Large Winery Application Rev. 10/2018 Replace 4/2017 Page 1 of 6 Bureau of Alcoholic Beverages and Lottery Operations Division of Liquor Licensing and Enforcement 8 State House Station, Augusta, ME 04333-0008 (Regular Mail) 10 Water Street, Hallowell, ME 04347 (Overnight Mail) Telephone: 207-624-7220 Fax: 207-287-3434 Email inquiries: MAINELIQUOR@MAINE.GOV NEW license Yes No PRESENT LICENSE EXPIRES: APPLICATION FOR LARGE WINERY $1,000.00 Winery License Fee The undersigned hereby applies for a Winery license to produce table wine and sparkling wine up to 24% alcoholic content exceeding 50,000 gallons per year. $10.00 Filing Fee $600.00 Additional Location Warehouse (1 Year Storage) Check Payable: Treasurer, State of Maine ALL QUESTIONS MUST BE ANSWERED IN FULL Corporation Name: Business Name (D/B/A) APPLICANT(S) (Sole Proprietor) DOB: Physical Location: DOB: City/Town State Zip Code Address Mailing Address City/Town State Zip Code City/Town State Zip Code Telephone Number Fax Number Business Telephone Number Fax Number Federal I.D. # Seller Certificate #: or Sales Tax #: Email Address: Please Print Website: 1. Is applicant a corporation, limited liability company or limited partnership? Yes No If Yes, complete the Corporate Information Required for Business Entities 2. Business records are located at: 3. Do you own or have any interest in any another Maine Liquor License? Yes No If yes, please list License Number, Name, and physical location of any other Maine Liquor Licenses. License # Name of Business Physical Location City / Town DIVISION USE ONLY License No: Class: By: Deposit Date: Amt. Deposited: Cash Ck Mo : American LegalNet, Inc. www.FormsWorkFlow.com Large Winery Application Rev. 10/2018 Replace 4/2017 Page 2 of 6 4. Is/Are applicant(s) citizens of the United States? Yes No 5. Is/Are applicant(s) citizens of the State of Maine? Yes No 6. If a corporation, does any officer, director, or stockholder of said corporation have in any way an interest, directly or indirectly, as a director or stockholder in any other corporation which is a holder of a wholesale license granted by the State of Maine? Yes No 7. Is the applicant directly or indirectly giving aid or assistance in the form of money, property, credit, or financial assistance of any sort, to any person, association, or corporation holding a liquor license granted by the State of Maine? Yes No 8. Will you maintain an additional warehouse location? Yes No If yes, check appropriate box(s) and enclose additional fee. Address:StateZip Code Telephone: Name of Manager Email address: 9. Will any law enforcement officer directly benefit financially in your license, if issued? Yes No If Yes, give name: 10. List name, date of birth, place of birth for all applicants and managers. Give maiden name, if married. Name in Full (Print Clearly) DOB Place of Birth 11 . Residence address on all of the above for previous 5 years (Limit answer to city & state) Name: City: State: Name: City: State: Name: City: State: 12. Has/have applicant(s) or manager ever been convicted of any violation of the law, other than minor traffic violations, of any State of the United States? Yes No Name: Date of Conviction: Offense: Location: Disposition: (use additional sheet(s) if necessary) American LegalNet, Inc. www.FormsWorkFlow.com Large Winery Application Rev. 10/2018 Replace 4/2017 Page 3 of 6 Payments to the Division of liquor licensing & enforcement by check subject to penalty provided by Section 3-B of Title 28A, MRS NOTE: 223I understand that false statements made on this form are punishable by law. Knowingly supplying false information on this form is a Class D offense under the Criminal Code, punishable by confinement of up to one year or by monetary fine of up to $2,000 or both.224 Dated at: on , 20 Town/City, State Date Year Please sign in blue ink Signature of Applicant or Corporate Officer(s) Signature of Applicant or Corporate Officer(s) Print Name Print Name Please be sure to include the following with your application: Completed original application with original signatures. Signed check with the correct fees and payment made out to: Treasurer, State of Maine Corporation Information Required for Business Entities. (if applicable) List with name and address of each wholesale dealer authorized to distribute products of your licensed winery. Attached the distributor territory form. Attached documentation of primary source. Complete the label registration form with the associated annual fees. Submit Completed Forms To: Bureau of Alcoholic Beverages Division of Liquor Licensing and Enforcement 8 State House Station, Augusta, Me 04333-0008 (Regular address) 10 Water Street, Hallowell, ME 04347 (Overnight address) Telephone Inquiries: (207) 624-7220 Fax: (207) 287-3434 Email Inquiries: MaineLiquor@Maine.gov American LegalNet, Inc. www.FormsWorkFlow.com Large Winery Application Rev. 10/2018 Replace 4/2017 Page 4 of 6 Bureau of Alcoholic Beverages Division of Liquor Licensing & Enforcement 8 State House Station Augusta, ME 04333-0008 Tel: (207) 624-7220 Fax: (207) 287-3434 MAINELIQUOR@MAINE.GOV Manufacturing Diagram (Facility Drawing/ Floor Plan) In an effort to clearly define your license premise and the areas that consumption and storage of liquor is allowed, The Division requires all applicants to submit a diagram of the premise to be licensed in addition to a completed license application. Diagrams should be submitted on this form and should be as accurate as possible. Be sure to label the following areas: 225 Entrances 225 Office area 225 Coolers 225 Storage areas 225 Display Cases & Shelves 225 Restroom 225Register 225Area of Manufacturing 225Area of retail sales 225 Area for on premise consumption 225 Outside area/ decks 225 All other areas that you are requesting approval. American LegalNet, Inc. www.FormsWorkFlow.com Large Winery Application Rev. 10/2018 Replace 4/2017 Page 5 of 6 Questions 1 to 4 must match information on file with the Maine Secretary of State222s office. If you have questions regarding this information, please call the Secretary of State222s office at (207) 624-7752. Please clearly complete this form in its entirety. 1. Exact legal name: 2. Doing Business As, if any: 3. Date of filing with Secretary of State: State in which you are formed: 4. If not a Maine business entity, date on which you were authorized to transact business in the State of Maine: 5. List the name and addresses for previous 5 years, birth dates, titles of officers, directors and list the percentage ownership: (attached additional sheets as needed) (Stock ownership in non-publicly traded companies must add up to 100%.) 6. If Co-Op # of members: (list primary officers in the above boxes) 7. Has any principal person involved in the entity ever been convicted of any violation of the law, other than minor traffic violations, in the United States? Yes No State of Maine Division of Alcoholic Beverages and Lottery Operations Division of Liquor Licensing and Enforcement Corporate Information Required for Business Entities Who A re Licensees NAME ADDRESS (5 YEARS) Date of Birth TITLE Ownership % American LegalNet, Inc. www.FormsWorkFlow.com Large Winery Application Rev. 10/2018 Replace 4/2017 Page 6 of 6 8. If Yes to Question 8, please complete the following: (attached additional sheets as needed) Name: Date of Conviction: Offense: Location of Conviction: Disposition: Signature: Signature of Owner or Corporate Officer Date Print Name of Owner or Corporate Officer Submit Completed Forms To: Bureau of Alcoholic Beverages Division of Liquor Licensing and Enforcement 8 State House Station, Augusta, Me 04333-0008 (Regular address) 10 Water Street, Hallowell, ME 04347 (Overnight address) Telephone Inquiries: (207) 624-7220 Fax: (207) 287-3434 Email Inquiries: MaineLiquor@Maine.gov American LegalNet, Inc. www.FormsWorkFlow.com