Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc The APPLICATION FOR A WINERY SHIPMENT LICENSE MONETARY TRANSMITTAL FORM [APPLICATION MUST BE COMPLETED ONLINE] ECRT CODE: DIRE CHECK PAYABLE TO ABCC OR COMMONWEALTH OF MA: $100.00 (CHECK MUST DENOTE THE NAME OF THE LICENSEE CORPORATION, LLC, PARTNERSHIP, OR INDIVIDUAL) CHECK NUMBER IF USED EPAY, CONFIRMATION NUMBER: A.B.C.C. LICENSE NUMBER (IF AN EXISTING LICENSEE): LICENSEE NAME: ADDRESS: CITY/TOWN: STATE ZIP CODE LICENSE TYPE FEE # OF PERMITS WINERY SHIPMENT LICENSE $100.00 1 COST $100.00 YOU MUST MAIL THIS TRANSMITTAL FORM ALONG WITH YOUR CHECK AND COMPLETED APPLICATION TO: ALCOHOLIC BEVERAGES CONTROL COMMISSION P. O. BOX 3396 BOSTON, MA 02241-3396 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) YEAR 20 1. Licensee Information: Name of Applicant: Business Name (d/b/a if different) : Mailing Address: City/Town: Manager of Record: Phone Number of Premises: Email: Other Phone: State Zip Website: Contact Person concerning this application (attorney if applicable): Name: Address: City/Town: Contact Number : Fax Number: State Zip Email: 2. Description of the Manufacturing Premises: Address of Premises for the Manufacturing of Wine: City/Town: State Is the entire building to be licensed? Zip Yes Phone Number of Premises: No Please describe below or attach a detailed floor plan of premises to be licensed, clearly delineate licensed from unlicensed areas and include dimensions, square footage and entrances/exits. 3. Sales Information: a. Is the location of premises from which wine sales will be made to Massachusetts retailers licensed under M.G.L. c. 138, §§12 and Yes No 15, different from above? If yes, please state address: Phone Number of Premises: b. Is the location of premises from which wines will be sold to Massachusetts consumers, different from above? If yes, please state address: Yes No Phone Number of Premises: American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 4. Shipment Information: c. Is the location of premises from which shipment will be made for Massachusetts retailers licensed under M.G.L. c. 138, §§12 and No 15, different from above? Yes If yes, please state address: Phone Number of Premises: d. Is the location of premises from which wine is to be shipped to Massachusetts consumers, different from above?Yes If yes, please state address: No Phone Number of Premises: 5. Occupancy of Premises: For each location identified in §3 & §4 above, by what right does the applicant have possession and/or legal occupancy of the premises? Landlord is a(n): Other Please Select Phone: Name Address: City/Town: Lease Term: Beginning Date Rent: Please select per year State Zip Ending Date Rent: per month IMPORTANT ATTACHMENTS: A copy of the signed lease must accompany this application in order for it to be processe 6. Existing License(s) to Manufacture, Export and Sell at Retail: List the license(s) you hold which authorize the manufacture, exportation and retail sale of wine to consumers and sale of wine to licensed retailers: (Attach a copy of each license) Name License Type License Address *If additional space is needed, please use last page* American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 7. Prior License at Location: Has the premises been previously licensed? Yes No By Whom: Licensed Term: Beginning Date: Ending Date: 8. Safety and Tax Registration: Have you registered with the Food and Drug Administration? Yes No Registration Date: Have you registered with the Massachusetts Department of Revenue to pay sales taxes and taxes due under M.G.L. c. 138, §21? Yes No Registration Date: 9. Licensee Structure: The Applicant is a(n): Other : Please select If the applicant is a Corporation or LLC, complete the following: Date of Incorporation/Organization: State of Incorporation/Organization: Shares of stock are authorized: Shares of stock are issued: IMPORTANT ATTACHMENTS: Attach the vote by the Board of Directors or LLC Managers appointing a manager or principal representative as well as the Articles of Organization as filed with the Secretary of State's Office. 10. Interests in this License: List all individuals involved in the entity (e.g. corporate stockholders, directors, officers and LLC members and managers) and any person or entity with a direct or indirect, beneficial or financial interest in this license (e.g. landlord with a percentage rent based on alcohol sales). IMPORTANT ATTACHMENTS: All individuals or entities listed below are required to complete a Personal Information Form. Name Title Beneficial Interest Stock or % Owned *If additional space is needed, please use last page. American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 11. Existing Interests in Other Licenses: a. Does the applicant hold a direct or indirect beneficial or financial in any other license, permit or certificate to sell No alcoholic beverages?Yes If yes, list said interest below: Name License Type Licensee Name & Address Please Select Please Select Please Select Please Select 12. Previously Held Interests in Other Licenses: Has any individual or entity who has a direct or indirect beneficial interest in this license ever held a direct or indirect, No beneficial or financial interest in a license to sell alcoholic beverages, which is not presently held? Yes If yes, list said interest below: Name Licensee Name & Address Date Reason Terminated Please Select Please Select Please Select 13. Disclosure of License Disciplinary Action: Have any of the disclosed licenses to sell alcoholic beverages listed in §11 and/or §12 ever been suspended, revoked or No cancelled? Yes If yes, list said interest below: Date License Reason why license was Suspended, Revoked or Cancelled 14. Criminal Record: Has any individual who has a direct or indirect beneficial interest in this license ever been convicted of a municipal, state, No federal or military crime? Yes IMPORTANT ATTACHMENTS: If yes, the individual must provide an affidavit as to any and all charges as well as the disposition. American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 15. Existing Wholesalers: Identify ALL Massachusetts Wholesaler(s)/Importer(s) who are distributing your product(s) and the product(s) each distributes: Wholesaler/Importer Products Distributed *If additional space is needed, please use last page. 16. Wine Produced Last