Fillable Multiamendment2019mgmt

Fill Online, Printable, Fillable, Blank Multiamendment2019mgmt Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Multiamendment2019mgmt

On average this form takes 136 minutes to complete

The Multiamendment2019mgmt form is 24 pages long and contains:

  • 4 signatures
  • 99 check-boxes
  • 481 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
APPLICATION FOR MULTIPLE AMENDMENTS
Please select all of the amendments you are applying for:
CHANGE OF CATEGORY
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Category Application
Vote of the Corporate Board
Abutter's Notification*
Advertisement*
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
CHANGE OF LICENSE TYPE
Change of License Type Application
Vote of the Corporate Board
Advertisement*
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
CHANGE OF CORPORATE STRUCTURE
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Corporate Structure Application
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
Vote of the Corporate Board
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
CHANGE OF CLASSIFICATION
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Classification Application
Vote of the Corporate Board
Abutter's Notification*
Advertisement*
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
*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
APPLICATION FOR MULTIPLE AMENDMENTS
Please select all of the amendments you are applying for(continued):
CHANGE OF OFFICERS/DIRECTORS/LLC MANAGERS
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Officers/Directors Application
CORI Authorization Complete one for the proposed manager of record. This form must be notarized with a stamp or raised
seal.
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
Vote of the Entity Board
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
CHANGE OF OWNERSHIP INTEREST (e.g. LLC Members, LLP Partners, Trustees etc.)
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Officers/Directors Application
Financial Statement
CORI Authorization Complete one for the proposed manager of record. This form must be notarized with a stamp or raised
seal.
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
Vote of the Entity Board
Purchase and Sale Agreement
Supporting Financial Records
Advertisement*
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
CHANGE OF STOCK INTEREST (e.g. New Stockholders or Transfer or Issuance of Stock)
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Officers/Directors Application
Financial Statement
CORI Authorization Complete one for the proposed manager of record. This form must be notarized with a stamp or raised
seal.
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
Vote of the Entity Board
Purchase and Sale Agreement
Supporting Financial Records
Advertisement*
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
2
*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
APPLICATION FOR MULTIPLE AMENDMENTS
Please select all of the amendments you are applying for(continued):
CHANGE OF CORPORATE NAME OR DBA
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Corporate Name/DBA Application
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
Vote of the Corporate Board
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
CHANGE OF PLEDGE OF LICENSE, STOCK OR INVENTORY
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Pledge of License, Stock or Inventory Application
Pledge documentation
Promissory note
Vote of the Corporate Board
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
CHANGE OF MANAGER
Change of Manager Application
CORI Authorization Complete one for the proposed manager of record. This form must be notarized
with a stamp or raised seal.
Vote of the Entity Board.
Proof of Citizenship. Passport, birth certificate, voter registration, or naturalization papers will be
accepted.
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
3
*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
4
APPLICATION FOR MULTIPLE AMENDMENTS
Please select all of the amendments you are applying for(continued):
CHANGE OF LOCATION
Alteration of Premises/Change of Location Application
Vote of the Corporate Board
Supporting financial records
Legal Right to Occupy
Floor Plan
Abutter's Notification*
Advertisement*
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
ALTERATION OF PREMISES
Alteration of Premises/Change of Location Application
Vote of the Corporate Board
Supporting financial records
Legal Right to Occupy
Floor Plan
Abutter's Notification*
Advertisement*
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
MANAGEMENT AGREEMENT
IMPORTANT NOTE: A management agreement is where a licensee authorizes a third party to control the daily
operations of the license premises, while retaining ultimate control over the license, through a written
contract. This does not pertain to a liquor license manager that is employed directly by the entity.
*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
Management Agreement Application
Management Agreement
Vote of the Entity
CORI Forms for all listed in Section 8A and attachments
APPLICATION FOR MULTIPLE AMENDMENTS
Please select all of the amendments you are applying for(continued):
Non-Profit Club CHANGE OF MANAGER
Change of Manager Application
CORI Authorization Complete one for the proposed manager of record. This form must be notarized with a
stamp or raised seal.
Vote of the club signed by an approved officer.
Updated Officers and Directors*
*Please ensure to update your officers and directors simultaneously or PRIOR to applying for a change of
manager. It will be returned with no action taken if the officers and directors do not match ABCC records.
Proof of Citizenship. Passport, birth certificate, voter registration, or naturalization papers will be accepted.
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
Non-Profit Club's ONLY
