LICENSING AUTHORITY CERTIFICATION
The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
For Reconsideration
ABCC License NumberCity /Town
TRANSACTION TYPE (Please check all relevant transactions):
The license applicant petitions the Licensing Authorities to approve the following transactions:
Name of Licensee
Manager
DBA
Street Address
Class
(Annual or Seasonal)
Granted under
Special Legislation?
Yes No
If Yes, Chapter
of the Acts of (year)
APPLICANT INFORMATION
Type
(i.e. restaurant, package store)
Category
(i.e. Wines and Malts / All Alcohol)
DESCRIPTION OF PREMISES
Complete description of the licensed premises
Decision of the LLA
Additional remarks or conditions
(E.g. Days and hours)
Alcoholic Beverages Control Commission
Ralph Sacramone
Executive Director
The Local Licensing Authorities By:
Application filed with the LLA: TimeDate
LOCAL LICENSING AUTHORITY INFORMATION
Date APPROVED by LLA
Abutters Notified:
Yes No
Publication
NoYes
Date PublishedAdvertised
Date of Notice
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)
For Transfers ONLY:
Seller License Number: Seller Name:
Zip Code
