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 CERTIFICATE OF COMPLIANCE APPLICATION -APPLICATION PROCEDURESPLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FULLY AND ACCURATELY. APPLICATIONS NOT COMPLETED OR PROPERLY SIGNED WILL BE RETURNED. SHOULD YOU NEED ASSISTANCE WITH THIS APPLICATION – PLEASE CONTACT DERON BOBB AT 617-727-3040 Ext. 23. WEBSITE ADDRESS: WWW.MASS.GOV/ABCC Please note, question #3 A) Type or print the location FROM which alcoholic beverages are to be shipped INTO Massachusetts. Do not put the mailing address unless it is the shipping location. There is a separate line at the bottom of the application for the mailing address. B) On the line where indicated, give the area code and telephone number at which an authorized individual can be contacted regarding your Certificate of Compliance application. C) If this is a RENEWAL, please insert your existing license number at the top right hand corner of the application (NO. C…). If this is a NEW LICENSE, please indicate by writing “NEW” at the top right hand corner of the application. - PAYMENT AND MAILING PROCEDURESALL APPLICANTS MUST COMPLETE THE ENCLOSED MONETARY TRANSMITTAL FORM. PRINT OR TYPE YOUR NAME, ADDRESS, CITY/TOWN, STATE, ZIP CODE, COUNTRY ON THE MONETARY TRANSMITTAL FORM, ATTACH YOUR PAYMENT AND APPLICATION TO THE FORM. MAIL TO: BANK OF AMERICA P.O. BOX 3396 BOSTON, MA 02241-3369 CHECKS MUST BE MADE PAYABLE TO THE COMMONWEALTH OF MASSACHUSETTS AND DRAWN ON ANY AMERICAN BANK. Please provide the date of registration and number or receipt number of registration QUUESTION 4A: filed with the Food and Drug Administration in compliance with the Public Health Security and Bioterrorism Preparedness And Response Act of 2002. American LegalNet, Inc. www.FormsWorkFlow.com 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 20-CERTIFICATE OF COMPLIANCE APPLICATION (Please type or print). NO. C…….. (HIGHLIGHT ALL CHANGES FROM LAST APPLICATION FILED Application is hereby made for a certificate as required by the provisions of Section 18B of Chapter 138 of the Massachusetts General Laws. 1._____________________________________________________________________________________________________________ (Full name of business including dba, if any) 2. State below if the applicant is an individual, partnership or corporation. _____________________________________________________________________________________________________________ 3. State below the location of the premise from which alcoholic beverages are to be shipped to Massachusetts licensed Wholesalers and Importers. Each shipping location requires an application. _____________________________________________________________________________________________________________ (Street and number, City/Town, State-Country-if outside U.S.A.) _____________________________________________________________________________________________________________ (Area Code) Telephone Number 4. List the licenses(s) you hold which authorize the exportation or sale of alcoholic beverages to licensees in this Commonwealth and the Licensing Authority, which issued said license (*Must correspond with No. 3 if licensing is mandatory by said State or Foreign Country). NAME LICENSE STATE LICENSING AUTHORITY _____________________________________________________________________________________________________________ 4A. Have you registered with the Food and Drug Administration? Date of Registration: _____________________________________ FDA REGISTRATION NO. ___________________________ 5. Do you or any member of your immediate family or does the Corporation or Partnership that you or any member of your immediate family belong to, own directly or indirectly 10% or more of any financial and/or beneficial interest of any Massachusetts License? No ____ Yes ____ (Note: Chapter 138, Section 18B defines immediate family as “ the certificate holder and his/her spouse and their parents, children, brothers and sisters”). American LegalNet, Inc. www.FormsWorkFlow.com IF YES, List below the name of the individual, title and name of the Massachusetts licensee. (Attach separate sheet if needed. _________________________________________________________________________________________________ _________________________________________________________________________________________________ 6. List any person or entity representing you