Massachusetts > Statewide > Alcoholic Beverages Commission
Application For A Certificate Of Compliance (Under 5000 Cases) - Massachusetts
| Application For A Certificate Of Compliance (Under 5000 Cases) Form. This is a Massachusetts form and can be used in Alcoholic Beverages Commission Statewide . |
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Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc The APPLICATION FOR A CERTIFICATE OF COMPLIANCE MONETARY TRANSMITTAL FORM [APPLICATION MUST BE COMPLETED ONLINE] ECRT CODE: CERT CHECK PAYABLE TO ABCC OR COMMONWEALTH OF MA: (CHECK MUST DENOTE THE NAME OF THE LICENSEE CORPORATION, LLC, PARTNERSHIP, OR INDIVIDUAL) CHECK NUMBER IF USED EPAY, CONFIRMATION NUMBER: A.B.C.C. LICENSE NUMBER (IF AN EXISTING LICENSEE): LICENSEE NAME: ADDRESS: CITY/TOWN: STATE ZIP CODE LICENSE TYPE FEE # OF PERMITS COST CERTIFICATE OF COMPLIANCE LESS THAN 5000 CASES $200.00 YOU MUST MAIL THIS TRANSMITTAL FORM ALONG WITH YOUR CHECK AND COMPLETED APPLICATION TO: ALCOHOLIC BEVERAGES CONTROL COMMISSION P. O. BOX 3396 BOSTON, MA 02241-3396 American LegalNet, Inc. www.FormsWorkFlow.com Application for a Certificate of Compliance (M.G.L. Chapter 138, §18B) 1. Certificate Holder Information: Year: 20 License Number: C Business Name (d/b/a, if different): Name of Applicant: Mailing Address: CITY/TOWN: STATE Zip Phone Number: Email: The Applicant is a(n): Please select Other : Identify Individual's Name and Address Where Possession of Certificate is Retained: Name : Address: City/Town: State Zip 2. Shipment Origin: State below the location of the premises from which alcoholic beverages are to be shipped to Massachusetts licensed Wholesalers and Importers. Each shipping location requires an application. Name Address Telephone 3. Required License(s): List the license(s) you hold which authorize the exportation or sale of alcoholic beverages from the location identified in Question 2 above to licensees in this Commonwealth and the Licensing Authority, which issued said license (must correspond with above if licensing is mandatory by said State or Foreign Country). License Name State Licensing Authority 4. F.D.A. Compliance: Have you registered with the Food and Drug Administration? Yes No Registration Date American LegalNet, Inc. www.FormsWorkFlow.com Application for a Certificate of Compliance (M.G.L. Chapter 138, §18B) 5. Cross-Ownership: Do you or any member of your immediate family or does the Corporation or Partnership that you or any member of your immediate family belong to, own directly or indirectly 10% or more of any financial and/or beneficial interest of any Massachusetts License? Yes No (Note: Chapter 138, §18B defines immediate family as "the certificate holder and his/her spouse and their parents, children, brothers and sisters"). If YES, list below the name of the individual, title and name of the Massachusetts licensee NAME OF INDIVIDUAL TITLE NAME OF MASSACHUSETTS LICENSEE *If additional space is needed, please use last page* 6. Brokers Information: List any person or entity representing you as an agent, broker or solicitor in Massachusetts: NAME ADDRESS TELEPHONE *If additional space is needed, please use last page* 7. Wholesaler(s) Information: List Massachusetts Wholesaler(s) who are distributing your products and the products each distributes: WHOLESALER PRODUCTS *If additional space is needed, please use last page* Pursuant to M.G.L. Ch. 62C, Sec. 49A, I certify under the penalties of perjury that, I have filed all state tax returns and paid all state taxes required under law. I further understand that each representation in this application is material to the determination of the application and state under penalty of perjury that all statements and representations therein are true. Signature Date Title American LegalNet, Inc. www.FormsWorkFlow.com Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc The Print Form SCHEDULE OF PRICES TO WHOLESALERS [This schedule must be typewritten or printed] Effective for the month of 20 This schedule is subject to such rules and regulations as the Alcoholic Beverages Control Commission has or may hereafter adopt. The undersigned licensee (or his duly authorized representative) files the following schedule of prices pursuant to the requirements of Sections 25A and 25B, Chapter 138 of the General Laws, as amended. This schedule is signed under the penalties of perjury. Date Name of Licensee Signature Address of licensed premises: City/Town State Zip Code Massachusetts License or Certificate Number Type of Beverage and brand name Capacity of Container Where stated on label Price # of Discount Bottles for Quanity Per Case Age If a blend % and kind of Neutral Spirits Proof or Alcoholic Content Per bottle (if so sold) Per Case American LegalNet, Inc. www.FormsWorkFlow.com Additional Space Please note which question you are using this space for. American LegalNet, Inc. www.FormsWorkFlow.com
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