e.g. Veteran's Club
Non-Profit Club CHANGE OF OFFICERS/DIRECTORS
DOR Certificate of Good Standing
DUA Certificate of Compliance
Change of Officers/Directors Application
Business Structure Documents-Articles of Organization from the Secretary of the
Commonwealth
CORI Authorization Form This form must be notarized with a stamp or raised seal.
Vote of the club signed by an approved officer
Monetary Transmittal Form
$200 fee via ABCC website and Payment Receipt
5
The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
95 Fourth Street, Suite 3, Chelsea, MA 02150-2358
www.mass.gov/abcc
APPLICATION FOR MULTIPLE AMENDMENTS
1. BUSINESS ENTITY INFORMATION
ABCC License NumberEntity Name
Municipality
Change of License Category
Change of License Class
Change of License Type*
All Alcohol, Wine and Malt,
Wine Malt and Cordials
Last-Approved License Category
Requested New License Category
Last-Approved License Class
Requested New License Class
Seasonal or Annual
Last-Approved License Type
Requested New License Type
i.e. Restaurant to Club
*Certain License Types
CANNOT change once issued*
2. AMENDMENT-Change of License Classification
APPLICATION CONTACT
The application contact is the person who should be contacted with any questions regarding this application.
EmailName
Phone
Title
Change of Corporate Name
Last-Approved Corporate Name:
Requested New Corporate Name:
Change of DBA
Last-Approved DBA:
Requested New DBA:
3. AMENDMENT-Change of Business Entity Information
Change of Corporate Structure
Last-Approved Corporate Structure
Requested New Corporate Structure
LLC, Corporation, Sole
Proprietor, etc
Please provide a narrative overview of the transaction(s) being applied for. On-premises applicants should also provide a description of
the intended theme or concept of the business operation. Attach additional pages, if necessary.
4. AMENDMENT-Pledge Information
To whom is the pledge being made:
Pledge of License
Pledge of Stock
Pledge of Inventory
6
The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
95 Fourth Street, Suite 3, Chelsea, MA 02150-2358
www.mass.gov/abcc
A. MANAGER INFORMATION
Change of License Manager
5. AMENDMENT-Change of Manager
Start Date End Date Position Employer Supervisor Name
C. EMPLOYMENT INFORMATION
Please provide your employment history. Attach additional pages, if necessary, utilizing the format below.
Date of Action Name of License State City Reason for suspension, revocation or cancellation
The individual that has been appointed to manage and control the licensed business and premises.
Proposed Manager Name
Email
Date of Birth
SSN
Phone
Please indicate how many hours per week
you intend to be on the licensed premises
Last-Approved License Manager
D. PRIOR DISCIPLINARY ACTION
Have you held a beneficial or financial interest in, or been the manager of, a license to sell alcoholic beverages that was subject to
disciplinary action? If yes, please fill out the table. Attach additional pages, if necessary,utilizing the format below.
Yes No
Have you ever been convicted of a state, federal, or military crime?
Are you a U.S. Citizen?*
Yes No
Yes No
B. CITIZENSHIP/BACKGROUND INFORMATION
If yes, fill out the table below and attach an affidavit providing the details of any and all convictions. Attach additional pages, if necessary,
utilizing the format below.
If yes, attach one of the following as proof of citizenship US Passport, Voter's Certificate, Birth Certificate or Naturalization Papers.
Date Municipality Charge Disposition
*Manager must be a U.S. Citizen
I hereby swear under the pains and penalties of perjury that the information I have provided in this application is true and accurate:
Date
7
Manager's Signature
Residential Address
click to sign
signature
click to edit
6. AMENDMENT-Change of Officers, Stock or Ownership Interest
Change of Officers/Directors
Change of Stock (E.g. New Stockholder/
Transfer or Issuance of Stock)
Change of Ownership Interest
(LLC Managers/LLP Partners, Trustees)
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?
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
Has any individual listed in question 6, 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
8
Are you requesting approval to utilize a management company through a management agreement?
Please provide a copy of the management agreement.
6. AMENDMENT-Change of Officers, Stock or Ownership Interest
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
6B. CURRENT OFFICERS, STOCK OR OWNERSHIP INTEREST
6A. INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Does any individual or entity identified in question 6, 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
6B. PREVIOUSLY HELD INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Has any individual or entity identified identified in question 6, 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
Name License Type License Name Municipality
Name License Type License Name Municipality
6C. DISCLOSURE OF LICENSE DISCIPLINARY ACTION
Have any of the disclosed licenses listed in question 6A or 6B 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
9
Alteration of Premises: (must fill out attached financial information form)
Please provide a complete description of the proposed premises, including the number of floors, number of rooms on each floor, any
outdoor areas to be included in the licensed area, and total square footage. You must also submit a floor plan.
PROPOSED DESCRIPTION OF PREMISES
Occupancy Number
Seating Capacity
Number of Entrances
Total Sq. Footage
Number of Exits Number of Floors
7A. ALTERATION OF PREMISES
Please summarize the details of the alterations and highlight any specific changes from the last-approved premises.
Last-Approved Street Address
Proposed Street Address
Change of Location: (must fill out attached financial information form)
7B. CHANGE OF LOCATION
