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Transferorissueanceofstock

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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RETAIL ALCOHOLIC BEVERAGES LICENSE APPLICATION
MONETARY TRANSMITTAL FORM
APPLICATION SHOULD BE COMPLETED ON-LINE, PRINTED, SIGNED, AND SUBMITTED TO THE
LOCAL LICENSING AUTHORITY.
REVENUE CODE: RETA
IF USED EPAY, CONFIRMATION NUMBER:
A.B.C.C. LICENSE NUMBER (IF AN EXISTING LICENSEE, CAN BE OBTAINED FROM THE CITY):
LICENSEE NAME:
ADDRESS:
CITY/TOWN: STATE ZIP CODE
The
Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
239 Causeway Street
Boston, MA 02114
www.mass.gov/abcc
CHECK PAYABLE TO ABCC OR COMMONWEALTH OF MA: $200.00
TRANSACTION TYPE (Please check all relevant transactions):
Cordials/Liqueurs Permit
6-Day to 7-Day License Management/Operating Agreement Wine & Malt to All Alcohol
New License
Transfer of License
New Stockholder
Alteration of Licensed Premises
Change of Location
Issuance of Stock
Change of Manager
New Officer/Director Change Corporate Name
Change of License Type
Seasonal to Annual
Pledge of License
Pledge of Stock
Transfer of Stock
Other
THE LOCAL LICENSING AUTHORITY MUST MAIL THIS TRANSMITTAL
FORM ALONG WITH THE CHECK, COMPLETED APPLICATION, AND
SUPPORTING DOCUMENTS TO:
ALCOHOLIC BEVERAGES CONTROL COMMISSION
P. O. BOX 3396
BOSTON, MA 02241-3396
CHECK NUMBER
(CHECK MUST DENOTE THE NAME OF THE LICENSEE CORPORATION, LLC, PARTNERSHIP, OR INDIVIDUAL)
Print Form
Application for Retail Alcoholic Beverage License
City/Town
2. Transaction:
Management/Operating Agreement New Stockholder
Issuance of StockTransfer of Stock
Transfer of License
New Officer/Director New License
The following transactions must be processed as new licenses:
Seasonal to Annual 6-Day to 7-Day License Wine & Malt to All Alcohol
IMPORTANT ATTACHMENTS: The applicant must attach a vote of the entity authorizing all requested
transactions, including the appointment of a Manager of Record or principal representative.
3. Type of License:
§12 Restaurant §12 Hotel
§15 Package Store§12 Tavern (No Sundays)§12 General On-Premise
§12 Veterans Club§12 Club
4. License Catagory:
All Alcoholic Beverages Wine & Malt Beverages Only
Wine & Malt Beverages with Cordials/Liqueurs Permit
Wine or Malt Only
5. License Class:
Annual Seasonal
Legal Name/Entity of Applicant:(e.g Corporation, LLC, Individual)
Business Name (if different) : Manager of Record:
Address of Licensed Premises:
Business Phone:
1. Licensee Information:
CITY/TOWN: STATE ZIP
Cell Phone:
Email:
Website:
ABBC License Number (for existing licenses only) :
7. Description of Premises:
Please provide a complete description of the premises to be licensed. The description should include the location of all entrances
and exits.
8. Occupancy of Premises:
Other:
By what right does the applicant have possession and/or legal occupancy of the premises?
Landlord is a(n):
Other
ZipStateCity/Town:Address:
Name
Phone:
Initial Lease Term: Beginning Date Ending Date
Rent:
per year
Rent:
per month
IMPORTANT ATTACHMENTS: The applicant must attach a floor plan with dimensions and square footage for each floor & room.
Occupancy Number: Seating Capacity:
IMPORTANT ATTACHMENTS: The applicant must submit a copy of the final lease or documents evidencing a
legal right to occupy the premises.
