm that I have reviewed the last issued license certificate and the premises description remains the same.0 1 room, 1 story building approximately 164,242 sq. ft., including stalls and/or canopy locations in parking lot speficically designated for online grocery pickup. 21. Mailing Address (if different from premises address) 22. City 23. State 24. Zip Code 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 If yes, list the details of violation below. Attach additional sheets if necessary. V No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? ❑ Yes ❑ No Law/Ordinance Violated Location Trial Date Penalty Imposed Was sentence completed? III Yes ❑ No AB-200 (R. 2-26) -1- Waconsin Department of Revenue 2. Are charges for any offenses pending against the business? Exclude traffic offenses unless related to alcohol beverages. If yes, describe the nature and status of pending charges using the space below. Attach additional sheets as needed. . Yes v No 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 wholesaler? ❑ Yes If yes, provide the name of the restricted investor and describe the nature of the interest. r No 4. Have the partners, agent, or sole proprietor satisfied the responsible beverage server training requirement for this license period? Submit proof of completion 5. Is the applicant business indebted to any wholesaler beyond 15 days for beer or 30 days for liquor/wine9 6. Does the applicant business owe past due municipal property taxes, assessments, or other fees? r ❑ ❑ Yes Yes Yes ❑ v v No No No Part C: Individual Information Check each box to attest that you have provided the appropriate supplementary information to complete your application. See the instructions for Part C of this application, beginning on page 2, to complete this section. Es I have accurately listed and provided contact and personal information for all required persons involved in the applicant business and any business identified in Part A, Question 6 using Form AB-200AA. MI I have provided an accurate Form AB -100 for each person listed in Form AB-200AA. &I (For corporations, limited liability companies, and nonprofit organizations only) I have provided an accurate Form AB-101 to appoint an agent on behalf of my business. MI I understand that my application is not complete until this supplementary paperwork is received by the municipal clerk where I am applying for an alcohol beverage license. Part D: Attestation 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 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 knowingly provides materially false information on this application may be required to forfeit not more than 51,000 if convicted. Last Name Little First Name Sarah M.I. C Title Assistant Secretary Email complic@wal-mart.com Phone (479) 258-7241 Signature ---Pkt., Date 3 i V__( / 2_ o'2_, Part E: For Clerk Use Only Dale pplication Was Filed With Clerk _Q, a .1 z.cf zoaco License Num r Date License Granted Date License Issued Si.. e o Clerk/De Cle n Date Provisional License Issued (if applicable) AB-200 (R. 2.26) - 2 - Form AB-220 elf -% yk.r TIN Temporary Alcohol Beverage License Municipality License(s) Requested Fees ❑ Temporary "Class B" Wine - - -,p, Temporary Class "B" Beer License Fees $ lb's' Background Check $ Total Fees $ la, u5 Part A: Organization Information 1.Organization Name r(v \ A\- AA \ r)1..1L( 2. Organization Permanent Address ..-77 On v_Tfcie , "'-'v-(-----k---3. City `---77- ,--,,,--‘ , I) LN--- V \\1 )\(-TLQ. 4. State ULJ 1 5. Zip Code SLI Lo IS 6. Mailing Address (if different from permanent address) L -')»c - 1O7. FEIN - I CI3 L IC 6 - 0 8. Date of Organization/Incorporation )C1 )-- ) 9. State of Organization/Incorporation SD) (c) 3 10.71c Phone 11. Email ;\11(11111(cSV-- 7 CA LO ; Cji (nc( .. i I. CC47-1 12. Organization type (check one) Organization 181, Wis. Stets. Bona Fide Club • Church • Fair Association/Agricultural Society • Veteran's of Commerce or similar Civic or Trade Organization under ch. • Lodge/Society • Chamber 13. Is this organization required to hold a Wisconsin Seller's permit? No ' Yes • 14. Wisconsin Seller's Permit Number (if applicable) Part B: Individual Information List the name, title, and phone number for all officers, directors, and agent of the organization. Include an Individual Questionnaire (Form AB-100) for each person listed below. Attach additional sheets if necessary. Corporations must also include Alcohol Beverage Appointment of Agent (Form AB-101). Last Name First Name Title Phone CLAL 'KOMI WI , -Pas ic) hill - -16 E5iL, - )31 a nilhov5t It.5SICC, Toir\vrt(si or; Ckrti(lr; iNcloi .Tec ci3i-EZL- MiY)--7 it-I - 9Lr1 Y,0v\c,' ? niniC, Continued —} AB-220 (R. 1-25) - 1 - Wisconsin Department or Revenue Part C: Event Information 1. Name of Event if applicable) i t i \ CNC It_ . W i ,V k\Air\ -h 1-iLf 10 Li n4y-)•15.6i1C6A-Ce 3. Hours of Operation ft \Tvxy\- 2_oNNA 2. Dates of Operation U) 121 (7k 4. Premises Address .3?9) 06\ine ' 'UC-t:IC 5.,_9ty VA\113/ VQ&)_‘ 6. State NI 7. Zi Code , i---lulc-.) 