STORAGE PERMITS FOR PUBLIC WAREHOUSEMAN PROCEDURES FOR APPLYING FOR OR RENEWING A PERMIT Enclosed application is to be completed when applying for or renewing your Warehouseman's Permit, under M.G.L. Chapter 138, Section 20A. IMPORTANT - PAYMENT AND MAILING PROCEDURES ALL APPLICANTS MUST COMPLETE THE ENCLOSED MONETARY TRANSMITTAL FORM, ATTACH YOUR PAYMENT AND APPLICATION TO THE TRANSMITTAL FORM AND MAIL TO: BANK OF AMERICA - ALCOHOLIC BEVERAGES CONTROL COMMISSION POST OFFICE BOX 3396 BOSTON, MA 02241-3396 The following must accompany your application: 1. NEW APPLICANTS: If applicant is a corporation, copy of approved Articles of Organization issued by the Secretary of State of Massachusetts. (RENEWAL APPLICANTS) need only submit a copy of amended Articles of Organization if there are changes in the document currently on file with this Commission. 2. PERMIT FEE: $500.00 (payable to the Commonwealth of Massachusetts). 4a. Please provide the date of registration and number or receipt number of registration filed with the Food and Drug Administration in compliance with the Public Health Security and Bioterrorism Preparedness and Response Act of 2002. Please make sure that the tax attestation on the back of the application is completed and signed. RENEWAL APPLICATIONS MUST BE SUBMITTED BY NOVEMBER 30 OF EACH CALENDAR YEAR. WEBSITE ADDRESS: www.mass.gov/abcc If you need assistance on above procedures, please contact Theresa Strianese, (617) 727-3040 x 21. American LegalNet, Inc. www.FormsWorkFlow.com 2010 NO. W.S._____________ APPLICATION FOR A WAREHOUSEMAN'S PERMIT TO STORE AND WAREHOUSE ALCOHOLIC BEVERAGES UNDER SECTION 20A OF CHAPTER 138 OF THE GENERAL LAWS, AS AMENDED. The undersigned being the holder of a Warehouseman's License, issued under Section 1 of Chapter 105 of the General Laws, hereby applies for a permit to store and warehouse alcoholic beverages during the year 20____. 1. APPLICANT NAME:___________________________________________ ADDRESS:____________________________________________________ 2. INDICATE: Individual - Partnership - Corporation 3. DESCRIPTION OF PREMISES: (State every entrance and exit to the particular premises to be covered by the permit, including cellar bulkheads). ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. Detailed description of the premises to be used for storage, (State number of rooms on each floor). ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 4a. Have you registered with the Food and Drug Administration?_____________ FDA Registration NO. ________ Date of Registration:_______________ 5. Business Telephone Number:______________________________________ 6. Is the premises located within 500 feet of a school or building devoted to divine worship such as a church or synagogue? YES_______NO_______ 7. List name(s) and addresses for whom you intend to store alcoholic beverages. Please type or print. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ *Note: Please inform the Commission in writing of any additions or deletions. 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 _____________________________ Federal Identification Number _________________________________ Signature of Individual Date _________________________________ Signature of Corporate Officer Date THE STATEMENTS IN THIS APPLICATION ARE MADE UNDER THE PENALTIES OF PERJURY. BY_________________________________________________________________ Signature of Applicant Date PERMIT FEE: $500.00 Payable to the Commonwealth of Massachusetts 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 PERMITS REQUESTED FEE AMOUNT 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