Renewal Term: Options/Extensions at
Years Each
Do the terms of the lease or other arrangement require payments to the Landlord based on a percentage of the alcohol sales?
Yes No
IMPORTANT ATTACHMENTS: If yes, the Landlord is deemed a person or entity with a financial or beneficial interest in this license.
Each individual with an ownership interest in the Landlord must be disclosed in §10 and must submit a completed Personal
Information Form attached to this application. Entity formation documents for the Landlord entity must accompany the application to
confirm the individuals disclosed.
NAME:
6. Contact Person concerning this application (attorney if applicable)
ZIP CODESTATECITY/TOWN:
ADDRESS:
CONTACT PHONE NUMBER: FAX NUMBER:
EMAIL:
Please select
Please Select
9. Licensee Structure:
10. Interests in this License:
The Applicant is a(n): Other :
If the applicant is a Corporation or LLC, complete the following:
State of Incorporation/Organization:
Date of Incorporation/Organization:
Is the Corporation publicly traded?
Yes No
IMPORTANT ATTACHMENTS: All individuals or entities listed below are required to complete a Personal Information Form.
Name Title Stock or % Owned Other Beneficial Interest
*If additional space is needed, please use last page.
11. Existing Interests in Other Licenses:
Does any individual listed in §10 have any direct or indirect, beneficial or financial interest in any other license to sell alcoholic
beverages?
If yes, list said interest below:
Yes No
Name License Type Licensee Name & Address
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).
*If additional space is needed, please use last page.
Please select
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
12. Previously Held Interests in Other Licenses:
Has any individual listed in §10 who has a direct or indirect beneficial interest in this license ever held a direct or indirect, beneficial or
financial interest in a license to sell alcoholic beverages, which is not presently held? If yes, list said interest below:
Yes No
Name Licensee Name & Address Date
Reason
Terminated
14. Criminal Record:
Has any individual listed in §10 or who has a direct or indirect beneficial interest in this license ever been convicted of a municipal,
state, federal or military crime?
If yes, the individual must provide an affidavit as to any and all charges as well as the disposition.
Yes No
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 cancelled?
If yes, list said interest below:
Yes No
Date License Reason of Suspension, Revocation or Cancellation
15. Citizenship and Residency Requirements for a (§15) Package Store License ONLY:
Yes No
Yes No
Yes No
Yes No
1. Are all Directors/LLC Managers U.S. Citizens?
2. Are a majority of Directors/LLC Managers Massachusetts Residents?
3. Is the License Manager or Principal Representative a U.S. Citizen?
4. Are all members and partners involved at least twenty-one years old?
16. Citizenship and Residency Requirements for (§12) Restaurant, Hotel, Club, General On Premise, Tavern, Veterans Club
License ONLY:
Yes No
Yes No
Yes No
1. Are all Directors/LLC Managers U.S. Citizens?
2. Are a majority of Directors/LLC Managers Massachusetts Residents?
3. Is the License Manager or Principal Representative a U.S. Citizen?
Please Select
Please Select
Please Select
17. Costs Associated with License Transaction:
A. Purchase Price for Real Property:
I. TOTAL AMOUNT FINANCED
H. TOTAL CASH
G: TOTAL COST
F. Other: (Specify)
E. Purchase Price for Inventory:
D. Initial Start-Up Costs:
C. Costs of Renovations/Construction:
B. Purchase Price for Business Assets:
IMPORTANT ATTACHMENTS: Submit any and all
records, documents and affidavits including loan
agreements that explain the source(s) of money for this
transaction. Sources of cash should include a minimum
of three (3) months of bank statements.
The amounts listed in subsections (H) and (I)
must total the amount reflected in (G).
18. Provide a detailed explanation of the form(s) and source(s) of funding for the costs identified in §17 (include loans,
mortgages, lines of credit, notes, personal funds, gifts):
*If additional space is needed, please use last page.
