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Amendment-chgoffdirsownershiptockinterest2018

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File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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1. BUSINESS ENTITY INFORMATION
ABCC License NumberEntity Name
Municipality
APPLICATION CONTACT
The application contact is the person who should be contacted with any questions regarding this application.
EmailName
Phone
Title
Please provide a narrative overview of the transaction(s) being applied for. Attach additional pages, if necessary.
• DOR Certificate of Good Standing
• DUA Certificate of Compliance
• Change of Officer/Directors Application
• CORI Authorization
• Vote of the Entity
• Payment Receipt
• Business Structure Documents
• If Sole Proprietor, Business Certificate
• If partnership, Partnership Agreement
• If corporation or LLC, Articles of Organization
from the Secretary of the Commonwealth
• If Sole Proprietor, Business Certificate
• If partnership, Partnership Agreement
• If corporation or LLC, Articles of Organization
from the Secretary of the Commonwealth
• DOR Certificate of Good Standing
• DUA Certificate of Compliance
• Change of Stock Application
• CORI Authorization
• Financial Statement
• Vote of the Entity
• Purchase & Sale Agreement
• Supporting Financial Records
• Advertisement
• Payment Receipt
• Business Structure Documents
Change of Officers/ Directors/LLC Managers
Change of Stock Interest
(e.g. New Stockholders or Transfer or Issuance of Stock)
APPLICATION FOR AMENDMENT
-Change of Officers, Stock or Ownership Interest
• If Sole Proprietor, Business Certificate
• If partnership, Partnership Agreement
• If corporation or LLC, Articles of Organization
from the Secretary of the Commonwealth
• DOR Certificate of Good Standing
• DUA Certificate of Compliance
• Change of Stock Application
• CORI Authorization
• Financial Statement
• Vote of the Entity
• Purchase & Sale Agreement
• Supporting Financial Records
• Advertisement
• Payment Receipt
• Business Structure Documents
Change of Ownership Interest
(e.g. LLC Members, LLP Partners, Trustees etc.)
Management Agreement
• DOR Certificate of Good Standing
• DUA Certificate of Compliance
• Management Agreement
• Vote of Entity
• Payment Receipt
Non-Profit Club Change of Officers/ Directors
• DOR Certificate of Good Standing
• DUA Certificate of Compliance
• Change of Officer/Directors Application
• Vote of the club signed by an approved officer
• Payment Receipt
• Business Structure Documents -Articles of
Organization from the Secretary of the Commonwealth
1
*If abutter notification and advertisement are required for transaction, please see the local licensing authority.
The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
95 Fourth Street, Suite 3, Chelsea, MA 02150-2358
www.mass.gov/abcc
List all individuals or entities that will have a direct or indirect, beneficial or financial interest in this license (E.g. Stockholders, Officers,
Directors, LLC Managers, LLP Partners, Trustees etc.). Attach additional page(s) provided, if necessary, utilizing Addendum A.
• The individuals and titles listed in this section must be identical to those filed with the Massachusetts Secretary of State.
• The individuals identified in this section, as well as the proposed Manager of Record, must complete a CORI Release Form.
• Please note the following statutory requirements for Directors and LLC Managers:
On Premises (E.g.Restaurant/ Club/Hotel) Directors or LLC Managers - At least 50% must be US citizens;
Off Premises(Liquor Store) Directors or LLC Managers - All must be US citizens and a majority must be
Massachusetts residents.
• If you are a Multi-Tiered Organization, please attach a flow chart identifying each corporate interest and the individual owners of
each entity as well as the Articles of Organization for each corporate entity. Every individual must be identified in Addendum A.
NoYes
Additional pages attached?
2. PROPOSED OFFICERS, STOCK OR OWNERSHIP INTEREST
Has any individual listed in question 2, and applicable attachments, ever been convicted of a
State, Federal or Military Crime? If yes, attach an affidavit providing the details of any and all convictions.
