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Application For Alcoholic Beverage License For Retail Sale Form. This is a Massachusetts form and can be use in Alcoholic Beverages Commission Statewide.
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Tags: Application For Alcoholic Beverage License For Retail Sale, Massachusetts Statewide, Alcoholic Beverages Commission
The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
239 Causeway Street
Boston, MA 02114
Application for Alcoholic Beverage License for Retail Sale
City/Town: ________________________
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New License
Transfer of License
Transfer of Stock
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New Officer/Director
Other _______________
(specify)
Section 1
Name to appear on the license: ___________________________________________________________________
Business Name (d/b/a, if different): ________________________________________________________________
Manager of Record: ___________________________________
FID of Licensee: ________________________
Address of Premises: __________________________________________________ Zip Code: _______________
Phone number of premises: ______________________________________________________________________
Section 2 Type of license: (check one only)
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Club
General on Premise
Innholder
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Package Store
Restaurant
Tavern
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Veterans Club
Other ________________
Section 3 License Category
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All Alcoholic
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Wine and Malt
Malt Only
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Wine Only
Wine and Malt with Cordials Permit
Section 4 License Class
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Annual
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Seasonal
Section 5 Person (attorney if applicable) who can be contacted concerning this application
Name: _______________________________________________________________________________________
Address: _____________________________________________________________________________________
Phone Number: _______________________________________________________________________________
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Section 6 Give a full description of the premises to be licensed, including location of all entrances and exits:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
6a.
Seating Capacity: ____________________________
Occupancy Number: __________________________
Section 7
Applicant is an:
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Association
Partnership
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Corporation
Non-profit corporation
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Individual
LLC
Section 8 If applicant is an individual or partnership – List for individual or each partner:
Full Name
Home Address
DOB
8a. Is individual or all partners United States citizens?
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SSN
Yes
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No
Yes
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No
If no, specify citizenship: ___________________________________
8b. Is individual or all partners involved at least twenty-one years old?(
)
Section 9 If the applicant is a corporation, complete the following:
State of Incorporation: _________________________
Date of Incorporation: ________________________
Fiscal Year Ends: ____________________________
Date qualified to do business in MA: ____________
9a. How many shares of stock are authorized: ______________
How many shares are issued: ___________
Provide in the box the names if all officers, directors, stockholders and manager.
Use * to indicate director
Title
Full Name
Home Address
DOB
SSN
Shares of stock
owned or controlled
9b. Attach a copy of the vote by the Board of Directors appointing a manager or principal representatives.
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9c. If the applicant is a corporation, answer the following questions:
1. Are the majority of directors United States citizens?
2. Are the majority of directors citizens of Massachusetts?
3. Is the manager or principal representative a U.S. citizen?
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Yes
Yes
Yes
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No
No’
No
Section 10 If the applicant is an association, provide in the box below the names of all
association officers and members.
Title
Full Name
Home Address
DOB
SSN
Phone Number
10b. Attach a list of all members of the LLC.
Section 11 Will there be any construction, remodeling, redecorating or building on the premises for this license?
( )
Yes
( )
No
(If yes complete a,b, c and d)
a. Give an exact description of the construction, remodeling, redecorating or building on the premises:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
b. What are the estimated costs: ___________________________________________________________________
c. What is the construction schedule: _______________________________________________________________
d. State all sources of construction financing: ________________________________________________________
_____________________________________________________________________________________________
Section 12
Do you own the premises?
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) Yes
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As an individual
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No. If yes, please respond to the question below.
Jointly _________________________Name of Realty Trust
__________________________________________Name of Corporation
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Other______________________________
(If you do not own the premises to be licensed, provide the following information about the owner.)
Name: ________________________________________
Phone Number: _____________________________
Address: _____________________________________________________________________________________
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12a.
If a lease or rental, provide the following information: $________________ per _____________________
(month, year, etc.)
Beginning date of lease _____________________
(provide copy of the lease)
Ending Date of lease___________________
FINANCIAL
Section 13
What assets were purchased and cost?
Equipment: $__________
Furniture: $_____________
Goodwill: $___________
Inventory: $___________
License: $______________
Premise: $____________
13a.
Total Purchase Price: $_______________________
13b.
Identify below all sources of financing:
Mortgage: $_________________________________
Seller: $____________________________
Cash: $_____________________________________
Other (specify): $_____________________
Document all sources e.g. Loan papers, checking accounts, stock sales, etc.
13c.
All other terms and conditions: ____________________________________________________________________
(provide purchase and sale documents)
13d. Are you seeking approval for license to be pledged:
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Yes
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No
If yes, to whom: ________________________________________________________________________
13e. Will the inventory be pledged:
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Yes
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No
If yes, specify to whom: __________________________________________________________________
13f.
If a corporation, are you seeking approval for any corporate stock to be pledged:
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Yes
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No
If yes, identify to whom and identify the number of shares: ______________________________________
OWNERSHIP INTERESTS
Section 14 State the following information for all persons or entities who will have any direct or indirect beneficial
or financial interest in this license:
Full Name
Home Address
DOB
SSN
Phone Number
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14a. Describe all types of beneficial or financial interest each person or entity identified in Question 14 will have in
this license:
Person or entity
Beneficial or financial interest
14b. Does any person or entity listed in Question 14 have any direct or indirect beneficial or financial interest in any
other license granted under Chapter 138?
(
Name
Type of license
)
Yes
(
License Name and Address
)
No
Description of Interest
14c. Has any person or entity named in Question 14 ever held a license or a beneficial interest in a license issued
under Chapter 138 which is not presently held?
( )
Yes
( )
No
(If yes, provide the following for each person or entity.)
Name
Type of License
License Name and Address
Date ownership surrendered
14d. Describe how all licenses in Question 14c were terminated (e.g. transfer of ownership, non-renewal, surrender,
etc.)
Date
License
Reason why the license was terminated
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14e. Has any person or entity named in Question 14 ever had a license suspended, revoked or cancelled?
( )
Yes
( )
No
(If yes, provide the following information)
Date
License
Reason why the license was suspended, revoked or cancelled
14f. Has any person or entity named in Question 14 ever been convicted of violating any state, federal or military
law?
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Yes
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No
15.
a.
b.
c.
d.
e.
Each individual applicant must sign.
Applications by a partnership must be signed by a majority of the partners.
Applications by a corporation must be signed by an officer authorized by a vote of the
corporations Board of Directors.
Applications by an association must be signed by a majority of the members if the governing
body. All signers must have answered question 10.
False information or failure to disclose are reasons to revoke a license or deny a license
application.
Signed and subscribed to under the penalty of perjury, this ___ day of _________________, 20______ .
By: Signature of Full Name
Title
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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