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Application For A Winery Shipment License - Massachusetts
| Application For A Winery Shipment License 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 WINERY SHIPMENT LICENSE MONETARY TRANSMITTAL FORM [APPLICATION MUST BE COMPLETED ONLINE] ECRT CODE: DIRE $100.00 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 WINERY SHIPMENT LICENSE FEE $100.00 # OF PERMITS 1 COST $100.00 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 WINERY SHIPMENT LICENSE (CH.138, §19F) 1. Licensee Information: Name of Applicant: Mailing Address: Manager of Record: Other Phone: Email: Business Name (d/b/a if different) : City/Town: Phone Number of Premises: Website: State YEAR 20 Zip Contact Person concerning this application (attorney if applicable): Name: Address: Contact Number : City/Town: Fax Number: State Email: Zip 2. Description of the Manufacturing Premises: Address of Premises for the Manufacturing of Wine: City/Town: State Yes Zip No Phone Number of Premises: Is the entire building to be licensed? Please describe below or attach a detailed floor plan of premises to be licensed, clearly delineate licensed from unlicensed areas and include dimensions, square footage and entrances/exits. 3. Sales Information: a. Is the location of premises from which wine sales will be made to Massachusetts retailers licensed under M.G.L. c. 138, §§12 and Yes No 15, different from above? If yes, please state address: Phone Number of Premises: b. Is the location of premises from which wines will be sold to Massachusetts consumers, different from above? If yes, please state address: Yes No Phone Number of Premises: American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 4. Shipment Information: c. Is the location of premises from which shipment will be made for Massachusetts retailers licensed under M.G.L. c. 138, §§12 and No 15, different from above? Yes If yes, please state address: Phone Number of Premises: d. Is the location of premises from which wine is to be shipped to Massachusetts consumers, different from above?Yes If yes, please state address: No Phone Number of Premises: 5. Occupancy of Premises: For each location identified in §3 & §4 above, by what right does the applicant have possession and/or legal occupancy of the premises? Please select Landlord is a(n): Name Address: Please Select Other Phone: City/Town: 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 processe 6. Existing License(s) to Manufacture, Export and Sell at Retail: List the license(s) you hold which authorize the manufacture, exportation and retail sale of wine to consumers and sale of wine to licensed retailers: (Attach a copy of each license) Name License Type License Address *If additional space is needed, please use last page* American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 7. Prior License at Location: Has the premises been previously licensed? Yes By Whom: Licensed Term: Beginning Date: Ending Date: No 8. Safety and Tax Registration: Have you registered with the Food and Drug Administration? Yes No Registration Date: Have you registered with the Massachusetts Department of Revenue to pay sales taxes and taxes due under M.G.L. c. 138, §21? Yes No Registration Date: 9. 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: Date of Incorporation/Organization: Shares of stock are issued: Shares of stock are authorized: 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. 10. 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 Beneficial Interest Stock or % Owned *If additional space is needed, please use last page. American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 11. 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 No alcoholic beverages?Yes If yes, list said interest below: Name License Type Please Select Please Select Please Select Please Select Licensee Name & Address 12. 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 13. Disclosure of License Disciplinary Action: Have any of the disclosed licenses to sell alcoholic beverages listed in §11 and/or §12 ever been suspended, revoked or No cancelled? Yes If yes, list said interest below: Date License Reason why license was Suspended, Revoked or Cancelled 14. Criminal Record: Has any individual who has a direct or indirect beneficial interest in this license ever been convicted of a municipal, state, No federal or military crime? Yes IMPORTANT ATTACHMENTS: If yes, the individual must provide an affidavit as to any and all charges as well as the disposition. American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 15. Existing Wholesalers: Identify ALL Massachusetts Wholesaler(s)/Importer(s) who are distributing yo
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