CRIMINAL HISTORY
NoYes
MANAGEMENT AGREEMENT
NoYes
APPLICATION FOR AMENDMENT-Change of Officers, Stock or Ownership Interest
2
Name of Principal
Title and or Position
SSN DOB
NoYes
Percentage of Ownership US Citizen MA Resident
NoYes
Residential Address
Director/ LLC Manager
NoYes
Name of Principal SSN DOBResidential Address
Name of Principal SSN DOBResidential Address
Name of Principal SSN DOBResidential Address
Title and or Position
NoYes
Percentage of Ownership US Citizen MA Resident
NoYes
Director/ LLC Manager
NoYes
Title and or Position
NoYes
Percentage of Ownership US Citizen MA Resident
NoYes
Director/ LLC Manager
NoYes
Title and or Position
NoYes
Percentage of Ownership US Citizen MA Resident
NoYes
Director/ LLC Manager
NoYes
Name of Principal SSN DOBResidential Address
Name of Principal SSN DOBResidential Address
Title and or Position
NoYes
Percentage of Ownership US Citizen MA Resident
NoYes
Director/ LLC Manager
NoYes
Title and or Position
NoYes
Percentage of Ownership US Citizen MA Resident
NoYes
Director/ LLC Manager
NoYes
Are you requesting approval to utilize a management company through a management agreement?
Please provide a copy of the management agreement.
Name of Principal Title/Position Percentage of Ownership
Name of Principal Title/Position Percentage of Ownership
Name of Principal Title/Position Percentage of Ownership
Name of Principal Title/Position Percentage of Ownership
Name of Principal Title/Position Percentage of Ownership
List the individuals and entities of the current ownership. Attach additional pages if necessary utilizing the format below.
Name of Principal Title/Position Percentage of Ownership
3. CURRENT OFFICERS, STOCK OR OWNERSHIP INTEREST
4. INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Does any individual or entity identified in question 2, and applicable attachments, have any direct or indirect, beneficial or financial
interest in any other license to sell alcoholic beverages? If yes, list in table below. Attach additional pages, if
necessary, utilizing the table format below.
Yes No
Name License Type License Name Municipality
5. PREVIOUSLY HELD INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Has any individual or entity identified identified in question 2, and applicable attachments, 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 in table below. Attach additional pages, if necessary, utilizing the table format below.
Yes No
6. DISCLOSURE OF LICENSE DISCIPLINARY ACTION
Have any of the disclosed licenses listed in question 4 or 5 ever been suspended, revoked or cancelled?
If yes, list in table below. Attach additional pages, if necessary, utilizing the table format below.
Yes No
Date of Action Name of License City Reason for suspension, revocation or cancellation
Name License Type License Name Municipality
APPLICATION FOR AMENDMENT-Change of Officers, Stock or Ownership Interest
3
7. FINANCIAL DISCLOSURE
Name of Contributor Amount of Contribution
Total:
Name of Lender Amount Type of Financing
SOURCE OF CASH CONTRIBUTION
Is the lender a licensee pursuant
to M.G.L. Ch. 138.
No
Yes
Yes
No
Yes
No
Yes
No
Please provide documentation of available funds. (E.g. Bank or other Financial institution Statements, Bank Letter, etc.)
Please provide signed financing documentation.
SOURCE OF FINANCING
FINANCIAL INFORMATION
Provide a detailed explanation of the form(s) and source(s) of funding for the cost identified above.
4
Associated Cost(s):
Associated Cost(s): (E.g. Costs associated with License Transaction including but not limited to: Property price,
Business Assets, Renovations costs, Construction costs, Initial Start-up costs, Inventory costs, or specify other
costs):”
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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signature
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ADDITIONAL INFORMATION
Please utilize this space to provide any additional information that will support your application or to clarify any answers
provided above.
A true copy attest,
__________________________
Corporate Officer /LLC Manager Signature
For Corporations ONLY
A true copy attest,
__________________________
Corporation Clerk's Signature
CORPORATE VOTE
The Board of Directors or LLC Managers of
duly voted to apply to the Licensing Authority of and the
Commonwealth of Massachusetts Alcoholic Beverages Control Commission on
“VOTED: To authorize
to sign the application submitted and to execute on the Entity's behalf, any necessary papers and
do all things required to have the application granted.”