Year by Affiliates: Please identify all affiliates, franchisors, franchisees, subsidiaries, and parent corporations of the applicant and the gallons of wine produced by each in the last calendar year: Name Address Telephone FID# Gallons of Wine *If additional space is needed, please use last page. 17. Wine Produced Last Year by Applicant: Please identify the total gallons of wine produced last calendar year by the applicant and the state and federal agencies to which you reported this quantity produced: Gallons of Wine State Agency Federal Agency *If additional space is needed, please use last page. American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 18. Wine Shipped Last Year by Applicant and Affiliates: Please identify the total gallons of wine shipped into Massachusetts last calendar year by the applicant and all affiliates, franchisors, franchisees, subsidiaries, and parent corporations of the applicant: Name Address Telephone FID# Gallons of Wine *If additional space is needed, please use last page. 19. Proof of Age for Sale to Consumers: Please identify in detail all methods by which you will obtain proof of age before making any sale of wine to consumers in Massachusetts: *If additional space is needed, please use last page. 20. Wine Produced Last Year by Applicant: Please identify the total gallons of wine produced last calendar year by the applicant and the state and federal agencies to which you reported this quantity produced: Do you intend to sell to wine at wholesale to a person licensed under M.G.L. c. 138, §§12, 14, 15 or 18? Yes No a. If yes, please identify in detail all methods by which you will comply with M.G.L. c. 138, §25A and not discriminate, directly or indirectly, in price, in discounts for time of payment or in discounts on quantity of merchandise sold, between one wholesaler and another wholesaler, or between one retailer and another retailer purchasing alcoholic beverages bearing the same brand or trade name and of like age and quality. *If additional space is needed, please use last page. b. If yes, also please identify in detail all methods by which you will comply with M.G.L. c. 138, §25 regarding the sale and delivery of wine on credit to licensees under M.G.L. c. 138, §§12, 15. *If additional space is needed, please use last page. American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR A WINERY SHIPMENT LICENSE (CH.138, §19F) 21. Transportation and Delivery: Please identify in detail all persons or businesses that are licensed under M.G.L. c. 138, §22 that will be making any delivery of wine on your behalf to consumers in Massachusetts. *If additional space is needed, please use last page. 22. Proof of Age for Delivery to Consumers: Please identify in detail the methods by which the delivery person will obtain proof of age before making any delivery of wine to consumers in Massachusetts. *If additional space is needed, please use last page. Pursuant to M.G.L. Ch. 62C, Sec. 49A, I certify under the penalties of perjury that, I have filed all state tax returns and paid all state taxes required under law. I further understand that each representation in this application is material to the determination of the application and state under penalty of perjury that all statements and representations therein are true. Signature Date Title American LegalNet, Inc. www.FormsWorkFlow.com The Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc Manager Application All proposed managers are required to complete a Personal Information Form, and attach a copy of the corporate vote authorizing this action and appointing a manager. 1. Licensee Information: Business Name (d/b/a) Legal Name of Licensee: Address: City/Town State ABCC License Number: (If existing licensee) Zip Code Phone Number of Premise 2. Manager Information: Name: Cell Phone Number: Are you a U.S. Citizen: Yes No Court and Date of Naturalization: (Submit proof of citizenship and/or naturalization such as Voter's Certificate, Birth Certificate or Naturalization Papers) List the number of hours per week you will spend on the licensed premises: Have you ever been charged or convicted of a state, federal or military crime? Yes No If yes, attach an affidavit as to all charges and disposition. Do you now, or have you ever, held any direct or indirect, beneficial or financial interest in a license to sell No alcoholic beverages? Yes If yes, please describe: Have you ever been the Manager of Record of a license to sell alcoholic beverages that has been suspended, No revoked or cancelled? Yes If yes, please describe: *If additional space is needed, please use the last page* Please list your employment for the past ten years (Dates, Position, Employer, Address and Telephone): *If additional space is needed, please use the last page* I hereby swear under the pains and penalties of perjury that the information I have provided in this application is true and accurate: Signature Date American LegalNet, Inc. www.FormsWorkFlow.com The Commonwealth of Massachusetts Alcoholic Beverages Control Commission 239 Causeway Street Boston, MA 02114 www.mass.gov/abcc Personal Information Form Each individual listed in §10 of this application must complete this form. 1. Licensee Information: Business Name (d/b/a) Legal Name of Licensee: Address: City/Town ABCC License Number: (If existing licensee) State Phone Number of Premise Zip Code EIN of License: 2. Personal Information: Individual Name Home Phone Number: Address: City/Town State Social Security Number Zip Code Date of Birth Place of Employment Have you ever been convicted of a state, federal or military crime? Yes If yes, attach an affidavit as to all charges and disposition. No 3. Financial Interest: Provide a detailed description of your direct or indirect, beneficial or financial interest in this license. IMPORTANT ATTACHMENTS: For all cash contributions, attach last 3 months of bank statements for the source(s) of this cash. *If additional space is needed, please use the last page* I hereby swear under the pains and penalties of perjury that the information I have provided in this application is true and accurate: Signature Title Date (If Corporation/LLC Representative) American LegalNet, Inc. www.FormsWorkFlow.com Additional Space Please note which question you are using this space for. American LegalNet, Inc. www.FormsWorkFlow.com