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2. 
3. City of Middleton Mobile Food Establishment Application

   Pursuant to Middleton General Ordinances 7.01

5. Mobile Food Establishment Application
   Chapter 7 City of Middleton Code of Ordinances
7. License Type*

   1. Annual (1 operator)

   1. Single Event (1 operator)
8. Have you held a previous license in Middleton?*

   1. Yes
   2. No
10. Previous License Number (if applicable)
11. Effective dates
13. List (3) cities in which business was conducted preceding this application*
15. Have you ever had a permit suspended, revoked, or denied in any municipality?*

    1. Yes

    1. No
17. If yes, please list municipality and date
21. Applicant Information
23. First Name*
24. Last Name*
26. Former Name or Aliases
27. Upload Driver's License/State ID*
29. Address1*
31. City*
32. State*
33. Zip*
35. Phone Number*
36. E-mail address*
38. Are you a Wisconsin Resident?*

    1. Yes
    2. No
39. If no, what state are you a permanent resident of and for how long?
43. Arrests and Convictions

    List all offenses for which you have been charged or convicted. This list is to include all felony, misdemeanor, forfeiture, and ordinance violations, including traffic citations. The omission of offenses will result in the denial of your permit. 

    Renewals: Since the filing of your last application, have you been convicted of any offenses for violation of any federal, or state laws, or any ordinances of any county or municipality? 

45. If none, initial here
46. Upload additional page (if necessary)
48. If yes, complete below
50. Year
51. City/State
52. Nature of Offense
54. Year
55. City/State
56. Nature of Offense
58. Year
59. City/State
60. Nature of Offense
64. Business Information
66. Business Name*
67. Phone Number*
69. Address1*
71. City*
72. State*
73. Zip*
75. Description of goods/food to be sold/prepared*
79. Vehicle Information
81. How many vehicles will be operated?*
83. Make*
84. Model*
85. Year*
86. License Plate #*
88. Make
89. Model
90. Year
91. License Plate #
93. Make
94. Model
95. Year
96. License Plate #
100. Sales Locations
102. Is this application associated with a special event permit?*

     1. Yes

     1. No
103. If yes, please list the event contact person and phone number
105. Will sales be mobile?*

     1. Yes

     1. No
106. Will sales be stationary?*

     1. Yes

     1. No
108. Locations/routes where business will be conducted*
109. Length of time*
113. Please attach the following to your application
115. Valid Food & Beverage License Issued by the State of WI or Dane County Public Health*
117. Photograph (approx 2x2) showing head and shoulders of application*

     Not more than one year old

119. Payment Method*

     1. Online
     2. Mailing Check

     Once you hit submit, you will be directed to the credit card processing page.  You may also mail a check to our office at 7426 Hubbard Avenue, Middleton, WI  53562.

123. I have read and agree with the ordinances of the City of Middleton pertaining to the licensing and regulating of mobile food establishments in the City of Middleton. I agree to abide by these and all other ordinances in the City and the laws of the State of Wisconsin. I affirm that I have made complete and true answers to each question and understand that incomplete or false answers may result in denial or revocation of permit. I authorize a review of and full disclosure of any and all records, files, and reports, which include any police contact as well as arrests. I understand that if this license is not issued, fees that have been paid will not be refunded.
125. I attest that the above information is true and correct and that any false or incomplete information may result in denial of my application.
127. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
128. Initial here*
130. Please type name as shown on application above*
131. Date*
     Date
Leave This Blank:


133. 1. Receive an email copy of this form.
134. Email address

     This field is not part of the form submission.

135. Submit

* indicates a required field