City/Town
Name of Person
Date of Meeting
Entity Name
For the following transactions (Check all that apply):
Issuance/Transfer of Stock/New Stockholder
Management/Operating Agreement
Change of Officers/Directors/LLC Manager
Other
Change of Ownership Interest (LLC Members, LLP Partners, Trustees)
(Print Name)
__________________________
(Print Name)
__________________________
Name of Principal
Title and or Position
SSN DOB
NoYes
Percentage of Ownership
US Citizen MA Resident
NoYes
Residential Address
Director
NoYes
Name of Principal
Title and or Position
SSN DOB
NoYes
Percentage of Ownership
US Citizen MA Resident
NoYes
Residential Address
Director
NoYes
Name of Principal
Title and or Position
SSN DOB
NoYes
Percentage of Ownership
US Citizen MA Resident
NoYes
Residential Address
Director
NoYes
Name of Principal
Title and or Position
SSN DOB
NoYes
Percentage of Ownership
US Citizen MA Resident
NoYes
Residential Address
Director
NoYes
Name of Principal SSN DOBResidential Address
List all proposed individuals or entities that will have a direct or indirect, beneficial or financial interest in this license (E.g. Stockholders,
Officers, Directors, LLC Managers, LLP Partners, Trustees etc.).
Name of Principal
Title and or Position
SSN DOB
NoYes
Percentage of Ownership
US Citizen MA Resident
NoYes
Residential Address
Director
NoYes
Entity Name Percentage of Ownership in Entity being Licensed
(Write "NA" if this is the entity being licensed)
Title and or Position
NoYes
Percentage of Ownership
US Citizen MA Resident
NoYes
Director
NoYes
Has any individual identified above ever been convicted of a State, Federal or Military Crime?
If yes, attach an affidavit providing the details of any and all convictions.
CRIMINAL HISTORY
NoYes
Name of Principal
Title and or Position
SSN DOB
NoYes
Percentage of Ownership
US Citizen MA Resident
NoYes
Residential Address
Director
NoYes
2. PROPOSED OFFICERS, STOCK OR OWNERSHIP INTEREST(Continued...)
RETAIL ALCOHOLIC BEVERAGES LICENSE APPLICATION
MONETARY TRANSMITTAL FORM
APPLICATION SHOULD BE COMPLETED ON-LINE, PRINTED, SIGNED, AND SUBMITTED TO THE LOCAL
LICENSING AUTHORITY.
ABCC LICENSE NUMBER (IF AN EXISTING LICENSEE, CAN BE OBTAINED FROM THE CITY)
ENTITY/ LICENSEE NAME
ADDRESS
CITY/TOWN STATE ZIP CODE
For the following transactions (Check all that apply):
THE LOCAL LICENSING AUTHORITY MUST MAIL THIS
TRANSMITTAL FORM ALONG WITH
COMPLETED APPLICATION, AND SUPPORTING DOCUMENTS TO:
APPLICATION FOR AMENDMENT-Change of Officers, Stock or Ownership Interest
Change of Class (i.e. Annual / Seasonal)
New License
Transfer of License
Issuance/Transfer of Stock/New Stockholder
Alteration of Licensed Premises
Management/Operating Agreement Change of Manager Change Corporate Name
Change of License Type (i.e. club / restaurant)
Change of DBA
Pledge of Collateral (i.e. License/Stock)
Change of Officers/
Directors/LLC Managers
Change of Category (i.e. All Alcohol/Wine, Malt)
Change Corporate Structure (i.e. Corp / LLC)
Change of Hours
Other
Change of Location
Change of Ownership Interest
(LLC Members/ LLP Partners,
Trustees)
ECRT CODE: RETA
Please make $200.00 payment here: ABCC PAYMENT WEBSITE
PAYMENT MUST DENOTE THE NAME OF THE LICENSEE CORPORATION, LLC, PARTNERSHIP, OR INDIVIDUAL AND INCLUDE THE
PAYMENT RECEIPT
The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
95 Fourth Street, Suite 3, Chelsea, MA 02150-2358
www.mass.gov/abcc
Alcoholic Beverages Control Commission
95 Fourth Street, Suite 3
Chelsea, MA 02150-2358
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Amendment-chgoffdirsownershiptockinterest2018

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Completed 30 November 2019

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