The Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 2010 APPLICATION FOR A STORAGE PERMIT (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. ADDRESS OF PREMISES: (State every entrance and exit to the particular premises to be covered by the permit, including cellar bulkheads.) ………………………………………………………………………………………………. ……………. ADDRESS ZIP CODE ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… DETAILED DESCRIPTION OF THE PREMISES TO BE USED FOR STORAGE: (State number of rooms on each floor, number of entrances and exits.) ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… 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.) ………………………………………………………………………………………………………………… Have you registered with the Food and Drug Administration?…….. Date of Registration:…………… FDA REGISTRATION NO. ……………………………………………………………………………….. THE ABOVE STATEMENTS ARE MADE UNDER THE PENALTIES OF PERJURY. Signature ………………………………………………………………………………Date: ……………... Position/Title ……………………………………………………………………………………………….. Telephone Number ………………………………………………………………………………………… (Under the provisions of Section 20, of Chapter 138 of the General Laws, as amended, there shall not be granted to any Manufacturer, Farmer-Winery, Farmer-Brewery or Wholesaler and Importer, in the aggregate, more than three American LegalNet, Inc. Storage permits in the Commonwealth, not more than one such permit in any city or town.) www.FormsWorkFlow.com Pursuant to M.G.L. Chapter 62C, Section 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 _____________________________________ Signature of Corporate Officer Date $2,000.00 (Payable to the Commonwealth of Massachusetts) Check …………………… Money Order ..…………… 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. 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: DATE: LICENSE NAME STATE: # OF PERMITS, LICENSES, REV. CERTIFICATE CODE REQUESTED COMMERCIAL ALCOHOL 3008 ________ MANUFACTURERS, ALC. BEV. 3005 ________ FARMER WINERY 3005 _______ FARMER BREWERY 3005 ________ PUB BREWERS 3005 ________ MANUFACTURERS, WINE & MALT 3005 ________ WHOLESALERS ALL AB 3006 ________ WHOLESALERS WM 3006 ________ WHOLESALERS SAC 3006 ________ SALESMAN 3011 ________ TRANSP. FOR SALESMAN 3097 ________ STORAGE 3095 ________ TRANSPORTATION & DELIVERY 3097 ________ CERTIFICATE OF COMPLIANCE 2.17 REGISTRATION 3095 ________ ZIP CODE: FEE AMOUNT TOTAL $ 500.00 $ 9000.00 $22.00 - $110.00 22.00 - $110.00 $ 1000.00 $ 4500.00 $ 10000.00 $ 5000.00 $ 3000.00 $ 200.00 $ 150.00 $ 2000.00 $ 150.00 $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ 1000.00 $ ________ CHECK TOTAL $ ________ 10/03 REV. American LegalNet, Inc. www.FormsWorkFlow.com