Form At-212 - Application For Vessel Permit - Wisconsin Department Of Revenue

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Wisconsin Department of Revenue
DEPARTMENT USE ONLY
Excise Tax Section 6-107
TAX ACCOUNT NUMBER
PO Box 8900
Madison, WI 53708-8900
(608) 261- 6435
APPLICATION FOR
DATE OF ISSUANCE
Fax (608) 261-7049
VESSEL PERMIT
DATE
TELEPHONE NUMBER
BUSINESS TAX NUMBER
FEDERAL EMPLOYER IDENTIFICATION
SOCIAL SECURITY NUMBER
NUMBER (FEIN)
(
)
OR
Under the provisions of Sections 125.27(2) and 125.51(5)(c), application is being made for
Class “B” fermented malt beverage
“Class B” intoxicating liquor to sell alcohol beverages at retail on the following described vessel:
OWNED AND OPERATED BY
NAME OF VESSEL
A.
REGULAR PLACE OF MOORING
PASSENGER CAPACITY
U.S. COAST GUARD CERTIFICATION NUMBER/AMERICAN BUREAU OF SHIPPING CLASS
OR VERIFICATION OF LIABILITY INSURANCE
FROM THE
DAY OF
20
THROUGH THE
DAY OF
20
B.
APPLICANT:
INDIVIDUAL
PARTNERSHIP
CORPORATION
INDIVIDUAL OR PARTNERSHIP: (IF A PARTNERSHIP, ALL PARTNERS MUST BE LISTED)
NAME
HOME ADDRESS
NAME
HOME ADDRESS
NAME
HOME ADDRESS
NAME OF CORPORATION
STATE AND DATE OF INCORPORATION
IS APPLICANT CORPORATION A SUBSIDIARY OF ANY OTHER CORPORATION?
YES
NO
IF YES, INDICATE CORPORATE NAME:
OFFICERS AND DIRECTORS – AN AGENT MUST BE APPOINTED.
PRESIDENT
HOME ADDRESS
VICE PRESIDENT
HOME ADDRESS
SECRETARY
HOME ADDRESS
TREASURER
HOME ADDRESS
AGENT
HOME ADDRESS
MAILING ADDRESS
STATE
ZIP
C.
DESCRIBE AREA WHERE BEER AND/OR LIQUOR WILL BE SERVED AND STORED.
NAME OWNER OF BAR FIXTURES AND STATE TERMS OF LEASE OR RENTAL.
DOES THE APPLICANT UNDERSTAND A FEDERAL OCCUPATIONAL TAX STAMP MUST BE OBTAINED FOR THE SPECIFIED PERIOD?
YES
NO
DOES THE APPLICANT UNDERSTAND THAT FERMENTED MALT BEVERAGES AND INTOXICATING LIQUORS MAY BE SOLD ONLY IF
THE VESSEL LEAVES ITS PLACE OF MOORING?
YES
NO
IS THE APPLICANT AN EMPLOYE OR AGENT OF, OR ACTING ON BEHALF OF ANYONE EXCEPT THE NAMED APPLICANT?
YES
NO
EXPLAIN YES ANSWER IN DETAIL.
(CONTINUED ON REVERSE SIDE)
AT-212 (R. 11-11)

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