8. County AC_)an 9. Governing Municipali jCity Town of: EV,, WI V ; ' • Village 10. Aldermanic District 11. Organizer of Event (if not the named applicant) ?a_i -aver you'th --Ficr.iteLi 12. Email and/or Phone Number for Organizer of Event 0 \rnhov-v• 2:0140 0..kfroa r, corn 13. Organizer Website 1010f lb( vit YLicAAhhuClai.i,CCVY\ 14. Event Website 15. Premises Description - Describe the building or buildings and any outside areas where alcohol beverages stored, or consumed, and related records are kept. Describe all rooms within the building, including living alcohol beverage activities and storage of records may occur only on the premises described in this application. or diagram and additional sheets if necessary. .7--)\--CY W\\ ' - ''06 '\`•"A\nt \\-AkAAPN avtna n avua el\NN..-b1 QA -MACAValell/ and records are sold, quarters. Authorized Attach a map 1.YY -ht Part D: Attestation Who must sign this application? • one officer or director of the nonprofit organization 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 organization 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 according to the law, including but not limited to, purchasing alcohol beverages from Wisconsin-permitted 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name 1 M h Olt First ame M\C_C. M.I. T.__ Title .„-- VC NW, NbV Email \ Phone '1 ) ) 1 c131-WZ_L-IL Ign tur/ . 70 \z_ j_ ate LF 1 2-1 I 71 b7 Lo I,P rt E: For Clerk Use Only Date Application Was Filed With Clerk 5 -71-7L License Number Date License Granted Date License Issued Si n e O6f Csle,.. ir—ut, Clt LIN( kik ) AB-220 (R.1.25) - 2 - Form AB-220 COPY Temporary Alcohol Beverage License Municipality City Black River Falls License(s) Requested Fees gr Temporary "Class B" Wine License Fees IS 'a.(0 4 Temporary Class "B" Beer Background Check $ — Total Fees S 10.O Part A: Organization Information 1. Organization Name Rotary Club of Black River Falls 2. Organization Permanent Address P.O. Box 734 3. City Black River Falls 4. State WI 5. Zip Code 54615 6. Mailing Address (if different from permanent address) 7. FEIN 39 6078186 8. Date of Organization/Incorporation 07/01/28 9. State of Organization/Incorporation Wisconsin 10. Phone 608 387 1902 11. Email lmarta03553@gmail.com 12. Organization type (check one) Organization 181, Wis. Stats. II Bona Fide Club 1 Church • Fair Association/Agricultural Society II Veteran's of Commerce or similar Civic or Trade Organization under ch. • Lodge/Society F Chamber 13. Is this organization required to hold a Wisconsin Seller's permit? No • Yes 19 14. Wisconsin Seller's Permit Number (if applicable) Part B: Individual Information List the name. title. and phone number for all officers. directors, and agent of the organization. Include an Individual Questionnaire (Form AB-100) for each person listed below. Attach additional sheets if necessary. Corporations must also include Alcohol Beverage Appointment of Agent (Form AB-101). Last Name First Name Title Phone Martalock Wensel Lynn President/Pres.Elect 608 387 1902 Steien Michele Treasurer 715-299-8025 Torkelson Marianne Secretary 715 896 3122 N C))SQ, 4--) 175.na Historian 715 299 7937 .1 con Eberhardt Bradley Membership 715 896 2000 Continued (R 1-25) -1. MsconsinDacarane,leRevenue 2Patt Event 1. Name of Event (If applicable) Festival in the Park 2. Dales of Operation 07/11/2026 3. Hours of Operation 4 pm 10 pm 4. Premises Address 1400 Tyler Street 5. City Black River Falls 6. State WI 7. Zip Code 54615 8. County Jackson 9. Governing Municipality [ZI City El Town O Village of: Black River Falls 10. Aldermanic District 11. Organizer of Event (if not the named applicant) City of BRF/Lunda Park 13. Organizer Website https://blackriverfallswi.gov 12. Email and/or Phone Number for Organizer of Event 715 284 9246 14. Event Website na 15. Premises Description - Describe the building or buildings and any outside areas where alcohol beverages and records are 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. Rotary will help serve Beer for the Festival from Sand Creek Brewery beer wagon at The Lunda Community Park . Consumption to take place in the Upper Shelter and Great Lawn area of Lunda Park. PaitD,Patestation i Who must sign this application? • one officer or director of the nonprofit organization 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 organization 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 according to the law, including but not limited to, purchasing alcohol beverages from Wisconsin-permitted 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 knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted. Last Name Martalock-Wensel First Name Lynn M.I. C Title President Email lmarta03553@gmail.com Phone 608-387-1902 Sign lure f** 41rr''' -) 'Thil--+--O1O CR - IALuryact_ Date 05/26/2026 :i.1140A::.FArg-IOk40014.a. . , _ Date Application VVas Filed With Clerk , 5- 71,9 - 710 License Number Date License Granted Date License Issued Signal of Cler ty Cleftk OJ-1111 __.)Ka, blvi --) Ae-no(R.1-25) - 2 - LICENSE FOR REAL PROPERTY On this day, 27th day of April 2026, the Black River Area Chamber of Commerce and the City of Black River Falls, Jackson County, Wisconsin, hereafter called the Licensor, with authority over the real property located at 120 N Water St, Black River Falls, WI 54615, does hereby grant a license to the UNITED STATES OF AMERICA, hereinafter called the Licensee, under the authority of Title 10, United States Code, Section 2661, real property to conduct field exercises and training, pursuant to the terms and conditions stated herein. 