Massachusetts > Statewide > Alcoholic Beverages Commission
Application For Registration For Transportation By A Certificate Of Compliance Holder - Massachusetts
| Application For Registration For Transportation By A Certificate Of Compliance Holder 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 REGISTRATION FOR TRANSPORTATION BY A CERTIFICATE OF COMPLIANCE HOLDER MONETARY TRANSMITTAL FORM [APPLICATION MUST BE COMPLETED ONLINE] ECRT CODE: REGI $1000.00 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 Registration for transportation by a Certificate of Compliance holder FEE $1000.00 # OF PERMITS 1 COST $1000.00 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 Registration for Transportation by a Certificate of Compliance Holder (204 C.M.R. 2.17) 1.Certificate Holder Information: Year: 20 A. Name of Certificate Holder: B. Business Address of Certificate Holder: C. Shipping Address: *See 2A Below Business Telephone: Fax: Certificate of Compliance Number: Business Name (d/b/a if different): City/Town: City/Town: State State Zip Zip 2. Location From Which Beverages Will Be Shipped: A. Address: B. Business Telephone: Fax: City/Town: State Zip 3. Massachusetts Warehouse Information: A. Name of Licensed Warehouse: B. Warehouse Address: Business Telephone: Fax: License Number: City/Town: State Zip 4. F.D.A. Compliance: Have you registered with the Food and Drug Administration? Yes Registration Date: No 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 Title Date American LegalNet, Inc. www.FormsWorkFlow.com
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