Form At-106 - Original Alcohol Beverage Retail License Application printable pdf download

ORIGINAL ALCOHOL BEVERAGE RETAIL LICENSE APPLICATION

Applicant’s Wisconsin

Seller’s Permit Number:

Federal Employer Identification

Submit to municipal clerk.

Number (FEIN):

For the license period beginning

;

LICENSE REQUESTED

ending

TYPE

FEE

}

Class A beer

Town of

Class B beer

TO THE GOVERNING BODY of the:

Village of

Class C wine

City of

Class A liquor

Class B liquor

County of

Aldermanic Dist. No.

(if required by ordinance)

Reserve Class B liquor

1. The named

INDIVIDUAL

PARTNERSHIP

LIMITED LIABILITY COMPANY

Publication fee

CORPORATION/NONPROFIT ORGANIZATION

TOTAL FEE

hereby makes application for the alcohol beverage license(s) checked above.

2. Name (individual/partners give last name, first, middle; corporations/limited liability companies give registered name):

An “Auxiliary Questionnaire,” Form AT-103, must be completed and attached to this application by each individual applicant, by each member of a

partnership, and by each officer, director and agent of a corporation or nonprofit organization, and by each member/manager and agent of a limited

liability company. List the name, title, and place of residence of each person.

Title

Name

Home Address

Post Office & Zip Code

President/Member

Vice President/Member

Secretary/Member

Treasurer/Member

Agent

Directors/Managers

3. Trade Name

Business Phone Number

4. Address of Premises

Post Office & Zip Code

5. Is individual, partners or agent of corporation/limited liability company subject to completion of the responsible beverage server

training course for this license period? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

6. Is the applicant an employe or agent of, or acting on behalf of anyone except the named applicant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

7. Does any other alcohol beverage retail licensee or wholesale permittee have any interest in or control of this business?. . . . . . . . . . . . . . .

Yes

8. (a) Corporate/limited liability company applicants only: Insert state

and date

of registration.

(b) Is applicant corporation/limited liability company a subsidiary of any other corporation or limited liability company? . . . . . . . . . . . . . . . .

Yes

(c) Does the corporation, or any officer, director, stockholder or agent or limited liability company, or any member/manager or

agent hold any interest in any other alcohol beverage license or permit in Wisconsin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

(NOTE: All applicants explain fully on reverse side of this form every YES answer in sections 5, 6, 7 and 8 above.)

9. Premises description: Describe building or buildings where alcohol beverages are to be sold and stored. The applicant must include

all rooms including living quarters, if used, for the sales, service, and/or storage of alcohol beverages and records. (Alcohol beverages

may be sold and stored only on the premises described.)

1 0. Legal description (omit if street address is given above):

11. (a) Was this premises licensed for the sale of liquor or beer during the past license year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

(b) If yes, under what name was license issued?

1 2. Does the applicant understand they must file a Special Occupational Tax return (TTB form 5630.5)

before beginning business? [phone 1-800-937-8864] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

13. Does the applicant understand a Wisconsin Seller’s Permit must be applied for and issued in the same name as that shown in

Section 2, above? [phone (608) 266-2776] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

14. Does the applicant understand that they must purchase alcohol beverages only from Wisconsin wholesalers, breweries and brewpubs? . .

Yes

READ CAREFULLY BEFORE SIGNING: Under penalty provided by law, the applicant states that each of the above questions has been truthfully answered to the best of the knowl-

edge of the signers. Signers agree to operate this business according to law and that the rights and responsibilities conferred by the license(s), if granted, will not be assigned to

another. (Individual applicants and each member of a partnership applicant must sign; corporate officer(s), members/managers of Limited Liability Companies must sign.) Any lack of

access to any portion of a licensed premises during inspection will be deemed a refusal to permit inspection. Such refusal is a misdemeanor and grounds for revocation of this license.

SUBSCRIBED AND SWORN TO BEFORE ME

this

day of

, 20

(Officer of Corporation/Member/Manager of Limited Liability Company/Partner/Individual)

(Clerk/Notary Public)

(Officer of Corporation/Member/Manager of Limited Liability Company/Partner)

My commission expires

(Additional Partner(s)/Member/Manager of Limited Liability Company if Any)

TO BE COMPLETED BY CLERK

Date received and filed

Date reported to council/board