The Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 SHIP LICENSE APPLICANTS PROCEDURES FOR APPLYING FOR OR RENEWING A LICENSE Enclosed application is to be completed when applying for a new license or renewal of your ship license. The following must be submitted with your application: 1. If a corporation, copy of approved Articles of Organization, issued by the Secretary of State of Massachusetts. (RENEWAL APPLICANTS: ONLY REQUIRED IF THERE IS A CHANGE IN THE ARTICLES NOW ON FILE WITH THIS COMMISSION.) 2. Copy of APPROVED CURRENT Coast Guard Certification. 3. If vessel is leased or rented, a copy of the agreement. 4. FORM A - Appointment of Manager/Assistant Manager, specify which, separate form on each. (Criminal Offender Record Information Form must be completed, signed and submitted for each Manager/Assistant Manager). 5. LICENSE FEE: $500.00 per ship (payable to the Commonwealth of Massachusetts). A SEPARATE SHIP APPLICATION AND FORM A MUST BE COMPLETED FOR EACH VESSEL LICENSED. Please indicate the full address of the Pier, Wharf where the ship is docked in MASSACHUSETTS and a telephone number where a principal can be reached during the day. 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: Alcoholic Beverages Control Commission Post Office Box 3396 Boston, MA 02241-3396 Application, transmittal form and fee must be submitted by November of the calendar year. OUR WEBSITE ADDRESS: www.mass.gov/abcc TERRI STRIANESE (617) 727-3040 X 21. American LegalNet, Inc. www.FormsWorkFlow.com The Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 2010 Ship License Application (M.G.L. Ch. 138 Sec. 13) 1. TYPE OF APPLICATION: (check one) Corporation __________ Partnership__________ Individual __________ 2. FULL NAME OF BUSINESS, INCLUDE D/B/A IF ANY: ________________________________________________________________________ ________________________________________________________________________ (If applicant has a dba, applicant must include a copy of the certificate of doing business, required under Massachusetts General Law Ch. 110, s. 5, regardless of which name will appear on the license.) 3. APPLICANT’S BUSINESS ADDRESS ________________________________________________________________________ ________________________________________________________________________ 4. BUSINESS TELEPHONE NUMBER: (___________)____________________________ (AREA CODE) 5. BUSINESS FAX NUMBER: ( ) (AREA CODE) 6. NAME OF SHIP TO BE LICENSED:_________________________________________ 7. TYPE OF LICENSE: All-Alcoholic 8. Wine and Malt ____________ SHIP DOCKED AT: ___________________________________________________ MONTHS IN OPERATION: FROM __________________ TO ___________________ American LegalNet, Inc. www.FormsWorkFlow.com 9. STATE ALL PERSONS HOLDING A BENEFICIAL INTEREST IN APPLICANT BUSINESS, INCLUDING BUT NOT LIMITED TO: owners, partners, proprietors, officers, directors and stockholders. Name: __________________________________________________________________ Home Address: ___________________________________________________________ Soc. Sec. No.: ____________________________________________________________ Date of Birth: ____________________________________________________________ Tel. No.: _______________________________________________________________ Citizenship: _____________________________________________________________ Nature of Beneficial Interest: ________________________________________________ Name: __________________________________________________________________ Home Address: ___________________________________________________________ Soc. Sec. No.: ____________________________________________________________ Date of Birth: ____________________________________________________________ Tel. No.: ________________________________________________________________ Citizenship: _____________________________________________________________ Nature of Beneficial Interest: ________________________________________________ Name: _________________________________________________________________ Home Address: __________________________________________________________ Soc. Sec. No.: ___________________________________________________________ Date of Birth: ____________________________________________________________ Tel. No.: ________________________________________________________________ Citizenship: _____________________________________________________________ Nature of Beneficial Interest: ________________________________________________ (ATTACH ADDITIONAL SHEET IF NECESSARY) 9A. DOES APPLICANT OR ANY OTHER PERSON HOLD OR HAVE AN INTEREST IN ANY OTHER MASSACHUSETTS OR OUT-OF-STATE SHIP’S LIQUOR LICENSE? Yes No If yes, name each vessel and the companies, corporations, associations or other entity they are listed under: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 9B. HAS APPLICANT OR ANY OTHER PERSON OR ENTITY HAD THEIR SHIP’S LICENSE SUSPENDED, REVOKED OR CANCELLED? Yes No ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 9C. HAS APPLICANT OR ANY PERSON OR ENTITY BEEN CONVICTED OF ANY FELONY? Yes No If yes, state details. