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 Kim Gainsboro Treasurer and Receiver General Chairman OFFER IN COMPROMISE IN LIEU OF SUSPENSION 1. ________________________________________________________________________ Name of Licensee (include d.b.a., if any) 2. ________________________________________________________________________ Street Address of Premises City/Town 3. ________________________________________________________________________ Mailing Address (if different from line 2) 4. ________________________________________________________________________ Type of License (Restaurant, Package Store, Club, Hotel, Tavern, General on Premise, Veterans Club) 5. The above referenced licensee is submitting this Offer to the Alcoholic Beverages Control Commission in reference to a recent decision, resulting in a suspension: a. Violation Date: b. Total Number of Days Suspended: ________________________ ________________________ 6. If this offer is accepted, the licensee waives all rights to appeal and waives judicial review of the Commission's decision. 7. The licensee certifies that this offer is calculated according to the formula set forth in M.G.L. Chapter 138, §23. 8. The amounts on the following line items (Item #10 and Item #11) may be from either the twelve months immediately preceding the date of this violation (Item # 5a above) or, for licensees that have been in business for more than one year, from the licensee's most recent full fiscal (income tax) year. 9. State the period covered by the figures on lines 10 and 11: 10. Total annual receipts from the sale of ONLY alcoholic beverages: $_________________ 11. Total annual invoiced costs of ONLY alcoholic beverages sold: $_________________ 12. Gross annual alcoholic beverage profit: Item# 10 (receipts) minus Item #11 (invoiced costs) $_________________ 1 _________________ Revised on February 4, 2009 American LegalNet, Inc. www.FormsWorkFlow.com 13. Annual number of days of operation: Example: - 7 day annual operation = 365 - 6 day annual operation = 313 - All others (Special Licenses/Seasonal Licenses) enter actual days of operation during the year preceding the violation date. __________________ 14. Daily gross alcoholic beverage profit: (Divide Line 12 by Line 13) $__________________ 15. Enter 50% of amount indicated on Line 14: $__________________ 16. Daily Fine (enter the greater of Line 15 or $40.00): $__________________ 17. Enter the number of days the License is suspended: (From Line 5b.) __________________ 18. Offer in Compromise: (Multiply Line 16 by Line 17) $__________________ Signed Under the Penalties of Perjury, ______________________________________________________________________________ Signature of Licensee (If Licensee is a Corporation, Manager of Record signs) ACCOUNTANT'S CERTIFICATION I swear under the pains and penalties of perjury that the figures contained in the petition are correct based on the books and records of the above referenced licensee. _____________________________________ Signature of Licensed Public Accountant _____________________ Mass. License No. _____________ Date _____________________________________ Print Name Clearly Licensed Public Accountant ______________________________________ Print Address Clearly Licensed Public Accountant PLEASE NOTE: Offer MUST be delivered to the A.B.C.C. within 20 calendar days after receipt of Commission’s Decision. Offer MUST be accompanied by a Bank or Certified check for the full amount on Line 18 made payable to the Commonwealth of Massachusetts, A.B.C.C. Offer MUST be examined and certified by a Massachusetts Licensed Accountant. 2 Revised on February 4, 2009 American LegalNet, Inc. www.FormsWorkFlow.com