as an agent, broker or solicitor in Massachusetts. __________________________________________________________________________________________ (Name and Address) _________________________________________________________________________________________ (Phone #) 7. List Massachusetts Wholesaler/Importer(s) who are distributing your products and the products each distributes. (Type or Print.) Please attach additional page if more space is needed. WHOLESALER/IMPORTER PRODUCTS DISTRIBUTED ___________________________________ ___________________________________ ___________________________________ _______________________________________ _______________________________________ _______________________________________ 8. 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 by law. __________________________ Social Security Number ______________________________________ Signature of Individual Corporation Name __________________________ Federal Identification Number Date by:____________________________________ Corporation Officer (if applicable) Date NOTATION REGARDING TAX ATTESTATION: No License, Permit or Certification will be issued unless the attestation is signed whether or not applicant believes he/she is required to file or pay Massachusetts taxes. THE STATEMENTS IN THIS APPLICATION ARE MADE UNDER THE PENALTY OF PERJURY 9. Signature of Applicant_____________________________________________________ (Title or Position Date 10. Mail Address _______________________________________________________________________________ __________________________________________________________________________________________ (Area Code) Telephone Number NOTE: ONLY DULY LICENSED MASSACHUSETTS WHOLESALERS AND IMPORTERS ARE AUTHORIZED UNDER THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS TO IMPORT ALCOHOLIC BEVERAGES INTO THIS STATE BUT THEY ARE PROHIBITED FROM IMPORTING SUCH BEVERAGES FROM OTHERS THAN HOLDERS OF CERTIFICATES FOR WHICH YOU HEREBY APPLY. Fee $500.00 – or $200.00 Money Order/Check (drawn on any American Bank) Payable to the Commonwealth of Massachusetts. *Fee $200.00 if Certification below is applicable and signed: I hereby note that the regular fee is $500.00 .I hereby certify that in paying the $200.00 fee, the applicant herein intends to ship in the Commonwealth no more than 5000 cases of any alcoholic beverage during the calendar year, and further certify that in the event that more than that amount is shipped during the calendar year, the applicant will pay forthwith with an additional fee of $300. 11. ______________________________________________ Signature Date American LegalNet, Inc. www.FormsWorkFlow.com MONETARY TRANSMITTAL FORM 4 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 P. O. BOX 3396 BOSTON, MA 02241-3396 APPLICANT MUST COMPLETE THE FOLLOWING: NAME: ADDRESS: CITY/TOWN: STATE: DATE: COUNTRY: 3 # OF PERMITS, 2 LICENSES, REV. CERTIFICATES CODE REQUESTED 1 LICENSE NAME CERT. OF COMP. CERT. OF COMP. ZIP CODE: (5000 CASES) 4 FEE AMOUNT 5 TOTAL (COL.3 X COL.4) 3100 3100 $ $ $ ________ $ ________ ________ ________ 200 500 CHECK TOTAL $ ________ 09/10/07 REV. u:\deron\coctransmittal American LegalNet, Inc. www.FormsWorkFlow.com U:\deron\cocappl THE COMMONWEALTH OF MASSACHUSETTS ALCOHOLIC BEVERAGES CONTROL COMMISSION THIS SCHEDULE MUST BE TYPEWRITTEN OR PRINTED SCHEDULE OF PRICES TO WHOLESALERS Effective for the month of _______________________________20-This schedule is subject to such rules and regulations as the Alcoholic Beverages Control Commission has or may hereafter adopt. The undersigned licensee (or his duly authorized representative) files the following schedule of prices pursuant to the requirements of Sections 25A and 25B, Chapter 138 of the General Laws, as amended. This schedule is signed under the penalties of perjury. Date ……………………………...………. ……………………………………………………………….. (Street Address of licensed premises) ……………………………………. ……….. ……………………………………………………………….. (Name of Licensee) (City or Town) Signed by ……………………………………… (Signature) Type of Beverage and brand name ……………………………………………………………….. (Massachusetts License or Certificate Number) Capacity of Container Where stated on label Age If a blend % and Proof or kind of Alcoholic Neutral Content Spirits PRICE Per bottle (if so sold) Per Case No. Of Bottles Per Case Discount for Quantity American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com