1. REVOCABLE LICENSE. The Licensor grants to the Licensee the right to access and use the lands and premises, described in paragraph 3, within the period of 12 September 2026 through to 23 September 2026, in order to conduct pre-coordinated military training. 2. COMPENSATION. The Licensor provides this license to the Government at no cost. 3. PROPERTY DESCRIPTION. The lands or premises affected by the License are located in the State of Wisconsin, City of Black River Falls, and are specifically described as: Black River Area Chamber of Commerce. 4. SCOPE OF ACTIVITIES. The land or premises affected will be used, generally, for occupancy of associated training event opposition force (OPFOR) and limited military participant activity. The specific uses or activities that will be conducted pursuant to this License agreement are outlined in the attached Walkthrough Worksheet. 5. WALKTHROUGH. Prior to Licensee's use of the premises under this License, representatives of the Licensee and Licensor will conduct a walkthrough of the premises to observe the general condition of the property and to discuss any necessary preparations, the scope of training activities to be conducted, and expected repairs. Should the Licensor elect to not participate in the walkthrough, the Licensee will still execute a walkthrough and will send a copy of the Walkthrough Worksheet to the Licensor. Subsequent to the training event. Representatives of the Licensee and Licensor will conduct a second walkthrough to discuss cleanup and repair issues, if any, documented on a Closeout Worksheet. 6. LIABILITY. Absent very rare circumstances, the Federal government is prevented, by law, from being subject to state or other municipal jurisdictions. The Licensee is responsible, under the terms of the Federal Tort Claims Act (FTCA), 28 U.S.C. 1346(b), 2671-2680, or the Military Claims Act (MCA), 10 U.S.C. § 2733, as applicable, to Licensor and any third parties for any injury to persons or damage to property proximately caused by the acts or omissions of Licensee employees acting within the scope of their employment. a. Licensor or injured third parties may use the FTCA or MCA to recover losses caused as a result of the training exercise that are not repaired or compensated adequately by the Licensee using other means. In no case will the Lessee's liability exceed that allowable unde applicable law, including the FTCA and MCA. b. Liability to the Licensee. Licensor is not liable to Licensee, or to third parties, for damage or destruction to Licensee property or equipment, or injury or death to Licensee personnel, unless negligence on the part of the Licensor causes said damage. Licensor makes no representation that the property is suitable for the contemplated training. Licensee representatives will inspect and evaluate the suitability and safety of the property for the proposed training. The Licensee acknowledges that these premises may contain hazardous conditions. 7. CONTRACT DAMAGES TO PROPERTY. Licensee agrees to return the property to the Licensor in substantially the same condition it was prior to the training event, unless otherwise agreed upon. The Licensee reserves the right to make repairs to the property that would return it to such condition. The right to make repairs should not be construed as a modification of the rights and obligations under the FTCA or MCA. Licensor agrees to proactively find and communicate any damages to Licensee; Licensee agrees to repair damage in a timely manner. Both parties agree to work in good faith to directly resolve issues before turning to the claims process. 8. SECURITY. Licensor consents to the Licensee's placement of guards at various points, if deemed necessary, to ensure the safety of, prevent unauthorized observation by, and avoid interference by third parties during the training. 9. LICENSOR'S REPRESENTATION. Licensor makes no representation as to whether the premises are occupied or vacant. It is the Licensee's responsibility to maintain control of training activity during times of property occupation to ensure safety of training participants and potential property occupants. 