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 10. IS THE APPLICANT THE OF THE SHIPPING COMPANY? 11. IS THE APPLICANT A: LESSEE OTHER __________ OWNER OR SUBLESSEE OPERATOR ASSIGNEE If other, please explain: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 12. IS SHIP FULLY BUILT AND READY FOR INSPECTION? ______________________ 13. PROVIDE A FULL AND COMPLETE DESCRIPTION OF THE SHIP TO BE LICENSED INCLUDING ITS MAXIMUM CAPACITY AND SIZE OF CREW: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ MANAGER - (Questions 14 thru 19) PROVIDE THE FOLLOWING INFORMATION ON THE MANAGER IN CHARGE OF THE SALES AND SUPERVISION OF THE ALCOHOLIC BEVERAGES: (The manager must be at least 21-years-old). 14. NAME: __________________________________________________________ First Middle Last American LegalNet, Inc. www.FormsWorkFlow.com 15. HOME ADDRESS: Street: _________________________________________________________________ City/Town: _____________________________________________________________ Zip Code: _______________________________________________________________ 16. DATE OF BIRTH: ________________________________________________________ 17. SOCIAL SECURITY NO.: _________________________________________________ 18. TELEPHONE NO. /AREA CODE: ___________________________________________ 19. HAS THE MANAGER BEEN CONVICTED OF A FELONY? Yes No If yes, please describe offense (s) (specific charge) and disposition (fine, penalty, etc.) ____________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 20. ALL PERSONS LISTED ON QUESTION 9 AND MANAGER MUST COMPLETE THE CERTIFICATION AND AUTHORIZATION BELOW. Certification and Authorization for Release of Information This application is signed under penalty of perjury. Each signer authorizes the release of any information pertaining to the applicant or the signer, including but not limited to any criminal records to the Alcoholic Beverages Control Commission. SIGNATURE 21. PRINT OR TYPE NAME TITLE DATE NAME OF ATTORNEY, IF ANY, FILING ON BEHALF OF THE APPLICANT: ________________________________________________________________________ Name Office Address Area Code/Tel. No. Fax No. Time of Filing Date of Filing American LegalNet, Inc. www.FormsWorkFlow.com 22. 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. ________________________________________________________________________ Signature of applicant or authorized corporate officer ________________________________________________________________________ Title Date _______________________________________________________________________ If Individual Social Security Number (OR) Applicant Federal ID Number Note: If applicant is a corporation, a copy of the approved articles of organization, issued by the Massachusetts Secretary of State must be included. A copy of approved U.S. Coast Guard Certificate of Inspection must also be submitted. Fees: Sell: Transport: Payable to the Commonwealth of Massachusetts $500.00 $1,500.00 American LegalNet, Inc. www.FormsWorkFlow.com FORM A Application for appointment of Ship Manager/Assistant Manager (ABCC REGULATION 204 CMR 19.06) 1. LICENSEE NAME: __________________________________________________________ 2. ADDRESS: ________________________________________________________________ 3. AREA CODE AND TELEPHONE NUMBER: ____________________________________ 4. AREA CODE AND FAX NUMBER: ____________________________________________ 5. NAME OF SHIP: ____________________________________________________________ 6. PORT: ____________________________________________________________________ 7. NAME OF PROPOSED MANAGER/ASSISTANT MANAGER: _____________________ 8. HOME (STREET) ADDRESS: _________________________________________________ 9. AREA CODE AND TELEPHONE NUMBER: ____________________________________ 10. PLACE OF BIRTH: __________________________ 11. DATE OF BIRTH: __________ 12. REGISTERED VOTER: ______ YES _____ NO 12a. WHERE? _______________ 13. U.S. CITIZEN: ______YES ______ NO 14. SOCIAL SEC. NO.: ________________ 15. COURT AND DATE OF NATURALIZATION (IF APPLICABLE): ___________________ (Submit proof of citizenship and/or naturalization). 