The Commonwealth of Massachusetts Department of the State Treasurer Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 2010 Transportation Permit Application: General Express or Caterers (Chapter 138, Section 22) NOTE: FOR RENEWAL, APPLICATION MUST BE IN BY NOVEMBER 30TH OF EACH YEAR. ABCC website address: www.mass.gov/abcc 1. Name to appear on the license: (including dba, if any) 2. ______ Individual ____ Partnership _____ Corporation 3. ______ Trucking/General Express _____ Caterer 4. ______ New Permit _______ Renewal 5. Business Address: ____________________________________________________________ 5a. Mailing address: _____________________________________________________________ 6. Business Telephone: _____________________ Fax: ___________________________ 6a. Have you registered with the Food and Drug Administration? ___________________ FDA REGISTRATION NO._______________ Date of Registration: ________________ 7. For all persons having a beneficial interest in the applicant business, state: NAME INTEREST ADDRESS NATURE OF BENEFICIAL ______________________________________________________________________________ ______________________________________________________________________________ 8. Has any Individual, Member of a Partnership, or if a Corporation, any Officer or Director thereof, and any person listed in #7 been convicted of a felony within the past five years or of a misdemeanor within the last three years? ____ YES ____ NO (If YES, please attach, for each person, a supplemental answer sheet stating that person’s name, date of birth, and social security number, and for each offense, state the court, date of conviction, offense, and disposition). 9. ______Common Carrier _____ Contract Carrier ________ Private Carrier American LegalNet, Inc. www.FormsWorkFlow.com 10. State the address where the vehicle or vehicles are usually garaged or kept. 11. Does the applicant certify that the applicant has filed all state tax returns and paid all state taxes under law? _____ YES _____NO _________________________ Social Security Number ___________________________________ Federal Identification Number THE STATEMENTS IN THIS APPLICATION ARE MADE UNDER THE PENALTIES OF PERJURY. By _________________________ Signature of Applicant ______________________ Date PLEASE ATTACH THE FOLLOWING: 1. PERMIT FEE: $150.00 for the master permit; $50.00 for each certified copy: Make check Payable to: COMMONWEALTH OF MASSACHUSETTS. (A certified copy must be obtained for each vehicle which is to transport alcoholic beverages). STATE NUMBER OF CERTIFIED COPIES NEEDED: _____________________ 2. Caterers must attach a copy of the caterer’s permit issued by the city or town board of health. 3. (MASSACHUSETTS CORPORATIONS ONLY) must attach (FOR NEW APPLICATIONS) a copy of the corporate articles of organization approved by the Secretary of State, OR (FOR RENEWALS ONLY) a copy of the corporation’s most recent updated articles of organization. NOTICE Permit for transportation only. Does not permit purchase or resale of alcoholic beverages. All vehicles licensed to caterers for transport and delivery must be registered in Massachusetts. Caterers may only receive, transport, deliver or store alcoholic beverages obtained from M.G.L. Chap. 138, Section 15 (packages stores) licensees only. Caterers may only receive transport deliver and store within the Commonwealth of Massachusetts. ABCC Regulation 204 CMR 2.05 (3): “The person in charge of any vehicle used for the delivery of alcoholic beverages or alcohol shall carry an invoice or sales slip, starting the name and addresses of the purchaser and seller, the date and the amount of the purchase, also itemizing the number of various kinds of containers and the kinds, quantities and brands of alcoholic beverages or alcohol.” Private Carriers may not charge customers for transportation or delivery of alcoholic beverages. 1. 2. 3. 4. 5. 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 GENERAL EXPRESS OR CATERERS (CHAPTER 138, s. 22) REQUEST FORM FOR ADDITIONAL VEHICLES NUMBER OF CERTIFIED COPIES FOR EACH TRUCK: ____________. EXPRESS MASTER PERMIT NUMBER: XP- _________. ________________________________________________________________________ DATE ________________________________________________________________________ NAME OF COMPANY ________________________________________________________________________ ADDRESS ________________________________________________________________________ SIGNATURE OF CORPORATE OFFICER Have you registered with the Food and Drug Administration?______________ FDA Registration NO._________________ Date of Registration:__________ FEE: $50.00 FOR EACH CERTIFIED COPY (PAYABLE TO COMMONWEALTH OF MASSACHUSETTS) PLEASE SEND CHECK TO: POST OFFICE BOX 3396, BOSTON, MA 02241-3396 American LegalNet, Inc. www.FormsWorkFlow.com MONETARY TRANSMITTAL FORM 2 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: COUNTRY: ZIP CODE: DATE: LICENSE NAME REV. CODE # OF FEE PERMITS AMOUNT REQUESTED TOTAL (COL.3 X COL.4) EXPRESS MASTER EXPRESS (EACH VEHICLE OR ADDITIONAL) 3096 3096 ________ ________ $ ________ $ ________ $ 150.00 $ 50.00 CHECK TOTAL $_______ 10/03 REV American LegalNet, Inc. www.FormsWorkFlow.com