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Application For A Farmer-Winery License (5000 Gallons Or Less) - Massachusetts
| Application For A Farmer-Winery License (5000 Gallons Or Less) 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 FARMER-WINERY LICENSE MONETARY TRANSMITTAL FORM [APPLICATION MUST BE COMPLETED ONLINE] ECRT CODE: FAWY 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 FARMER-WINERY 5,000 GALLONS OR LESS $22.00 FEE # OF PERMITS COST 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 Farmer-Winery License (CH.138, §19B) YEAR 20 Application for (Check One): 1. Licensee Information: New License Renewal Other Business Name (if different) : Name of Applicant: Manager of Record: ABCC License Number: Address of Premises: Address of Warehouse (if different from above) CITY/TOWN: CITY/TOWN: Other Phone: Website: STATE STATE ZIP ZIP Phone Number of Premises: Email: 2. 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. 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 3. Occupancy of Premises: By what right does the applicant have possession of the premises? Please select Landlord is a(n): Please Select Other Other Name Address: City/Town: Phone: State Zip Lease Term: Beginning Date Ending Date Rent: per year Rent: per month IMPORTANT ATTACHMENTS: A copy of the signed lease must accompany this application in order for it to be processed. American LegalNet, Inc. www.FormsWorkFlow.com Application for a Farmer-Winery License (CH.138, §19B) YEAR 20 4. Licensee Structure: The Applicant is a(n): Please select Other : 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 at least 50% of the Directors/ LLC Managers United States citizens? Are the majority of the Directors/ LLC Managers Massachusetts residents? Is the manager or principal representative a U.S. citizen? Are all Members and Partners involved at least twenty-one years old? Date of Incorporation/Organization: Shares of stock are issued: Yes Yes Yes Yes Yes No No No No No 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. 5. 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: All individuals or entities listed below are required to complete a Personal Information Form. Name Title Stock or % Owned Other Beneficial Interest *If additional space is needed, please use last page. 6. Existing Interests in Other Licenses: a. Does the applicant hold a direct or indirect beneficial or financial in any other license, permit or certificate to sell Yes No alcoholic beverages? 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 Farmer-Winery License (CH.138, §19B) b. 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? Yes If yes, list said interest below: No Name License Type Please Select Please Select Please Select Licensee Name & Address 7. 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, No beneficial or financial interest in a license to sell alcoholic beverages, which is not presently held?Yes If yes, list said interest below: Name Licensee Name & Address Date Reason Terminated Please Select Please Select Please Select 8. Prior Disciplinary Action: Has any person or entity identified in this license application ever been involved directly or indirectly in an alcoholic Yes No beverage license, permit or certificate suspension, revocation or cancellation? 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 Farmer-Winery License (CH.138, §19B) 9. Suppliers of Licenses: Identify suppliers that your company is presently doing business with (a computerized printout may be submitted.) Supplier Name Address FDA Registration Number 10. Wholesaler of Licensee: Identify other Massachusetts Wholesaler(s) who are distributing your product(s) and the product(s) each distributes: Wholesaler Products Distributed 11. Federal Compliance: a. b. Submit a copy of the permit issued by the Alcohol and Tobacco Tax and Trade Bureau (TTB). No Have you registered with the Food and Drug Administration? Yes Registration Date 12. Costs Associated with License Transaction: A. Real Property: B. Business Purchase C. Renovations/Construction: D. Start up/Operating Capital: E. Inventory: F. Goodwill: G. Fixtures / Equipment: H. TOTAL COST I. TOTAL CASH J. TOTAL AMOUNT FINANCED The amounts listed in subsections (I) and (J) must total the amount reflected in (H). American LegalNet, Inc. www.FormsWorkFlow.com IMPORTANT ATTACHMENTS: Submit any and all records, documents and affidavits including loan agreements that explain the source(s) of money for this transaction. Application for a Farmer-Winery License (CH.138, §19B) 13. Financing: Explain how financing this license (include loans, mortgages, lines of credit, notes, etc
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