16. FATHER’S NAME: ________________ 17. MOTHER’ S MAIDEN NAME: __________ 18. CRIMINAL RECORD (Massachusetts, Military any other State or Federal): ANY ARREST OR APPEARANCE IN CRIMINAL COURT CHARGED WITH A CRIMINAL OFFENSE REGARDLESS OF FINAL DISPOSITION: ________ YES ________ NO (MUST CHECK EITHER YES OR NO) IF YES, PLEASE DESCRIBE OFFENSE (S) (SPECIFIC CHARGE) AND DISPOSITION, (FINE, PENALTY, ETC.) __________________________________________________________________________ __________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 19. PRIOR EXPERIENCE IN THE LIQUOR INDUSTRY: __________YES _________ NO IF YES, PLEASE DESCRIBE: ______________________________________________________________________________ ______________________________________________________________________________ 20. FINANCIAL INTEREST, DIRECT OR INDIRECT, IN THIS OR ANY OTHER LIQUOR LICENSE, PERMIT OR CERTIFICATE: ________ YES _______ NO IF YES, PLEASE DESCRIBE: ______________________________________________ __________________________________________________________________________ __________________________________________________________________________ 21. EMPLOYMENT FOR THE LAST TEN YEARS: (Dates, Position, Employer, Address) _____________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________________ 22. HOURS PER WEEK TO BE SPENT ON THE LICENSED SHIP: ____________________ NOTE: Every applicant must complete, sign and date the attached Criminal Offender Record Information Form. This form will then be forwarded to the Criminal History Systems Board by this Commission for a record check. 23. I HEREBY SWEAR UNDER THE PAINS AND PENALTIES OF PERJURY THAT THE INFORMATION I HAVE GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND THAT I HAVE READ ABCC REGULATION 204 CMR 19.00 “SHIPS”. ____________________________ APPLICANT SIGNATURE ___________________ DATE 24. I HEREBY SWEAR UNDER THE PAINS AND PENALTIES OF PERJURY THAT I HAVE READ THIS APPLICATION IN FULL AND TO THE BEST OF MY KNOWLEDGE AND BELIEF THE INFORMATION SET FORTH IS TRUE. I REQUEST THAT THE APPLICANT BE APPOINTED AS A: (check which applies) SHIP MANAGER __________________ ASSISTANT MANAGER __________________ _____________________________________ LICENSEE SIGNATURE _________________ DATE American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETION OF THE ATTACHED CRIMINAL OFFENDER RECORD INFORMATION FORM The applicant for appointment of Manager or Assistant Manager must complete, sign and date the attached CORI request form. The completed form is to be returned to the Alcoholic Beverages Control Commission to be signed and forwarded to CORI. Please type or use ink, information except where a signature is required, DO NOT USE PENCIL. FIRST PARAGRAPH - Fill in where indicated the position applying for. Applicant/Employee Signature is required. Questions #1 through #5 - Applicant Information Questions #6 through #7 - Licensee Information Licensee Name is the name of the corporation, individual, partnership or ship for whom applicant seeks employment. OUR WEBSITE ADDRESS: www.mass.gov/abcc If you should have any questions, please call Terri Strianese at (617) 727-3040 x 21. American LegalNet, Inc. www.FormsWorkFlow.com The Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 GABCCL G CORI REQUEST FORM The Alcoholic Beverages Control Commission has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As an applicant/employee for the Position of _______________________, I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge. ___________________________________ Applicant/Employee Signature APPLICANT/EMPLOYEE INFORMATION (PLEASE PRINT) 1. ____________________ LAST NAME _________________ FIRST NAME _________________ MIDDLE NAME 2. MAIDEN NAME OR ALIAS (IF APPLICABLE): ____________________________________ 3. DATE OF BIRTH:________________ 5. HOME ADDRESS: 4. SOCIAL SECURITY NUMBER: ______-____-______ ___________________________________________________ ___________________________________________________ 6. LICENSEE NAME: ___________________________________________________ 7. LICENSEE ADDRESS: ___________________________________________________ ___________________________________________________ ************************************************************************************************* **** A.B.C.C. REQUESTED BY:______________________________________________________________ SIGNATURE OF A.B.C.C. CORI AUTHORIZED EMPLOYEE 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 Brokers (additional) 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. # OF CODE FEE TOTAL PERMITS AMOUNT REQUESTED 3094 3094 3007 3007 3095 3011 3097 ________ ________ ________ ________ ________ ________ ________ $ 500.00 $ 50.00 $ 5000.00 $ 500.00 $ 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 $_________ 3/04 REV American LegalNet, Inc. www.FormsWorkFlow.com