APPLICANT'S STATEMENT
I, the: sole proprietor; partner; corporate principal; LLC/LLP manager
Authorized Signatory
of
Name of the Entity/Corporation
hereby submit this application (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 statements 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 are in compliance with state
and local laws and regulations;
(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
ownership 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.
(10) I confirm that the applicant corporation and each individual listed in the ownership section of the application is in
good standing with the Massachusetts Department of Revenue and has complied with all laws of the Commonwealth
relating to taxes, reporting of employees and contractors, and withholding and remitting of child support.
Signature: Date:
Title:
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