Fillable ABCC - Beneficial Interest Contact (Individual)

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ABCC - Beneficial Interest Contact (Individual)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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ALCOHOLIC BEVERAGES CONTROL COMMISSION
BENEFICIAL INTEREST CONTACT - Individual (Formerly known as a Personal Information Form)
Please complete a Beneficial Interest - Individual sheet for all individual(s) who have a direct or indirect beneficial interest, with
or without ownership, in this license. This includes people with a financial interest and people without financial interest (i.e.
board of directors for not-for-profit clubs). All individuals with direct or indirect financial interest must also submit a CORI
Authorization Form.
An individual with direct beneficial interest is defined as someone who has interest directly in the proposed licensee. For
example, if ABC Inc is the proposed licensee, all individuals with interest in ABC Inc are considered to have direct beneficial
interest in ABC Inc (the proposed licensee).
An individual with indirect beneficial interest is defined as someone who has ownership in a parent level company of the
proposed licensee. For example, if ABC Inc is the proposed licensee and is 100% owned by XYZ Inc, all individuals with interest
in XYZ Inc are considered to have an indirect beneficial interest in ABC Inc (the proposed licensee).
Have you ever been convicted of a state, federal, or military crime?
Are you a U.S. Citizen? Are you a Massachusetts Resident?
Types of Interest (select all that apply)
Officer
Stockholder
LLC Member
Partner
Contractual
Management Agreement
Sole Proprietor
LLC ManagerDirector Landlord
Revenue Sharing Other
Yes No Yes No
Yes No
Citizenship / Residency Information
Business Address
Street Name:
Street Name:
State:
Zip Code:
City/Town:
Country:
Zip Code:
City/Town: State:
Street Number:
Country:
Mailing Address
Check here if your Mailing Address is the same as your Business Address
Street Number:
Criminal History
If yes, please provide an affidavit
explaining the charges.
Salutation First Name Middle Name Last Name Suffix
Primary Phone:
Alternative Phone:
Email:
Date of Birth
Mobile Phone: Fax Number
Social Security Number
Title:
ALCOHOLIC BEVERAGES CONTROL COMMISSION
BENEFICIAL INTEREST CONTACT - Individual (continued)
Using the definition above, do you hold a direct
or indirect interest in the proposed licensee?
Direct Indirect
Ownership / Interest
If you hold a direct beneficial interest
in the proposed licensee, please list
the % of interest you hold.
If you hold an indirect beneficial interest in this license, please complete the Ownership / Interest Table below.
If you hold an indirect interest in the proposed licensee, please list the organization(s) you hold a direct interest in which, in
turn, hold a direct or indirect interest in the proposed licensee. These generally include parent companies, holding companies,
trusts, etc. A Beneficial Interest - Organization Form will need to be completed for each entity listed below.
Ownership / Interest
Name of Beneficial Interest - Organization FEIN
Name of License Type of License License Number Premises Address
List any indirect or indirect beneficial or financial interest you have in any other Massachusetts Alcoholic Beverages License(s).
Other Beneficial Interest
Relationship to You ABCC License Number Type of Interest (choose primary function) Percentage of Interest
Familial Beneficial Interest
Does any member of your immediate family have ownership interest in any other Massachusetts Alcoholic Beverages Licenses?
Immediate family includes parents, siblings, spouse and spouse's parents. Please list below.
Have you ever been involved directly or indirectly in an alcoholic beverages license that was subject to disciplinary action? If
yes, please complete the following:
Date of Action Name of License State City Reason for suspension, revocation or cancellation
Prior Disciplinary Action
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ABCC - Beneficial Interest Contact (Individual)

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Completed 17 May 2020

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