Agency Renewal Rev. 3/2019 , Replace 10 /201 8 Page 1 of 6 B UREAU OF A LCOHOLIC B EVERAGES AND L OTTERY O PERATIONS D IVISION OF L IQUOR L ICENSING AND E NFORCEMENT 8 S TATE H OUSE S TATION A UGUSTA , M AINE 04333 - 0008 T EL : (207) 624 - 7220 F AX : (207) 287 - 3434 E MAIL INQUIRIES : MAINELIQUOR @ MAINE . GOV AGENCY RENEWAL APPLICATION CLASS VIII STORE AGENCY, MALT, VINOUS $ 7 0 0.00 FILING FEE $ 10.00 $710.00 TOTAL RESELLING AGENT $ 50.00 ( Must have Federal Basic Permit) $760.00 TOTAL Check Payable: Treasurer, State of Maine Present License E xpires 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 Same As Above? City/Town State Zip Code City/Town State Zip Code Telephone Number Fax Number Business Telephone Number Fax Number Fed eral I.D. # Seller Certificate #: or Sales Tax #: Email Address: Website: 1 . Is applicant a Corporation: Yes No If Yes , complete and attach Corporate Information Required for Business Entities form. 2 . Have any changes occurred in Ownership, Partnership or Corporate structure since last renewal? Yes N o (Please be sure to note changes on Corporate Information Required for Business Entities form.) 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: (Please use additional sheets as needed.) 4 . If a manager is to be employed, give name: DIVISION USE ONLY License No: Class: By: Deposit Date: Amt. Deposited: Cash Ck Mo : Good SOS & DBA: YES NO American LegalNet, Inc. www.FormsWorkFlow.com Agency Renewal Rev. 3 /201 9 , Replace 8/2018 Page 2 of 6 5 . Is/are applicant(s) citizens of t he United States? Yes No 6 . Is/are applicant(s) residents of the State of Maine? Yes No 7. List name, date of birth, place of birth for all applicants and man a gers, if any. Name in Full ( G ive maiden name if married) DOB Place of Birth 8 . 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: Name: City: State: 9 . Has applicant(s) or manager ever been convicted of any violation o f the law, other than minor traffic violations in any State of the Unite d States, within the past 5 years? Yes No (Attach other sheets as necessary) Name: Date of Conviction: Offense: Location: Disposition: 10 . Will any other person have any interest either directly or indirectly in your license, if issued? Yes No If Yes , give name: 1 1 . Is any principal person involved with the entity a law enforcement official? Yes No If Yes, give name: 1 2 . Has/have applicant(s) formerly held a Maine liquor license? Yes No 1 3 . Does/do applicant(s) own the premises? Yes No If No name and address of own er: Address: City/Town: State: 1 4 . Describe in detail the premise to be licensed: ( Off Premise Diagram Required ) American LegalNet, Inc. www.FormsWorkFlow.com Agency Renewal Rev. 3 /201 9 , Replace 8/2018 Page 3 of 6 1 5 . What are your present hours of operation? Sunday Open AM/PM Close AM/PM Wednesday Open AM/PM Close AM/PM Monday OpenAM/PM Close AM/PM Thursday Open AM/PM Close AM/PM Tuesday Open AM/PM Close AM/PM Friday Open AM/PM Close AM/PM Sat urday Open AM/PM Close AM/PM 16 . List the wholesale value and types of merchandise in inventory: ( Use separate sheet of paper if necessary .) Beer: $ Wine: $ Edible Foods: $ Tobacco Products: $ Greeting Cards, Magazines, and Newspapers: $ Paper Goods: $ Total of all other merchandise in inventory: $ List current on - hand inventory of spirit s, in dollars: $ List current annual dollar sales of: Retail SPIRITS sales ONLY : $ 17 . Have you received any assistance financially or otherwise, (including any mortgages), from any source other than yourself in the esta blishment of your business? Yes No If Yes , give details: 18 . Basic Fede ral Permit # ( Must have Federal number for reselling ) Note: I 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 $2,000.00, or by both. (Sign in blue ink) Dated at: on 20 City / Town Month / Day Year PLEASE SIGN IN BLUE INK X Signature(s) of Owner or Corporate Officer Printed Name(s) 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) American LegalNet, Inc. www.FormsWorkFlow.com Agency Renewal Rev. 3 /201 9 , Replace 8/2018 Page 4 of 6 Questions 1 to 4 must match information on file with the Maine Secretary of S - 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) NAME ADDRESS (5 YEARS) Date of Birth TITLE Ownership % ( 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 Are Licensees American LegalNet, Inc. www.FormsWorkFlow.com Agency Renewal Rev. 3 /201 9 , Replace 8/2018 Page 5 of 6 8. If Yes to Question 7 , please complete the following: (attached additional sheets as needed) Name: Date of Conviction: Offense: Location of Conviction: Disposition: PLEASE SIGN IN BLUE INK 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 Agency Renewal Rev. 3 /201 9 , Replace 8/2018 Page 6 of 6 AGENCY DIAGRAM (Facility Drawing/Floor Plan) In an effort to clearly define your license premise and the area that 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 thi s form and should be as accurate as possible. Be sure to label the areas of your diagram to include the following: Office A Storage Areas Malt/Wine Coolers Display Cases & Shelves Dining Rooms Restrooms Retail Sales Area All areas that you are requesting approval from the Division for liquor consumption. Bureau of Alcoholic Beverages and Lottery Operations Division of Liquor Licensing & Enforcement 8 State House Station, Augusta, ME 04333 - 0008 10 Water Street, Hallowell, ME 04347 Tel: (207) 624 - 7220 Fax: (207) 287 - 3434 Email Inquiries: MaineLiquor@main e.gov American LegalNet, Inc. www.FormsWorkFlow.com