10. NOTICE. a. Any notice under this License shall be in writing signed by a duly authorized representative of the party giving such notice. b. If given by the Licensee, such notice shall be addressed to the Licensor at the address above or by email of a scanned document to chamber@blackrivercountry.net and brad.chown@blackriverfallswi.gov or by hand delivery. Notice is effective the day after delivery to the Licensor. c. If given by the Licensor, such notice shall be addressed to the Licensee at Joint Aerospace Operations Center (JAOC), Mr. Donald Newton, 2744 Malvesti St, Fort Bragg, North Carolina 28307 or by email of a scanned document to newton@socom.mil, or by hand. Delivery notice is effective the day after the date of mailing, hand delivery to the Licensor. 11. AGAINST CONTINGENT FEES. The Licensor warrants that no person or selling agency has been employed or retained to solicit or secure this License upon an agreement or understanding for a commission, percentage, brokerage, or a contingent fee, excepting bona fide employees or bona fide established commercial or selling agencies maintained by the Licensor for the purpose of securing business. Upon discovery of breach or violation of this warranty, the Licensee shall have the right to, at the Licensee's discretion, terminate this License entirely. 12. GRATUITIES. a. The Licensee may, by written notice to the Licensor, terminate the right of the Licensor to proceed under this License if it is found, after notice and hearing by the Secretary of the Army or the Secretary of the Army's duly authorized representative, that gratuities (in any form) were offered or given by the Licensor, or any agent or representative of the Licensor, to any officer, or employee of the Licensee with a view toward securing a license or securing favorable treatment with respect to the awarding or amending the license. b. In the event this License is terminated as provided above, the Licensee shall be entitled: (i) to pursue the same remedies against the Licensor as it could pursue in the event of a breach of this License by the Licensor, and (ii) as a penalty in addition to any other damages to which it may be entitled by law, to exemplary damages in an amount (as determined by the Secretary of the Army or Secretary of the Army's duly authorized representative) which shall be not less than three nor more than ten times the costs incurred by the Licensor in providing any such gratuities to an officer or employee. c. The rights and remedies of the Licensee provided in this paragraph shall not be exclusive and are in addition to any other rights and remedies provided by law or under this License. 13. MODIFICATION. No change or modification of this License shall be effective unless it is in writing and signed by both parties to this License. 14. DISPUTES CLAUSE. a. If applicable (for instance, if there is a dispute over performance or activity outlined in the License) all disputes arising under or relating to this License shall be resolved under the provisions of the Contract Disputes Act of 1978, as amended (41 U.S.C. §§ 601-613). b. The parties shall proceed diligently with their performance of this License, pending final resolution of any request for relief, claim, appeal, or action arising under the License. 15. ENTIRE AGREEMENT. a. This License contains all terms and conditions agreed to by the parties and no other verbal statement or conditions will be honored without an amendment to this License in writing as provided above. The failure of either party to insist on strict performance of any covenant or condiction hereof or to exercise any option herein contained shall not be construed as a waiver of such covenant, condition, or option in any other instance. b. This License cannot be changed or terminated orally. The provisions of this License shall apply to, bind and inure to the benefit of Licensor and Licensee, and their respective heirs, successors, legal representatives and assigns of the parties hereto. c. Nothing in this license agreement shall constitute, or be deemed to constitute an obligation of future apporopriations by the Licensee, for the costs herein set forth. d. If any provision of this agreement is held to be invalid or illegal for any reason, that defect shall not affect the remaining provisions but instead shall be fully severable and this agreement shall be interpreted as if the invalid provision had never been included. IN WITNESS WHEREOF, the parties have subscribed their names as of the date first above written. By: Robert Crampes Black River Area Chamber of Commerce Executive Director Phone: (715) 284-4658 x203 Email: chamber@blackrivercountry.net Address for notice: 120 N Water Street Black River Falls, WI 54615 By: Brad Chown City Administrator, City of Black River Falls Phone: (715) 284-2315 Email: brad.chown@blackriverfallswi.gov Address for notice: 101 South 2' d Street Black River Falls, WI 54615 By: Donald Newton, GS-12 Joint Aerospace Operations Center Phone: (910) 951-8122 Email: newton cr socom.mil Address for notice: 2744 Malvest Street Fort Bragg, NC 28307