Fillable APPLICATION FOR ANNUAL CABARET LICENSE CITY OF PORT (City of Port Washington)

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APPLICATION FOR ANNUAL CABARET LICENSE CITY OF PORT (City of Port Washington)

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APPLICATION FOR ANNUAL CABARET LICENSE
CITY OF PORT WASHINGTON, WISCONSIN
$100.00
Definition: “Cabaret” is a restaurant, tavern, bar or any similar business, other than an adult cabaret as defined in
sec. 9.22.020(c), Municipal Code of the City of Port Washington (“Code”), having all the following characteristics:
a. Serves alcoholic or non-alcoholic beverages;
b. Provides musical or other entertainment or performance (such as singers or dancers), whether live or
recorded;
c. Provides space for dancing of patrons.
1. Proposed cabaret premises:
Trade name/doing business as: _____________________________________________________
Location: _______________________________________________________________________
Mailing address: _________________________________________________________________
Telephone number: ______________________________________________________________
2. Owner(s) of proposed licensed premises:
Full name(s): ____________________________________________________________________
Address: ________________________________________________________________________
Telephone number: _______________________________________________________________
3. For an individual applicant, each partner of a partnership or limited liability partnership, each member of a
limited liability company, each party to a joint venture, and each agent of a corporation or other entity,
state [attach additional sheets if necessary]:
a. Full name: ___________________________________________________________________
Address: _____________________________________________________________________
Telephone number: ____________________________________________________________
b. Last two addresses and dates of residence for the 3-year period immediately preceding the date of
this application:
Address: _____________________________________________________________________
Dates of residence From: _______________________ To: _______________________
Address: _____________________________________________________________________
Dates of residence From: _______________________ To: _______________________
c. Date of birth: _______________________________________ Height: ___________________
Weight: ___________________ Hair Color: ______________ Eye Color: _________________
d. Business or occupation for the 3-year period immediately preceding the date of this application:
Name of business: _____________________________________________________________
Occupation: __________________________________________________________________
Location of business/occupation: _________________________________________________
e. State whether applicant has, within the 3-year period immediately preceding the date of this
application, been licensed to operate or conduct a cabaret in the City of Port Washington or
elsewhere: Yes __________ No __________
If yes, state:
Location of cabaret: ____________________________________________________________
Dates of operation From: ________________________ To: _______________________
f. State whether a cabaret or similar license issued to the applicant has ever been nonrenewed,
suspended or revoked: Yes __________ No __________
If yes, state:
Location of cabaret: ____________________________________________________________
Dates of nonrenewal, suspension or revocation: _____________________________________
Explain reasons for nonrenewal, suspension or revocation: ____________________________
____________________________________________________________________________
g. State whether the applicant has been convicted of violating any law or ordinance regulating the
operator or conduct of a cabaret: : Yes __________ No __________
If yes, state:
Location of cabaret: ____________________________________________________________
Dates of conviction: ____________________________________________________________
Explain circumstances of offense(s): _______________________________________________
____________________________________________________________________________
4. If the applicant is a corporation, then for each officer, director and shareholder of such corporation state:
Full name: ______________________________________________________________________
Address: ________________________________________________________________________
Extent of ownership: ______________________________________________________________
Does such person hold office or stock in any other corporation operating or conducting a similar business
in Wisconsin? Yes __________ No __________
If yes, state: _____________________________________________________________________
Name of corporation: _____________________________________________________________
Office held: ___________________________ Number of shares of stock owned: _____________
[NOTE: Only the registered agent may make application for a cabaret license on behalf of the corporation.]
5. For each person employed or engaged by applicant to perform cabaret-related work or services on the
proposed licensed premises as of the date of this application, state [attach additional sheets if necessary]:
Full name: ______________________________________________________________________
Address: ________________________________________________________________________
Telephone number: _______________________________________________________________
6. Does applicant certify that, to the best of his, her or its knowledge, information and belief, as of the date
of this application the proposed licensed premises complies with all zoning, building, fire, health, safety
and sanitation ordinances and regulations of the City of Port Washington, and all such laws, codes and
regulations of the state of Wisconsin applicable to the premises? Yes ____ No _______
If no, explain any exceptions or circumstances: _________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7. If there are any building alterations to the proposed licensed premises that are required or in progress as
of the date of this application, does applicant acknowledge that he, she or it must file a bond with the City
assuring that any work required to be done to bring the premises into compliance with City and state laws,
codes and regulations must be completed and approved before opening or continuation of the business?
Yes __________ No __________
8. License applied for Annual __________ Daily __________
License date(s) From ____________________________ To ____________________________
9. Type of music/entertainment provided: _______________________________________________
_______________________________________________________________________________
10. Area of proposed licensed premises where music/entertainment/performance will be provided:
_______________________________________________________________________________
_______________________________________________________________________________
11. Agent’s full name: ________________________________________________________________
Agent’s address: _________________________________________________________________
Agent’s telephone number: ________________________________________________________
12. Date application filed with Clerk: ____________________________________________________
Amount of application fee: _________________________________________________________
Date application fee paid to Clerk: ___________________________________________________
_____________________________________________________________________________________
By signing below, each individual applicant and agent, partner of a partnership or limited liability partnership,
member of a limited liability company, party to a joint venture, and agent of a corporation or other entity, certifies
under penalty of perjury that: the foregoing information is true and correct; they have full authority to act for the
partnership, limited liability partnership, limited liability company, joint venture, corporation or other legal entity;
they are responsible for control of the licensed premises and all business relating to the cabaret license conducted
thereon; and providing false information herein is grounds for denial, revocation or nonrenewal of such license.
Signature of Applicant: _____________________________________________________________
Date: __________________
Signature of Applicant: _____________________________________________________________
Date: __________________
Signature of Agent: _____________________________________________________________
Date: __________________
CLERK’S CERTIFICATION
I certify that the foregoing application was reported to the Common Council on ____________, that the license
was granted on ______________, and that I issued Cabaret License # _______________ on _________________.
Date: ______________ ___________________________________________
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APPLICATION FOR ANNUAL CABARET LICENSE CITY OF PORT (City of Port Washington)

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Completed 20 August 2020

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