Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc The APPLICATION FOR A LICENSEE'S STORAGE PERMIT MONETARY TRANSMITTAL FORM [APPLICATION MUST BE COMPLETED ONLINE] ECRT CODE: STOR 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 LICENSE TYPE FEE STORAGE ZIP CODE # OF PERMITS COST $2,000.00 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 Licensee's Storage Permit (M.G.L. Chapter 138, §20) 1. Applicant Information: Name of Applicant: ABCC Permit #: (If an existing licensee) Business Name (d/b/a, if different) Address of Premises: City/Town: Telephone: State Zip E-mail Address The undersigned being the holder of a Please select to store alcoholic beverages during the calendar year 20 License No. here by applies for a permit . 2. Description of Premises: Provide a complete description of the premises to be used for storage including the number of rooms on each floor. 3. F.D.A. Compliance: Have you registered with the Food and Drug Administration? Yes No Registration Date: 4. Location of Premises: Is the premises located within 500 feet of a school or building devoted to divine worship such as a church or synagogue? Yes No (If yes, state information accurately and in full detail.) Pursuant to M.G.L. Ch. 62C, Sec. 49A, I certify under the penalties of perjury that, I have filed all state tax returns and paid all state taxes required under law. I further understand that each representation in this application is material to the determination of the application and state under penalty of perjury that all statements and representations therein are true. Signature Date Title American LegalNet, Inc. www.FormsWorkFlow.com Additional Space American LegalNet, Inc. www.FormsWorkFlow.com