2010 TD__________ ALCOHOLIC BEVERAGES CONTROL COMMISSION DEPARTMENT OF THE STATE TREASURER APPLICATION FOR A LICENSEE'S PERMIT TO TRANSPORT AND DELIVER CERTAIN ALCOHOLIC BEVERAGES Under Section 22 of Chapter 138 of the General Laws, as Amended ……………..….Mass…..…...…20……………… The undersigned being the holder of a ……………………………….…………………. license (State whether licensed as a Manufacturer, Wholesaler and Importer, Hotel, Restaurant, Club or Package Goods Store) for the sale of ...............................................................................beverages (State whether all kinds of alcoholic beverages, wines and malt beverages only) At…………………………………………………………………………………………………………MA (Street and Number, City, Town/Zip Code) Hereby applies for a permit to transport and deliver such beverages in a motor vehicle. Make and type of vehicle ……………...........Motor vehicle identification number .......................................... ................................................................... Registration Number ……………....................................... Usually garaged or kept at …………………………………………………….......................................... Name and address of the registrant ………………………………………………………………………………………………...................... if the vehicle is owned or leased by an employee, state in what capacity he is employed …………………………………………….................................................................................................. (If the vehicle is leased by the applicant or his employee this application shall be accompanied by a copy of a written authorization for its use to transport and deliver alcoholic beverages unless this information has been furnished to the Commission in connection with a previous application.) The Above Statements are made under the penalties of perjury Permit Fee $150.00 Enclosed find Applicant…………………………………………………………….. (Name of License (Telephone number) or Corporate Name) Check ……………………………. By …………………………………………………. (Signature and Title) Money Order …………………….. 1 American LegalNet, Inc. www.FormsWorkFlow.com Note: Section 22 referred to above provides in part as follows” Licensee for the sale of alcoholic beverages or alcohol, as the case may be, may transport and deliver anywhere in the Commonwealth, alcoholic beverages or alcohol lawfully bought or sold by them, in vehicles or leased by them or their employees, if each vehicle used for such transportation and delivery is covered by a permit issued by the commission, provided, that vehicles owned or leased by holders of permits under section nineteen A (Salesman) shall be used only for the transportation of samples.” Pursuant to M.G.L. Ch. 62C, 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 _______________________________ Signature of Individual Date or Corporate Name ______________________________ Federal Identification Number by:_____________________________ Corporate Officer Date (if applicable) 2 American LegalNet, Inc. www.FormsWorkFlow.com Procedures for Renewal of Permit to Transport and Deliver Alcoholic Beverages for the Calendar Year Application is enclosed to renew your Transport and Deliver Permits for the calendar year. (Application may be duplicated.) At the top right of each application, you will see the letters TD-, please add the TD-number from last years permit. If the VIN is different, we will change it on our data system. The application must be signed by the applicant and a contact telephone number given. Please type or print information on the application. If the VIN number is not legible, the application will be returned. Renewal application (s) should be submitted by November 30, 2008 with the required fee of $150.00 per vehicle. Mail Payment and Application to: Alcoholic Beverages Control Commission Post Office Box 3396 Boston, MA 02241-3396 If you should need assistance on above procedures, please contact Terri Strianese at 617 727-3040, Ext.21. (our website address): WWW.MASS.GOV/ABCC 3 American LegalNet, Inc. www.FormsWorkFlow.com MONETARY TRANSMITTAL This transmittal must accompany your application in order to assure proper credit. Please do not send cash. 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: 1 License Name 2 Rev. Code 4 Fee Amount 5 Total (Col.3 x Col.4) 3094 3094 3007 3095 3011 3097 3009 3009 3010 3099 3097 3095 3 # of Permits Requested ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Airline Master for sale to passengers Airline (each flight) Brokers Bonded Warehouse Salesman Transport for Salesman Railroad Master for sale to passengers Railroad (each car) Steamship Ship Chandler Transportation & Delivery Warehouseman Permit to Transport not for consumption Railroad, Ship, or Airline $ 500.00 $ 50.00 $ 5000.00 $ 1000.00 $ 200.00 $ 150.00 $ 500.00 $ 50.00 $ 500.00 $ 1000.00 $ 150.00 $ 500.00 $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ 3097 ________ $ 1500.00 $ ________ Check Total $_________ 10/03 rev 4 American LegalNet, Inc. www.FormsWorkFlow.com