Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 Telephone: (617) 727-3040 Fax: (617) 727-1258 Timothy P. Cahill Treasurer and Receiver General Kim Gainsboro Chairman 2010 Application for a storage permit in a duly licensed Bonded Warehouse (M.G.L. Chapter 138, Section 20) LICENSEE NAME: ____________________________________________________________________________________ The undersigned being the holder of a _________________________License No.________________ hereby applies for a permit to store alcoholic beverages during the year 20______. ADDRESS OF PREMISES: (State every entrance and exit to the particular premises to be covered by the permit, including cellar bulkheads). Street City or Town Zip Code DETAILED DESCRIPTION OF THE PREMISES TO BE USED FOR STORAGE: (State number of rooms on each floor). Have you registered with the Food and Drug Administration?____________________________________________ FDA REGISTRATION NO. __________________ Date of Registration:______________________________ American LegalNet, Inc. www.FormsWorkFlow.com 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.) ____________________________________________________________________________________________ THE ABOVE STATEMENTS ARE MADE UNDER THE PENALTIES OF PERJURY. ______________________________________________________________________________________________ SIGNATURE DATE / POSITION/TITLE TELEPHONE NUMBER/FAX NUMBER Pursuant to M.G.L. Ch. 62 C, Sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. ____________________________ SOCIAL SECURITY NUMBER _____________________________________ FEDERAL IDENTIFICATION NUMBER PERMIT FEE: ______________________________________ SIGNATURE OF INDIVIDUAL DATE OR CORPORATE NAME __________________________________________ SIGNATURE OF DATE CORPORATE OFFICER (IF APPLICABLE) $1,000.00 (PAYABLE TO THE COMMONWEALTH OF MASSACHUSETTS) CHECK: ______________ MONEY ORDER: _____________ (UNDER THE PROVISIONS OF SECTION 20, OF CHAPTER 138 OF THE GENERAL LAWS, THERE SHALL NOT BE GRANTED TO ANY MANUFACTURER OR WHOLESALER AND IMPORTER, IN THE AGGREGATE, MORE THAN THREE STORAGE PERMITS IN THE COMMONWEALTH, NOT MORE THAN ONE SUCH PERMIT IN ANY CITY OR TOWN.) FORM 15A 09/05 American LegalNet, Inc. www.FormsWorkFlow.com MONETARY TRANSMITTAL FORM 1 THIS TRANSMITTAL MUST ACCOMPANY YOUR APPLICATION IN ORDER TO ASSURE PROPER CREDIT. PLEASE DO NOT SEND CASH. PLEASE MAKE YOUR CHECKS PAYABLE TO COMMONWEALTH OF MASSACHUSETTS, ABCC. MAIL THIS TRANSMITTAL ALONG WITH YOUR CHECK AND COMPLETED APPLICATION TO: BANK OF AMERICA - ALCOHOLIC BEVERAGES CONTROL COMMISSION POST OFFICE BOX 3396 BOSTON, MA 02241-3396 APPLICANT MUST COMPLETE THE FOLLOWING: NAME: ADDRESS: CITY/TOWN: STATE: ZIP CODE: DATE: LICENSE NAME AIRLINE MASTER FOR SALE TO PASSENGERS AIRLINE (EACH FLIGHT) BROKERS BONDED WAREHOUSE SALESMAN TRANSP. FOR SALESMAN RAILROAD MASTER FOR SALE TO PASSENGERS RAILROAD (EACH RR CAR) STEAMSHIP SHIP CHANDLER TRANSPORTATION & DELIVERY WAREHOUSEMAN PERMIT TO TRANSPORT NOT FOR CONSUMPTION RR, SHIP, OR AIRLINE REV. CODE # OF FEE PERMITS AMOUNT REQUESTED TOTAL 3094 3094 3007 3095 3011 3097 ________ ________ ________ ________ ________ ________ $ 500.00 $ 50.00 $ 5000.00 $ 1000.00 $ 200.00 $ 150.00 $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ 3009 3009 3010 3099 3097 3095 ________ ________ ________ ________ ________ ________ $ 500.00 $ 50.00 $ 500.00 $ 1000.00 $ 150.00 $ 500.00 $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ 3097 ________ $ 1500.00 $ ________ CHECK TOTAL $_________ 10/03 REV American LegalNet, Inc. www.FormsWorkFlow.com