Form At-107 - Application For Sports Club Permit For Alcohol Beverage License
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4Excise Tax Section 6-107
DEPARTMENT USE ONLY
Wisconsin Department of Revenue
TAX ACCOUNT NUMBER
PO Box 8900
Madison, WI 53708-8900
APPLICATION FOR
(608) 261- 6435
DATE OF ISSUANCE
Fax (608) 261-7049
SPORTS CLUB PERMIT
FOR ALCOHOL BEVERAGE LICENSE
DATE
TELEPHONE NUMBER
BUSINESS TAX NUMBER
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
(
)
We hereby apply for a state country club permit to sell at retail
intoxicating liquor,
fermented malt beverages, on the premises
described below from the
day of
, 20
through the
day of
20
.
APPLICANT (Print)
CLUB NAME
DATE AND PLACE OF ORGANIZATION
ADDRESS
CITY
STATE
ZIP
OFFICERS, DIRECTORS, AND MEMBERS:
SS#
PRESIDENT/MEMBER
HOME ADDRESS
SS#
VICE PRESIDENT/MEMBER
HOME ADDRESS
SS#
SECRETARY/MEMBER
HOME ADDRESS
SS#
TREASURER/MEMBER
HOME ADDRESS
SS#
AGENT/MEMBER
HOME ADDRESS
LOCATION AND DESCRIPTION OF PREMISES:
(All parts of the premises occupied by the applicant and used in conjunction with the conduct of the business for
which application is made must be included in the description of the premises to be licensed; alcohol beverages may be sold and stored only on the premises described.)
COUNTY
TOWN
VILLAGE
CITY
OF
PHYSICAL DESCRIPTION OF BUILDINGS AND AREA IN WHICH ALCOHOL BEVERAGES WILL BE DISPENSED OR STORED
LEGAL DESCRIPTION (AS FILED WITH REGISTER OF DEEDS) OF ENTIRE PREMISES OWNED OR USED IN CONNECTION WITH CLUB OPERATIONS
DATE PREMISES DESCRIBED ABOVE WERE FIRST OCCUPIED BY APPLICANT
ARE PREMISES
IF LEASED, GIVE NAME AND ADDRESS OF OWNER
OWNED OR
LEASED
DOES THE CLUB UNDERSTAND THAT A FEDERAL OCCUPATIONAL TAX STAMP MUST BE
WHO OWNS BAR FIXTURES?
OBTAINED FOR THE SPECIFIED LICENSE PERIOD?
YES
NO
TOTAL CLUB MEMBERSHIP
ARE CLUB FACILITIES AVAILABLE TO NON-MEMBERS ON A DAILY OR WEEKLY FEE BASIS
EXCEPT AS SPECIFICALLY INVITED GUESTS OF DUES-PAYING MEMBERS OF THIS CLUB?
YES
NO
IF YES, EXPLAIN.
ANNUAL MEMBERSHIP FEE
TYPE OF SPORT CLUB IS ENGAGED IN
GOLF
TENNIS
YACHTING
CURLING
SKI JUMPING
ARE ALL ALCOHOL BEVERAGES SOLD ON THE PREMISES PURCHASED IN THE NAME OF
ARE ALL DAILY BAR RECEIPTS DEPOSITED TO THE ACCOUNT OF THE CLUB?
THE CLUB?
YES
NO
IF NO, EXPLAIN.
YES
NO
IF NO, EXPLAIN.
(CONTINUED ON REVERSE SIDE)
AT-107 (R. 7-12)
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