19. List each lender and loan amount(s) from which "total amount financed" noted in subsections 17(I) will derive:
Name Dollar Amount Type of Financing
*If additional space is needed, please use last page.
Does any individual or entity listed in §19 as a source of financing have a direct or indirect, beneficial or financial interest in this
license or any other license(s) granted under Chapter 138?
Yes No
If yes, please describe:
20. Pledge: (i.e. collateral for a loan)
Is
the applicant seeking approval to pledge the license?
If yes, describe terms and conditions and to whom:
Yes No
If a corporation, is the applicant seeking approval to pledge any of the corporate stock?
Yes No
If yes, to whom: Number of Shares
Is the applicant pledging the inventory?
Yes No
If yes, to whom:
IMPORTANT ATTACHMENTS: If you are applying for a pledge, submit the pledge agreement, the promissory note and a vote of
the Corporation/LLC approving the pledge.
21. Construction of Premise
Yes No
Are the premises being remodeled, redecorated or constructed in any way? If YES, please provide a description of the work being
performed on the premises:
If all the information is not completed the
application may be returned
APPLICANT'S STATEMENT
I, the: sole proprietor; partner; corporate principal; LLC/LLP member
of , hereby submit this application for (hereinafter the
“Application”), to the local licensing authority (the “LLA”) and the Alcoholic Beverages Control Commission (the
“ABCC” and together with the LLA collectively the “Licensing Authorities”) for approval.
I do hereby declare under the pains and penalties of perjury that I have personal knowledge of the information
submitted in the Application, and as such affirm that all statement and representations therein are true to the best of my
knowledge and belief. I further submit the following to be true and accurate:
(1) I understand that each representation in this Application is material to the Licensing Authorities' decision on
the Application and that the Licensing Authorities will rely on each and every answer in the Application and
accompanying documents in reaching its decision;
(2) I state that the location and description of the proposed licensed premises does not violate any requirement of
the ABCC or other state law or local ordinances;
(3) I understand that while the Application is pending, I must notify the Licensing Authorities of any change in the
information submitted therein. I understand that failure to give such notice to the Licensing Authorities may result in
disapproval of the Application;
(4) I understand that upon approval of the Application, I must notify the Licensing Authorities of any change in the
Application information as approved by the Licensing Authorities. I understand that failure to give such notice to the
Licensing Authorities may result in sanctions including revocation of any license for which this Application is
submitted;
(5) I understand that the licensee will be bound by the statements and representations made in the Application,
including, but not limited to the identity of persons with an ownership or financial interest in the license;
(6) I understand that all statements and representations made become conditions of the license;
(7) I understand that any physical alterations to or changes to the size of, the area used for the sale, delivery,
storage, or consumption of alcoholic beverages, must be reported to the Licensing Authorities and may require the
prior approval of the Licensing Authorities;
(8) I understand that the licensee's failure to operate the licensed premises in accordance with the statements and
representations made in the Application may result in sanctions, including the revocation of any license for which the
Application was submitted; and
(9) I understand that any false statement or misrepresentation will constitute cause for disapproval of the
Application or sanctions including revocation of any license for which this Application is submitted.
Signature: Date
Title
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signature
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Legal Name of Licensee:
Business Name (d/b/a)
2. Personal Information:
Individual Name Home Phone Number:
Social Security Number
1. Licensee Information:
Personal Information Form
The
Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
239 Causeway Street
Boston, MA 02114
www.mass.gov/abcc
City/Town State Zip Code
Address: ABCC License Number:
EIN of License:
(If existing licensee)
Place of Employment
Have you ever been convicted of a state, federal or military crime?
Yes No
Signature
Date
Phone Number of Premise
Zip CodeStateCity/Town
Address:
Date of Birth
If yes, attach an affidavit as to all charges and disposition.
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:
Title
(If Corporation/LLC Representative)
Each individual listed in Section 10 of this application and the proposed manager must complete this form.
