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Certificate Of Compliance Application Form. This is a Massachusetts form and can be use in Alcoholic Beverages Commission Statewide.
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Tags: Certificate Of Compliance Application, Massachusetts Statewide, Alcoholic Beverages Commission
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.
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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”).
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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
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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.
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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
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