Off Premise Application Rev. 3 /2019 Replace 8/2018 Page 1 of 7 Bureau of Alcoholic Beverages and Lottery Operations Division of Liquor Licensing & Enforcement 8 State House Station Augusta, ME 04333 - 0008 Tel: (207) 624 - 7220 Fax: (207) 287 - 3434 Email inquiries: MaineLiq uor@Maine.gov NOTICE To avoid any delay in the processing of your application and issuance of your liquor license, please make sure that: You completed the application in full. (Please allow up to 30 days to process) Application is signed by the o wner(s), corporate officer. The license fee is correct and you have also included the $10.00 filing fee. A diagram of the premises to be licensed accompanies the application. If the business is located in an unorganized township, the application must b e approved by the County Commissioners and the $10.00 filing fee must be paid to them. Please be sure to include a copy of the receipt of payment with your application. Corporations, limited liability companies, partnerships must complete and s ubmit the Corporate Information Required for Business Entities who are Licensees. If not a publicly traded entity, ownership must add up to 100%. 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 Off Premise Application Rev. 3 /2019 Replace 8/2018 Page 2 of 7 BUREAU OF ALCOHOL 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) TEL: (207) 624 - 722 0 FAX: (207) 287 - 3434 EMAIL INQUIRIES: MAINELIQUOR@MAINE.GOV NEW license Yes No Present License Expires If business is NEW indicate opening date: Business Hours Off - Premise Retailer Malt Liquor ................................ ................................ ................................ ....... $200.00 Off - Premise Retailer Table Wine ................................ ................................ ................................ ....... $200.00 Filing Fee ................................ ................................ ................................ ................................ ............... $ 10.00 NOTE: if the place of business is located in an unincorporated place, the County Co mmissioners must approve the application. All such applications shall be accompanied by receipt of payment of the $10.00 filing fee to the County Treasurer . 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 Same As Above? 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: Website : 1. List of Wholesale Value and Type s of Merchandise in inventory: (must be answered) Edible Foods $ Tobacco Produc ts $ Paper Goods # Greeting cards, Magazines, Newspapers $ Total all other inventory $ 2. Is applicant a Corporation, Limited Liability Co., or Limited Partnership? Yes No (If Yes complete Corporate Information Required for Business Entities) 3. If Manager is to be hired, 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 Off Premise Application Rev. 3 /2019 Replace 8/2018 Page 3 of 7 4. Is/Are applicant(s) citizens of the United States? Yes No 5. Is/Are applicant(s) resi dents of the State of Maine? Yes No Use a separate sheet of paper if necessary. 8. Has applicant(s) or manager(s) ever been convicted of any violation of the law, other then minor traffic violations of any State of the United St ates? Yes No Name: Date of Conviction: Offense: Location: Disposition: Use a separate sheet of paper if necessary. 9. Will any law enforcement official benefit directly in y our license, if issued? Yes No If Yes , give name: 10 . Has applicant(s) formerly held a Maine liquor license? Yes No 11 . Do applicant(s) own the premises? Yes No If No , give name a nd address of owner: 12 . Describe in deta il where liquor will be stored: ( Off Premise Diagram Required ) 13 . Have you received any assistance financially or otherwise (including any mortgages) from any source other than your - self in the establis hment of your business? Yes No If Yes , give details: 14. 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 Use an additional sheet (s) if necessary. Name in Full (Print Clearly) DOB Place of Birth 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: 7. List name, date of birth, place of birth for all applicants and managers. Give maiden name if married. American LegalNet, Inc. www.FormsWorkFlow.com Off Premise Application Rev. 3 /2019 Replace 8/2018 Page 4 of 7 1 5 . Does any other person have any interest directly or indirectly in your business (husband, wife, child, etc) ? Yes No If Yes , give d e tails PAYMENTS TO THE DIVISION OF LIQUOR LICENSING & ENFORCEMENT BY CHECK SU BJECT TO PENALTY PROVIDED BY SECTION 3 OF TITLE 28A, MAINE REVISED STATUTES NOTE: info r mation on this form is a Class D offense under the Criminal Cod e, punishable by confinement of up to one year or by Dated at: on ,20 City/Town Date Year PLEASE SIGN IN BLUE INK Signature(s) of Applicant(s) or Corporate Officer(s) Print Name of Applicant(s) or Corporate Officer(s) Signature(s) of Applicant(s) or Corporate Officer(s) Print Name of Applicant(s) or Corporate Officer(s) Submit Completed Forms To: Bureau of Alcoholic Beverages Division of Liquor Licensing and Enforcement 8 State House Statio n, 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 Off Premise Application Rev. 3 /2019 Replace 8/2018 Page 5 of 7 ques - 7752. Please clearly complete this form in its entirety. 1. Exact legal name: 2. Doing Business As, if any: 3. 4. Date of filing with Secretary of State: State in which you are formed: 5. If not a Maine business entity, date on which you were authorized to transact business in the State of Maine: 6. List the name and addresses for previous 5 years, birth dates, titles of officers, directors and list the percentage ownership: (attach 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%.) 7. If Co - Op # of members: (list primary officers in the above boxes) State of Maine Division of Alcoholic Bev erages and Lottery Operations Division of Liquor Licensing and Enforcement Corporate Information Required for Business Entities Who Are Licensees American LegalNet, Inc. www.FormsWorkFlow.com Off Premise Application Rev. 3 /2019 Replace 8/2018 Page 6 of 7 8. Has any principal person invo lved in the entity ever been convicted of any violation of the law, other than minor traffic violations, in the United States? Yes No 9. If Yes to Question 8 , please complete the following: (attached additional sheets as needed) Name: Date of Conviction: Offense: Location of Conviction: Disposition: Signature: PLEASE SIGN IN BLUE INK Signature of Owner or Corporate Officer Date Print Name of Owner or Corporate Officer Submit Completed Forms t o: Bure au 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 Off Premise Application Re