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signature
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Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
239 Causeway Street, First Floor
Boston, MA 02114
CORI REQUEST FORM
The Alcoholic Beverages Control Commission has been certified by the Criminal History Systems Board to access conviction and pending Criminal Offender Record
Information. For the purpose of approving each shareholder, owner, licensee or applicant for an alcoholic beverages license, I understand that a criminal record check
will be conducted on me, pursuant to the above. The information below is correct to the best of my knowledge.
LAST NAME: MIDDLE NAME:
MAIDEN NAME OR ALIAS (IF APPLICABLE): PLACE OF BIRTH:
ABCC NUMBER:
DATE OF BIRTH: ID THEFT INDEX PIN (IF APPLICABLE):
EYE COLOR:
FIRST NAME:
STATE: ZIP:
APPLICANT/EMPLOYEE SIGNATURE:
SSN:
MOTHER'S MAIDEN NAME:
CURRENT ADDRESS:
FORMER ADDRESS:
CITY/TOWN:
STATE: ZIP:CITY/TOWN:
WEIGHT:
GENDER: HEIGHT:
to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for
its stated purpose.
On this
before me, the undersigned notary public, personally appeared
(name of document signer), proved to me through satisfactory evidence of identification, which were
NOTARY
STEVEN GROSSMAN
TREASURER AND RECEIVER GENERAL
KIM S. GAINSBORO, ESQ.
CHAIRMAN
DRIVER'S LICENSE #:
LICENSEE NAME:
STATE LIC. ISSUED:
PRINTED NAME:
CITY/TOWN:
NOTARY INFORMATION
PRINT AND SIGN
APPLICANT INFORMATION
ABCC LICENSE INFORMATION
(IF EXISTING LICENSEE)
REQUESTED BY:
SIGNATURE OF CORI-AUTHORIZED EMPLOYEE
The DCJI Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft
PIN Number by the DCJI. Certified agencies are required to provide all applicants the opportunity to include this
information to ensure the accuracy of the CORI request process. ALL CORI request forms that include this field are
required to be submitted to the DCJI via mail or by fax to (617) 660-4614.
DIVISION USE ONLY
Alabama
PETITION FOR TRANSFER OF OWNERSHIP
ABCC License Number City/Town
The licensee and the proposed transferee
respectfully petition the Licensing Authorities to approve the following transfer of ownership.
Is the PRESENT licensee a Corporation/LLC duly registered under the laws of the Commonwealth of Massachusetts?
Yes No
If YES, please list the officers, directors and stockholders, their residences, and shares owned by each.
Name Title Address Stock or % Owned
Is the PROPOSED transferee a Corporation/LLC, duly registered under the laws of the Commonwealth of Massachusetts?
Yes No
If YES, please list the officers, directors and stockholders, their residences, and shares owned by each.
Name Title Address Stock or % Owned
TO: (Place an * before the name of each DIRECTOR/LLC Manager.)
The above named proposed transferee hereby joins in this petition for transfer of said license.
SIGNATURE OF LAST-APPROVED LICENSEE:
(If a Corporation/LLC, by its authorized representative)
SIGNATURE OF PROPOSED TRANSFEREE:
Date Signed
The
Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
239 Causeway Street
Boston, MA 02114
www.mass.gov/abcc
Additional Space
Please note which question you are using this space for.
Transfer/Issuance of Stock Checklist
This application will be returned if the following documentation is not submitted:
Retail Transmittal Form
$200.00 Fee made payable to the Commonwealth of Massachusetts or the ABCC
Petition for Transfer of Ownership
Newspaper Notice
Retail Application
Personal Information Form
Purchase & Sale Agreement
Supporting Financial Records
All records, loan agreements, documents, as well as affidavits detailing the
source(s) of money for this license transaction
3 months worth of bank statements confirming the sources of funds
Vote of Corporate Board or LLC
Form 43 (From Local Licensing Board)
CORI Application
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Completed 25 October 2019

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