Please provide a complete description of the premises to be licensed, including the number of floors, number of rooms on each floor, any
outdoor areas to be included in the licensed area, and total square footage. You must also submit a floor plan.
DESCRIPTION OF PREMISES
Occupancy Number
Seating Capacity
Number of Entrances
Total Sq. Footage
Number of Exits Number of Floors
7. AMENDMENT-Change of Premises Information
Landlord Name
Landlord Phone
Landlord Address
Lease Beginning Date
Lease Ending Date
Rent per Month
Rent per Year
Will the Landlord receive revenue based on percentage of alcohol sales?
NoYes
Please indicate by what means the applicant has to occupy the premises
Landlord Email
OCCUPANCY OF PREMISES
Please complete all fields in this section. Please provide proof of legal occupancy of the premises. (E.g. Deed, lease, letter of intent)
10
8A. MANAGEMENT ENTITY
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
List all proposed individuals or entities that will have a direct or indirect, beneficial or financial interest in the management Entity (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
Address
Phone
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
8. AMENDMENT-Management Agreement
Management Agreement: (must fill out all pages in section 8)
11
8B. EXISTING MANAGEMENT AGREEMENTS AND INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Does any individual or entity identified in question 8A, and applicable attachments, have any direct or indirect, beneficial or financial
interest in any other license to sell alcoholic beverages; and or have an active management agreement with any other licensees?
Yes No
Name License Type License Name Municipality
If yes, list in table below. Attach additional pages, if necessary, utilizing the table format below.
NoYes
Are you requesting approval to utilize a management company through a management agreement?
If yes, please fill out section 8.
Please provide a narrative overview of the Management Agreement. Attach additional pages, if necessary.
IMPORTANT NOTE: A management agreement is where a licensee authorizes a third party to control the daily operations of the
license premises, while retaining ultimate control over the license, through a written contract. This does not pertain to a liquor
license manager that is employed directly by the entity.
8C. PREVIOUSLY HELD INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Has any individual or entity identified in question 8A, 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?
Yes No
8E. DISCLOSURE OF LICENSE DISCIPLINARY ACTION
Have any of the disclosed licenses listed in question 8B, 8C or 8D 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
If yes, list in table below. Attach additional pages, if necessary, utilizing the table format below.
8D. PREVIOUSLY HELD MANAGEMENT AGREEMENT
Has any individual or entity identified in question 8A, and applicable attachments, ever held a management agreement with any
other Massachusetts licensee?
Yes No
Licensee Name License Type Municipality Date(s) of Agreement
If yes, list in table below. Attach additional pages, if necessary, utilizing the table format below.
8. AMENDMENT-Management Agreement
8F. TERMS OF AGREEMENT
a. Does the agreement provide for termination by the licensee?
b. Will the licensee retain control of the business finances?
c. Does the management entity handle the payroll for the business?
Yes No
Yes No
Yes No
f. How will the management company be compensated by the licensee? (check all that apply)
$ per month/year (indicate amount)
% of overall sales (indicate percentage)
% of alcohol sales (indicate percentage)
other (please explain)
d. Management Term Begin Date e. Management Term End Date
Signature:
Date:
Title:
Management Agreement Entity Officer/LLC Manager
Signature:
Date:
Title:
ABCC Licensee Officer/LLC Manager
12
9. FINANCIAL DISCLOSURE
Required for the following transactions:
• Change of Officers, Stock or Ownership Interest (E.g. New Stockholder/Transfer or Issuance of Stock)
• Change of Premises Information
• Pledge of License, Inventory or Stock
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.
Purchase Price(s):
SOURCE OF FINANCING
FINANCIAL INFORMATION
Provide a detailed explanation of the form(s) and source(s) of funding for the cost identified above.
13
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:
ADDITIONAL INFORMATION
Please utilize this space to provide any additional information that will support your application or to clarify any answers
provided above.
as its manager of record, and hereby grant him or her with full authority and control of the
premises described in the license and authority and control of the conduct of all business
therein as the licensee itself could in any way have and exercise if it were a natural person
residing in the Commonwealth of Massachusetts.”
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.”
“VOTED: To appoint
City/Town
Name of Person
Name of Liquor License Manager
Date of Meeting
Entity Name
For the following transactions (Check all that apply):
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)
(Print Name)
__________________________
(Print Name)
__________________________
6. Change of Officers, Stock or Ownership Interest (Continued...)
ADDENDUM A
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.).
Entity Name Percentage of Ownership in Entity being Licensed
(Write "NA" if this is the entity being licensed)
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
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
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
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 MULTIPLE AMENDMENTS
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
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Multiamendment2019mgmt

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 January 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document