Off Premise Rev 5/2017 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: 1. You completed the application in full. (Please allow 30 days to process) 2. Application is signed by the owner( s), corporate officer. 3. The license fee is correct and you have included the $10.00 filing fee. 4. A diagram of the premises to be licensed accompanies the application. 5. If business is located in an unorganized township, the application must be 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. 6. Corporations, limited liability companies, partnerships must complete and submit the Corp orate Information Required for Business Entities who are Licensees. 7. If not a publicly traded entity, ownership must add up to 100%. American LegalNet, Inc. www.FormsWorkFlow.com Off Premise Rev 5/2017 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@Maine.gov NEW license Yes No Present License Expires 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 Commissioners must approve the application. All such applications shall be accompanied by receipt of payment of the $10.00 filing fee to the County T reasurer . 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 Stat e 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. If business is NEW indicate opening date: Business Hours 2. List of Wholesale Value and Types of Merchandise in inventory: (must be answered) Edible Foods $ Tobacco Products $ Paper Goods # Greeting cards, Magazines, Newspapers $ Total all other inventory $ 3. Is applicant a Corporation, Limited Liability Co., or Limited Partnership? Yes No (If Yes complete Corporate Information Required for Business Entities) 4. If Manager is to be hired, give name: DIVISION USE ONLY License No: Class: By: Deposit Date: Amt. Deposited: Cash Ck Mo : American LegalNet, Inc. www.FormsWorkFlow.com Off Premise Rev 5/2017 5. Is/Are applicant(s) citizens of the United States? Yes No 6. Is/Are applicant(s) residents 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 vio lation of the law, other then minor traffic violations of any State of the United States? Yes No Name: Date of Conviction: Offense: Location: Disposition: Use a separate sheet of paper if necessary. 9. Will any law enforcement official benefit financially either directly or indirectly in 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 and address of owner: 12 . Describe in detail 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 establishment of your business? Yes No If Yes , give details: Name in Full (Print Clearly) DOB Place of Birth Re sidence 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 Rev 5/2017 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 neces sary. 1 5 . Does any other person have any interest directly or indirectly in your business? Yes No If Yes , give d e tails: PAYMENTS TO THE DIV ISION OF LIQUOR LICENSING & ENFORCEMENT BY CHECK SUBJECT TO PENALTY PROVIDED BY SECTION 3 OF TITLE 28A, MAINE REVISED STATUTES NOTE: info r mation on th is form is a Class D offense under the Criminal Code, punishable by confinement of up to one year or by Dated at: on ,20 City/Town Dat e Year 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) American LegalNet, Inc. www.FormsWorkFlow.com Off Premise Rev 5/2017 questions regarding this informat - 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 Ownersh ip % ( 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) State of Maine Division of Alcoholic Beverages and Lottery Operations Division of Liquor Licensing an d Enforcement Corporate Information Required for Business Entities Who Are Licensees For Office Use Only: License #: SOS Checked: 100% Yes No American LegalNet, Inc. www.FormsWorkFlow.com Off Premise Rev 5/2017 7. Is any princ ipal person involved with the entity a law enforcement official? Yes No If Yes, Name: Agency: 8. 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 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: Signature of Duly Authorized Person Date Print Name of Duly Authorized Person Submit Completed Forms To: Bureau of Alcoholic Beverages Division of Liquor Li censing 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 Off Premise Rev 5/2017 OFF PREMISE DIAGRAM 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 ad dition to a completed license application. Diagrams should be submitted on this form and should be as accurate as possible. Be sure to label the areas of your diagram including entrances, office area, malt and wine coolers, cold and regular storage areas , display cases and shelves, restrooms, check out register(s) and all areas that you are requesting approval from the Division for your retail liq