Massachusetts > Statewide > Alcoholic Beverages Commission
Application For A Commercial Alcohol (License) - Massachusetts
| Application For A Commercial Alcohol (License) Form. This is a Massachusetts form and can be used in Alcoholic Beverages Commission Statewide . |
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The Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc APPLICATION FOR A COMMERCIAL ALCOHOL MONETARY TRANSMITTAL FORM [APPLICATION MUST BE COMPLETED ONLINE] ECRT CODE: COMM $500.00 CHECK PAYABLE TO ABCC OR COMMONWEALTH OF MA: 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 (CHECK MUST DENOTE THE NAME OF THE LICENSEE CORPORATION, LLC, PARTNERSHIP, OR INDIVIDUAL) LICENSE TYPE COMMERCIAL ALCOHOL FEE $500.00 # OF PERMITS 1 COST $500.00 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 Commercial Alcohol License (M.G.L. c. 138, §76) Application for (Check One): New License Renewal Other YEAR 20 1. LICENSE CATEGORY: Mechanical Manufacturing Chemical 2. LICENSEE INFORMATION: Name of Applicant: Manager of Record: Address of Premises: Address of Warehouse (if different from above) Business Name (if different) : ABCC License Number: City/Town: City/Town: Alternate Phone: Website: State State Fax: Zip Zip Phone of Premises: Email: 3. DESCRIPTION OF PREMISES: Please attach a detailed floor plan of premises to be licensed, clearly delineate licensed from unlicensed areas and include dimensions, square footage and entrances / exits. Do you lease or otherwise provide space for any other entity to store alcoholic beverages? Yes No Provide the distance to the nearest Church or School from any storage location: Do you provide transportation delivery service for any other person or entity? If yes, please explain: Yes No 4. OCCUPANCY OF PREMISES: By what right does the applicant have possession of the premises? Please select Landlord is a(n): Name Address: Lease Term: Beginning Date Rent: per year Rent: City/Town: Ending Date per month Please Select Other Phone: State Zip Other IMPORTANT ATTACHMENTS: A copy of the signed lease must accompany this application in order for it to be processe American LegalNet, Inc. www.FormsWorkFlow.com Application for a Commercial Alcohol License (M.G.L. c. 138, §76) 5. LICENSE STRUCTURE: The Applicant is a(n): Please select If the applicant is a Corporation or LLC, complete the following: State of Incorporation/Organization: Shares of stock are authorized: Is the Corporation publicly traded? Are all directors United States citizens? Are the majority of directors' residents of Massachusetts? Is the manager or principal representative a U.S. citizen? Date of Incorporation/Organization: Shares of stock are issued: Yes Yes Yes Yes No No No No Other : IMPORTANT ATTACHMENTS: Attach the vote by the Board of Directors or LLC Managers appointing a manager or principal representative as well as the Articles of Organization as filed with the Secretary of State's Office. 6. INTERESTS IN THIS LICENSE: List all individuals involved in the entity (e.g. corporate stockholders, directors, officers and LLC members and managers) and any person or entity with a direct or indirect, beneficial or financial interest in this license (e.g. landlord with a percentage rent based on alcohol sales). IMPORTANT ATTACHMENTS (5): A. All individuals or entities listed below are required to complete a Personal Information Form. B. All shareholders, LLC members or other individuals with any ownership in this license must complete a CORI Release Form. Name All Titles and Positions Specific # of Stock or % Owned Other Beneficial Interest *If additional space is needed, please use last page. 7. EXISTING INTERESTS IN OTHER LICENSES: 7A. Does any individual listed in §10 have any direct or indirect, beneficial or financial interest in any other license to sell alcoholic No beverages? Yes If yes, list said interest below: Name License Type Please Select Please Select Please Select Please Select Please Select American LegalNet, Inc. www.FormsWorkFlow.com Licensee Name & Address Application for a Commercial Alcohol License (M.G.L. c. 138, §76) 7B.Does any person, entity or member of their immediate family (spouse, children, parents or siblings) who has a direct or indirect beneficial interest in this license have any direct or indirect beneficial or financial interest in any other license, permit or certificate to sell alcoholic beverages? If yes, list said interest below: Yes No Name License Type Licensee Name & Address Type of Interest 8. PREVIOUSLY HELD INTERESTS IN OTHER LICENSES: Has any individual or entity who has a direct or indirect beneficial interest in this license ever held a direct or indirect, beneficial or No If yes, list said interest below: financial interest in a license to sell alcoholic beverages, which is not presently held? Yes Name Licensee Name & Address Date Reason Terminated Please Select Please Select Please Select 9. PRIOR DISIPLINARY ACTION: Has any person or entity identified in this license application ever been involved directly or indirectly in an alcoholic beverage license, No permit or certificate suspension, revocation or cancellation?Yes If yes, complete the following for each person or entity. Date of Action Licensee Name Reason of Suspension, Revocation or Cancellation American LegalNet, Inc. www.FormsWorkFlow.com Application for a Commercial Alcohol License (M.G.L. c. 138, §76) 10. SUPPLIERS OF LICENSE: Identify suppliers that your company is presently doing business with (a computerized printout may be submitted.) Supplier Name Address FDA Registration Number 11. WHOLESALER OF LICENSEE: Identify other Massachusetts Wholesaler(s) who are distributing your product(s) and the product(s) each distributes: Wholesaler Products Distributed 12. FEDERAL COMPLIANCE: a. b. Submit a copy of the permit issued by the Alcohol and Tobacco Tax and Trade Bureau (TTB). Yes No Have you registered with the Food and Drug Administration? Registration Date 13. SURETY BOND: Submit the required surety bond in the penal sum of$1,000.00. 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,
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