Fillable 4075 March 2019 AT-106 Original Alcohol Beverage Retail License Application (fillable)

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4075 March 2019 AT-106 Original Alcohol Beverage Retail License Application (fillable)

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Original Alcohol Beverage Retail License Application
(Submit to municipal clerk.)
Wisconsin Department of RevenueAT-106 (R. 3-19)
Applicant’s Wisconsin Seller’s Permit Number
FEIN Number
Publication fee $
TYPE OF LICENSE
REQUESTED
FEE
Class A beer $
TOTAL FEE $
Class B beer $
Class C wine $
Class A liquor $
Class A liquor (cider only) $
Class B liquor $
Reserve Class B liquor $
Class B (wine only) winery $
N/A
For the license period beginning:
ending:
}
Town of
To the Governing Body of the: Village of
City of
County of
Aldermanic Dist. No
.
(if required by ordinance)
(mm dd yyyy) (mm dd yyyy)
Check one: Individual Limited Liability Company
Partnership Corporation/NonprotOrganization
President / Member Last Name
Vice President / Member Last Name
Secretary / Member Last Name
Treasurer / Member Last Name
Agent Last Name
(First)
(First)
(First)
(First)
(First)
Directors / Managers Last Name (First)
1. Trade Name Business Phone Number
2. AddressofPremises PostOce&ZipCode
3. 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, consumption, and/or
storage of alcohol beverages and records. (Alcohol beverages may be sold and stored only on the premises
described.)
4. Legal description (omit if street address is given above):
5. (a) Was this premises licensed for the sale of liquor or beer during the past license year? .................. Yes No
(b) If yes, under what name was license issued?
Name(individual/partnersgivelastname,rst,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 ocer, director and agent of a corporation or nonprot organization, and by
each member/manager and agent of a limited liability company. List the full name and place of residence of each person.
(Middle Name)
(Middle Name)
(Middle Name)
(Middle Name)
(Middle Name)
HomeAddress(Street,CityorPostOce,&ZipCode)
(Middle Name)
HomeAddress(Street,CityorPostOce,&ZipCode)
HomeAddress(Street,CityorPostOce,&ZipCode)
HomeAddress(Street,CityorPostOce,&ZipCode)
HomeAddress(Street,CityorPostOce,&ZipCode)
HomeAddress(Street,CityorPostOce,&ZipCode)
FYI - click mouse in 'For the license period beginning' field
to begin and tab throughout. Use mouse to check
appropriate boxes, spacebar or enter.
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Clear
AT-106 (R. 3-19)
6. Is individual, partners or agent of corporation/limited liability company subject to completion of the responsible
beverage server training course for this license period? If yes, explain ................................ Yes No
7. Is the applicant an employe or agent of, or acting on behalf of anyone except the named applicant? .......... Yes No
If yes, explain.
8. Does any other alcohol beverage retail licensee or wholesale permittee have any interest in or control of this
business? If yes, explain .................................................................. Yes No
9. (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? If yes, explain .............................................................. Yes No
(c) Doesthecorporation,oranyocer,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 No
If yes, explain.
10. Does the applicant understand they must register as a Retail Beverage Alcohol Dealer with the federal
government,AlcoholandTobaccoTaxandTradeBureau(TTB)byling(TTBform5630.5d)beforebeginning
business? [phone 1-877-882-3277] ............................................................ Yes No
11. Does the applicant understand they must hold a Wisconsin Seller’s Permit? [phone (608) 266-2776] ......... Yes No
12. Does the applicant understand that they must purchase alcohol beverages only from Wisconsin wholesalers,
breweries and brewpubs? .................................................................... Yes No
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 knowledge of the signer. Any person who knowingly provides materially false information on this application may be required to forfeit not more
than $1,000. Signer agrees 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, or one member of a partnership applicant must sign; one corporate ofcer, one member/manager 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.
TO BE COMPLETED BY CLERK
Datereceivedandledwithmunicipalclerk
Date license granted
Date reported to council / board Date provisional license issued
Date license issued License number issued
Signature of Clerk / Deputy Clerk
Title/Member
Signature
Contact Person’s Name (Last, First, M.I.)
Phone Number Email Address
Date
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4075 March 2019 AT-106 Original Alcohol Beverage Retail License Application (fillable)

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Completed 12 July 2020

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